Clinical Guide to Psychiatric Assessment of Infants and Young Children Clinical Guide to Psychiatric Assessment of Infants and Young Children Karen A

Karen A. Frankel Joyce Harrison Wanjiku F. M. Njoroge Editors Clinical Guide to Psychiatric Assessment of Infants and Young Children Clinical Guide to Psychiatric Assessment of Infants and Young Children Karen A. Frankel • Joyce Harrison Wanjiku F. M. Njoroge Editors

Clinical Guide to Psychiatric Assessment of Infants and Young Children Editors Karen A. Frankel Joyce Harrison Department of Psychiatry Department of Psychiatry and Behavioral Irving Harris Program in Child Sciences Development and Infant Mental Health Johns Hopkins University School of University of Colorado School of Medicine Medicine Aurora, CO, USA Baltimore, MD, USA

Wanjiku F. M. Njoroge Child and Adolescent Psychiatry Fellowship Philadelphia, PA, USA Young Child Clinic Department of Child and Adolescent Psychiatry and Behavioral Sciences Children’s Hospital of Philadelphia Philadelphia, PA, USA Policy Lab Children’s Hospital of Philadelphia Philadelphia, PA, USA Department of Psychiatry Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, USA

ISBN 978-3-030-10634-8 ISBN 978-3-030-10635-5 (eBook) https://doi.org/10.1007/978-3-030-10635-5

Library of Congress Control Number: 2019934197

© Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland This book is dedicated to our families Doug and Jess Carrel; Mbugua, Josephine, Njoroge M. Njoroge, and Suzanna Reiss; and John, Matt, and Kat Harrison, who supported us, tolerated us, and loved us while we undertook this effort across the years and globe. Foreword

The validity and the importance of early childhood psychopathology have both become increasingly clear over the last two decades. An expanding body of empirical research on the manifestations, longitudinal outcomes, and neural correlates of psychopathology in young children, as well as the unique efficacy of early intervention, has catalyzed this field. Disorders of infants and preschoolers are now a widely accepted clinical phenomenon and of interest to groups beyond those with a specific focus on early childhood development and psychopathology, to those practicing in mainstream mental health. Based on this, the need for clear guidelines on developmentally sensitive and appropriate assessment techniques has taken on even greater importance and urgency. Innovations in this area have facilitated the clinical research providing the advances in our ability to detect and understand the etiology and course of early childhood psychopathology. Now, many of these methods and measures can be utilized in clinical settings and may serve as very useful tools for conducting an age-appropriate and clinically meaningful assessment as outlined in the following chapters. The chapters contained in this volume outline developmentally sensitive principles and approaches to the clinical mental health assessment of young children. While these methods may be applied using a variety of adaptations and forms and in different clinical settings, it is important to note that such developmentally specific approaches are critical to obtaining a valid and clinically meaningful mental health assessment of a young child. Failure to utilize age-appropriate methods may result in both overdiagnosis and failure to detect symptoms and disorders of the young child. Several central principles underlying the unique features of the assessment of the young child are outlined in the book. First is the central importance of the dyad to the emotional and social functioning of young children and the related need to conduct the evaluation in the context of the caregiver-child relationship. Related to this, the assessment of parenting style and internal representations which impact parenting is also central and elaborated upon in several chapters. These issues while important in all child assessments are critical to the mental status exam and diagnostic formulation of the young child. The importance of the play setting and the use of play as the medium of expression is also a central theme. Several

vii viii Foreword other principles are key, such as the need to consider behavior in context (including relationship context) and the need to assess the child with different caregivers and on more than one occasion to account for the significant effect of state on a young child’s mental status. The reader can utilize the information in this volume to apply these methods and principles to conduct an age-appropriate mental health assessment of young children. This volume also touches on diagnostic systems that can be applied in early childhood, reviewing the merits and limitations of both DSM 5 and DC:0-5. While it does not provide a review of empirically supported treatments for mental disorders in young children, it does touch on more global issues such as how to assess for the need to evaluate the potential use of psychopharmacology. The volume, while not prescriptive, provides a comprehensive overview of the key principles to be considered and numerous tools and approaches that can be utilized in the age- appropriate mental health assessment of the young child. Importantly, a true embrace of these principles and methods is nothing short of prerequisites for the appropriate and accurate mental health assessment of the young child. This comprehensive book provides a highly clinically useful review of these essential principles.

Washington University Joan L. Luby St. Louis, MO, USA Preface

We are pleased to offer this volume as a hands-on guide to the assessment of very young children and their caregivers. Each of the editors (and most of the authors) has worked for decades in the area of infant and early childhood mental health, training and teaching new generations of providers. Joyce, Wanjiku, and I have longed for a single text that brought together resources describing the comprehensive process of evaluating infants, toddlers, preschoolers, and their caregivers. Infant and early childhood mental health is a complex subspecialty of child mental health which takes a unique lens toward assessment—one that is relationship-based, contextually grounded, culturally sensitive, and diversity-informed and requires competence in adult, child, and relationship assessment skills. Learning all of these domains can be daunting for trainees and seasoned professionals as well. We hope this volume will make the task more accessible and enticing! This volume is intended to provide conceptual frameworks as well as specific information on the “how-to’s” of conducting an infant/early childhood evaluation. We intend that each chapter can stand alone to teach a particular type of assessment and/or skill and that the complete text will provide a guide to a thorough and comprehensive evaluation. Each chapter highlights the particular principles of assessment that apply to that domain and describes specialized tools that can be used by the clinician in academic, public, and/or private practice settings. This volume imparts to the reader the critical importance of understanding culture and diversity such that special attention is paid to the role of culture and its impact on assessment of families with young children. Finally, each of the chapters concludes with a brief case vignette which hopefully brings the material alive and illustrates the use of the highlighted tools.

Aurora, CO, USA Karen A. Frankel

ix Acknowledgments

We would first like to thank Springer for approaching us with the request to edit this book which turned out to be the answer to prayers we didn’t know we had. Second, thank you to all of our wonderful chapter authors who, as experts in each of their respective fields, provided state-of-the-art information and a reassuringly consen- sual approach to evaluation in early childhood. It is with deepest gratitude that we would like to thank all of our mentors, supervisors, and teachers, who taught us about infant mental health. These dedicated, brilliant, hard-working leaders in the field of infant mental health took the time to nurture our interests and development in this field Here are but a few we wanted to recognize: Kathy Barnard, Irene Chatoor, Robert Emde, Robert J. Harmon, Linda Mayes, Christiana Mills, Kyle Pruitt, Charley Zeanah, Zero to Three, and the Irving Harris Foundation Professional Development Network. Thank you also to Stacey L’hommedieu, our invaluable administrative assistant who tracked every detail of the finalizing of the book. And a special thanks to the hundreds of babies, toddlers, young children, and families that we have had the pleasure to serve and work with over the course of our careers.

xi Contents

1 Introduction Assessment in Early Childhood �� 1 Rachel Stein, Wanjiku F. M. Njoroge, and Dena M. Dunn 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental Health Assessment �� 21 Gerard Costa and Carmen Rosa Noroña 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications �� 77 Amy Dickson and Shannon Bekman 4 Observational Assessment of the Dyad �� 107 Sherryl Scott Heller, Kate Wasserman, Anna Kelley, and Roseanne Clark 5 Observational Assessment of the Young Child �� 143 Diane Misch, Giovanni Billings, Ji Su Hong, and Joyce Harrison 6 Assessing the Inner World of the Young Child �� 185 Theodore J. Gaensbauer, Sarah Gray, and Virginia I. Hatch 7 Rating Scales for Social-Emotional Behavior and Development �� 217 Leandra Godoy, Alison E. Chavez, Rachel A. Mack, and Alice S. Carter 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood �� 253 Kathleen Mulrooney, Helen Egger, Stephanie Wagner, and Lauren Knickerbocker 9 Psychopharmacologic Considerations in Early Childhood �� 285 Julianna Finelli and Mary Margaret Gleason

xiii xiv Contents

10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families �� 327 Vivian L. Tamkin, Bhavin Dave, Adeela T. N. Whittaker, and Karen A. Frankel

Index �� 357 Contributors

Shannon Bekman University of Colorado School of Medicine, Aurora, CO, USA Giovanni Billings Vanderbilt University Medical Center, Nashville, TN, USA Alice S. Carter Department of Psychology, University of Massachusetts Boston, Boston, MA, USA Alison E. Chavez Department of Psychology, University of Massachusetts Boston, Boston, MA, USA Roseanne Clark School of Medicine and Public Health, University of Wisconsin- Madison, Madison, WI, USA Gerard Costa Center for Autism and Early Childhood Mental Health, College of Education and Human Services, Montclair State University, Montclair, NJ, USA Bhavin Dave Infant and Toddler Mental Health Program, Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC, USA Amy Dickson Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA, USA Dena M. Dunn The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Helen Egger Department of Child and Adolescent Psychiatry and Director, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA Julianna Finelli Department of Psychiatry and Behavioral Sciences Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA Karen A. Frankel Department of Psychiatry, Irving Harris Program in Child Development and Infant Mental Health, University of Colorado School of Medicine, Aurora, CO, USA

xv xvi Contributors

Theodore J. Gaensbauer Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA Mary Margaret Gleason Department of Psychiatry and Behavioral Sciences Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA Leandra Godoy Child Health Advocacy Institute, Children’s National Health System, Washington, DC, USA Division of General and Community Pediatrics, Children’s National Health System, Washington, DC, USA Sarah Gray Department of Psychology, Tulane University, New Orleans, LA, USA Joyce Harrison Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA Virginia I. Hatch Department of Psychology, Tulane University, New Orleans, LA, USA Sherryl Scott Heller Department of Psychiatry and Behavioral Medicine, Tulane University Medical School, New Orleans, LA, USA Ji Su Hong Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA Anna Kelley Department of Psychiatry and Behavioral Medicine, Tulane University Medical School, New Orleans, LA, USA Lauren Knickerbocker Department of Child and Adolescent Psychiatry, and Clinical Psychologist, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA Rachel A. Mack Department of Psychology, The George Washington University, Washington, DC, USA Diane Misch Department of Psychiatry, Institute for Juvenile Reseach, University of Illinois at Chicago, Chicago, IL, USA Kathleen Mulrooney Infant and Early Childhood Mental Health, Professional Development and Workforce Innovations Department, ZERO TO THREE, Washington, DC, USA Wanjiku F. M. Njoroge Child and Adolescent Psychiatry Fellowship, Philadelphia, PA, USA Young Child Clinic, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, USA Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Contributors xvii

Carmen Rosa Noroña Boston Medical Center, Child Witness to Violence, Boston, MA, USA Rachel Stein School of Education and Human Development, University of Colorado Denver, Denver, CO, USA Vivian L. Tamkin The Department of Counseling Psychology, University of Wisconsin-Madison, Madison, WI, USA Stephanie Wagner Department of Child and Adolescent Psychiatry, and Licensed Clinical Psychologist, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA Kate Wasserman University of Maryland School of Social Work, Baltimore, MD, USA Adeela T. N. Whittaker JAW Solutions, LLC, Atlanta, GA, USA About the Editors

Karen A. Frankel, Ph.D. is Associate Professor of Psychiatry at the University of Colorado School of Medicine and Director of the Harris Program in Child Development and Infant Mental Health. Dr. Frankel is a licensed clinical psychologist who has specialized in the assessment and treatment of young children for more than 30 years. She is the supervising psychologist for the University of Colorado Young Child Clinic, the Executive Director for Fussy Baby Network Colorado, and a national trainer for the Diagnostic Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood (DC:0–3R™). Dr. Frankel received her bachelor’s degree from Oberlin College and her doctoral degree in clinical psychology from Indiana University. She completed an internship at the University of Washington School of Medicine and a postdoctoral fellowship through the Developmental Psychobiology Research Group at the University of Colorado School of Medicine.

Joyce Harrison, M.D. is Assistant Professor in the Division of Child Psychiatry at Johns Hopkins University. She received her bachelor’s in psychology from Harvard University and her M.D. from Dartmouth Medical School. She completed an internship in pediatrics in the Triple Board Program at Tufts/New England Medical Center, residency in adult psychiatry at the University of Maryland Medical Center, and child psychiatry residency at Johns Hopkins Hospital, where she was chief resident. Dr. Harrison has received numerous grants and teaching awards, most recently a Special Achievement Award from the American Academy of Pediatrics. Dr. Harrison has been a member of the American Academy of Child and Adolescent Psychiatry’s Infant and Preschool Committee since 2010. She is a staff psychiatrist at the Kennedy Krieger Institute’s Preschool Interdisciplinary Clinic and is currently Project Director for a US Health Services and Resources Administration funded project of Early Childhood Mental Health Tele-education.

xix xx About the Editors

Wanjiku F. M. Njoroge, M.D. is Assistant Professor at the University of Pennsylvania, Perelman School of Medicine, and Medical Director of the Young Child Clinic at the Children’s Hospital of Philadelphia (CHOP). Dr. Njoroge is the Program Director for the Child and Adolescent Psychiatry Fellowship Training Program in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the CHOP. She received her bachelor’s at Columbia University and her M.D. from Baylor College of Medicine. She completed her adult psychiatry residency training at the University of Pennsylvania and child psychiatry fellowship at the Yale Child Study Center. Dr. Njoroge also completed postgraduate training programs with the Harris Infant Psychiatry fellowship at the Yale Child Study Center as well as a postdoctoral NIMH research fellowship at the Yale Child Study Center. In addition, she was also a postdoctoral fellow at Yale University’s Edward Zigler Center in Child Development and Social Policy and a Solnit fellow in the Zero to Three program based in Washington, DC. Dr. Njoroge successfully received multiple research development awards from the National Institute of Mental Health (NIMH) and Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and teaching awards, most recently from the University of Pennsylvania School of Medicine. Chapter 1 Introduction Assessment in Early Childhood

Rachel Stein, Wanjiku F. M. Njoroge, and Dena M. Dunn

Introduction

Infant and Early Childhood Mental Health (IECMH) is a broad topic that includes a multitude of considerations contributing to social-emotional well-being in early childhood. The definition is typically inclusive of very young children between the ages of 0 and 6. The field of IECMH describes how early childhood is shaped by both individual development and the context where development takes place (Zeanah, 2009). Clinicians from diverse fields and backgrounds have applied this understanding to efforts supporting the social and emotional well-being of children in the early years of life. What sets IECMH apart is the focus on the caregiver–child relationship and treating any challenges that arise within the framework of that relationship (Zeanah, Stafford, & Zeanah, 2005). While individual psychopathologies are considered, the relationship itself is often determined to be an important

R. Stein (*) School of Education and Human Development, University of Colorado Denver, Denver, CO, USA e-mail: [email protected] W. F. M. Njoroge Child and Adolescent Psychiatry Fellowship, Philadelphia, PA, USA Young Child Clinic, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA, USA Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA e-mail: [email protected] D. M. Dunn The Children’s Hospital of Philadelphia, Philadelphia, PA, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_1 2 R. Stein et al. component of any dysfunction that arises. Assessing mental health, behavior and development in early childhood is different than at other points in life. Even though very young children are individuals, they are heavily reliant on their caregivers and are greatly influenced by their environment. Very young children are often unable to describe concerns or share their experiences verbally, therefore, social and emotional challenges may manifest in the reports of their adult caregivers or through the child’s behavior. Many of the usual methods of expressing oneself during the assessment process (e.g., self-report survey measures) are not applicable to young children because they lack the developmental, cognitive, language, and motor skills. The approach to assessment in early childhood differs from other types of assessment in that it relies heavily on input from a child’s caregivers and considers any information provided within the context of the caregiving relationship. While many forms of assessment take an ecological perspective, IECMH acknowledges that early childhood experiences fundamentally take place within the surrounding relationships and contexts. This chapter provides an introduction and overview of IECMH and assessment in early childhood. First, a brief history of the field of IECMH is described. Against this historical context, modern definitions and conceptualizations of IECMH are explored. Guiding principles and ideas related to IECMH and assessment are discussed, followed by an explanation of pragmatic considerations for assessment in early childhood. Finally, a synopsis of this volume is included to help guide the use of this book, based on specific reader goals and needs.

Defining Infant and Early Childhood Mental Health

Infant and Early Childhood Mental Health (IECMH) includes an age range that encapsulates very early childhood, frequently 0–3 years, with some definitions going up to age 8 and others that include the prenatal period. Each definition acknowledges the role of caregivers and the environment in a child’s earliest experience. A few of the most widely accepted definitions of infant mental health are presented below, in order to help the reader to define and contextualize early childhood assessment within the field of IECMH. The World Association for Infant Mental Health (WAIMH) aims to promote healthy development and well-being for infants worldwide. Central to this mission is an understanding of developmental differences between children. WAIMH views Infant Mental Health (IMH) as encompassing the dual goals of generating and dis- seminating science that works to promote healthy development and well-being from conception until three years of age. Specifically, WAIMH articulates that IMH is: The ability to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system (WAIMH Handbook of Infant Mental Health, 2017, vol 1, p. 25). 1 Introduction Assessment in Early Childhood 3

ZERO TO THREE (ZTT) defines IMH as: “How well a child develops socially and emotionally from birth to three” (2017). ZTT further articulates: Infant-early childhood mental health, sometimes referred to as social and emotional health, is the developing capacity of the child from birth to 5 years of age to form close and secure adult and peer relationships; experience, manage, and express a full range of emotions; and explore the environment and learn—all in the context of family, community, and culture. Strategies to improve I-ECMH fall along a promotion, prevention and treatment continuum. A young child’s mental health is crucial to their ability to form relationships, engage a range of emotions, and to explore his or her environment (ZTT, 2017), all of which are building blocks for subsequent healthy development. According to ZTT, comprehensive IECMH services include a continuum of promotion, prevention, and treatment.

Important Influences in Infant Mental Health

Throughout history there was little acknowledgement that very young children have emotional states or are impacted by their surroundings. Over time there was a grad- ual realization that children are not just small adults (i.e., Rathus, 2008), but rather have their own internal states and developmental processes. The field of Infant and Early Childhood Mental Health (IECMH) was shaped by a number of theoretical perspectives, with origins in psychoanalytic tradition, systems-based approaches, and a medical foundation of illness and psychopathology. In the historical overview presented below, key individuals in the formulation of the field of IECMH are briefly described, alongside their contributions to the field.

Sigmund Freud

Psychoanalytic tradition was the first perspective of mental health that considered early childhood an important and significant time. Freud articulated that individuals develop attachment relationships in the early years of life, with the potential for problems if these relationships are conflictual or do not meet the young child’s needs (Fitzgerald, Weatherston, & Mann, 2011). However, Freud did not work directly with children and examined these theories through his work with adult patients, looking retrospectively at their lives. Nonetheless, his ideas compelled others to begin to think about the importance of experiences early in life. 4 R. Stein et al.

Anna Freud

Anna Freud built upon the work of her father, Sigmund Freud, with a specific focus on understanding the early childhood period. Through her work Freud helped connect early childhood behavior to trauma, developmental challenges, and emotional conflicts. Although contemporary work often connects behavior in early childhood with both external and internal struggles, these ideas were novel when Freud began providing trainings to teachers and parents. Throughout her career Freud worked to better understand the causes and treatments of behavior in infancy, both through clinical and academic work (Freud, 1983).

Jean Piaget

Jean Piaget contributed to IECMH through his work on early childhood cognitive processes. Piaget’s study of children’s understanding of the world helped illuminate that children’s reasoning is not the same as adults. Although Piaget did not identify himself as someone treating early childhood mental health, his work moved psychology towards the realization that children need to be thought of as individuals with different types of mental reasoning than adults. In turn, this influenced how both healthy functioning and challenging behavior are thought about in the early childhood years.

Donald Winnicott

Winnicott was a British pediatrician who articulated the importance of parenting practices on children. Winnicott is famous for his quote, “There is no such thing as an infant, meaning, of course, that whenever one finds an infant one finds maternal care, and without maternal care there would be no infant” (Winnicott, 1953, p. 585). In contrast to some earlier psychoanalytic approaches, Winnicott aimed to help parents be “good enough” parents, rather than perfect parents (Winnicott, 1953). Although these ideas may sound like common sense, they were novel during the time in which Winnicott proposed them. They helped to propel the understanding of young children’s early emotional experiences, specifically the important role of caregiving.

Erick Erickson

Erick Erickson expanded upon many psychoanalytic ideas to consider more of the context in which development takes places, with a specific focus on social context (Fitzgerald et al., 2011). This understanding helped frame IECMH as transactional 1 Introduction Assessment in Early Childhood 5 and relationship-based. Thinking about IECMH in this lens helped articulate how IECMH takes place within a context and is a dynamic process (Fitzgerald et al., 2011).

John Bowlby

Bowlby was a psychological theorist who advanced the understanding of caregiver– child relationships, called attachment, through his work (e.g., Bowlby, 1969). Although Bowlby was trained in the psychoanalytic tradition, he began to see the importance of considering the social environment when thinking about mother– infant relationships (Holmes, 2014). Ultimately, Bowlby developed the idea of attachment theory which stated that being proximal to a loved one created positive feelings, whereas being physical distant resulted in feelings of anxiety, sadness, and loneliness (Holmes, 2014). Over time, every individual’s attachment experience shapes subsequent psychological experiences and skills, even once past the age of needing physical proximity to a caregiver. Bowlby articulated that it is essential for infants to experience a, “warm, intimate, and continuous relationship” with a primary attachment figure (Bowlby,1953 , p. 13), which has important implications for their later functioning. Bowlby illustrated this idea in a number of ways, including his filmA Two Year Old Goes to the Hospital, which demonstrates the painful feelings a young child may have when separated from a caregiver. Ultimately, Bowlby’s work was pivotal in beginning conceptualization of the origins of dysfunction in early childhood. Bowlby’s attachment theory has expanded to consider the quality of attachment relationships and their implications. Specifically, attachment is often thought of in terms of both attachment style and related attachment behaviors. One’s style of attachment is classified as eithersecure or insecure. Secure attachments create a sense of consistency and safety, whereas insecure attachments cause conflictual and sometimes negative feelings (Holmes, 2014). In turn, attachment behaviors are those behaviors that result in the seeking or distancing oneself from attachment figures. Although these attachment relationships take place early in life, they are thought to impact mental health and relationships throughout life.

Selma Fraiberg

In the 1970s Selma Fraiberg and her colleagues began to study social and emotional states in early childhood. Fraiberg worked collaboratively with individuals from across disciplines to learn more about IECMH. Specifically, she used this terminology to describe the social-emotional experiences of children under 3 years of age (Weatherston, 2000). Selma Fraiberg and her colleagues engaged in research that highlighted how caregivers influence babies and how babies also influence their 6 R. Stein et al. caregivers. Specifically, Fraiberg and her colleagues (1980) realized that they needed to think about caregivers’ early experiences, or the Ghosts in the Nursery, in order to work with young children. They found that caregivers unknowingly adopted caregiving practices that were influenced by their own pasts and intervention was successful when considering the caregivers early experiences and their impact on the young child in question (Fraiberg, 1980). Fraiberg’s work helped to integrate her psychoanalytic perspective with an understanding of transactional systems (Fitzgerald et al., 2011). Fraiberg and her interdisciplinary team of social workers, psychologists, nurses, and psychiatrists treated infants and their caregivers, often within the home environment, with the ultimate goal of decreasing childhood psychopathology and relationship challenges (Weatherston, 2000). In a then novel approach to treatment, Fraiberg and her team worked to understand each child and his or her family to remediate challenges faced by the infant within his or her caregiver relationships (Weatherston, 2000). In addition to the unique understanding of early childhood that Fraiberg and her team used to guide their work, they also recognized each family’s urgent concern and immediate risk factors (e.g., the need for formula). Shaped by the work of Selma Fraiberg, medical and mental health providers propelled the conceptualization of IECMH.

Contemporary Theorists and Contributors

This multidisciplinary approach of the field of IECMH has been adopted by important figures who have furthered ideas and research in this area. Many contemporary professionals like T. Berry Brazelton, Alicia Lieberman, Charles Zeanah, and Arnold Sameroff have advanced the science and practice of supporting mental health during the early years of life. While there are too many important individuals to comprehensively describe in this text, the field has grown and progressed due to the contributions of many.

Development and Infant Mental Health

During early childhood, development takes place at a very rapid pace, with periods of important growth and acquisition of new abilities. In the first 5 years of life, significant growth occurs within multiple “sensitive” periods (Knudsen,2004 ). During these periods the secure caregiver–infant relationship provides a strong foundation for the growing infant’s developmental competencies (Knudsen, 2004). One of the key facts of early childhood is that early experiences are the foundation of later development and affect developing connections between neurons (Neurons to Neighborhoods, 2000; Shonkoff et al., 2012). Therefore, when assessing young children it is vital to consider the role of their rapid cognitive, motor, communication and social-emotional developmental capabilities in the context of their relationships. Neurons to Neighborhoods (2000) stated: 1 Introduction Assessment in Early Childhood 7

Virtually every aspect of human development, from the brain’s evolving circuitry to the child’s capacity for empathy is affected by the environments and experiences that are encountered in a cumulative fashion beginning in the prenatal period and extending (p. 6). Although the specific stages and mechanisms of child development are vast, this section briefly outlines some of the developmental frameworks and considerations important for social-emotional assessment in early childhood. Each of the models below provides a perspective on positive and negative influences on a child’s development. While there is some overlap between the different theoretical approaches, each tries to conceptualize how the developing young child is impacted by their world, and how the young child impacts their world. During the process of assessment, it is critical to keep these frameworks in mind, to conceptualize findings in the context of the many important influences in the functioning of young children.

Ecological Theory and Transactional Relationships

The ecological perspective of development draws upon the foundation of early theorists who considered the importance of looking at development within context. Although it is easy to dichotomize experiences as due to either nature or nurture, a more realistic perspective recognizes that both nature and nurture are important (Sameroff & Fiese, 2000). Indeed longitudinal research efforts provide support for both the impact of the individual and the environment (Sameroff & Fiese, 2000). Ecological theory conceptualizes environmental influences through a series of concentric rings based on their impact on an individual. Specifically, an ecological perspective begins with the most proximal influences (e.g., caregivers) and moves outward to factors that are influential in a more distal way (e.g., neighborhood, policy). Through this lens, ecological theorists acknowledge that individuals are shaped by a multitude of contributions outside of themselves, with some playing a more prominent role than others. When assessing very young children, an ecological perspective is helpful to account for the various ways in which children are affected by the world around them. For example, a child’s emotional state might be impacted by their caregiver yelling at them for making a mess or because their preschool has a high ratio of children to adults. When thinking about social-emotional health in the early stages of life children are extremely vulnerable to a range of influences, from the nutrition they receive, to the amount of attention adults give them, and to the types of opportunities available. Although children are often seen as subject to their environment, they contribute to their surroundings. Transactional relationships describe the mutual interaction between the individual and environment, where one constantly influences the other (Sameroff & Fiese, 2000). In the context of early childhood assessment, considering the transactional relationship between a child and his or her surroundings is critical. For example, an infant born with a difficult temperament (e.g., difficult to soothe, slow to adjust) 8 R. Stein et al. may thrive with easy-going parents but may struggle with parents who prefer rigid routine. In either of these instances the baby is influencing the caregivers while the caregivers influence the child. Together their interaction describes a great deal about the infant’s development and social-emotional health, which might be lacking if only one or the other is considered.

Risk and Protective Factors

There are many factors which can act as either protection against adversity or increase the risk for challenges. In early childhood, the impact of risk and protective factors is magnified due to the pace of development. During the first 3 years of life there are significant changes in neurodevelopmental processes with increases in synaptic density, dopamine receptor density, and cerebral metabolic rates peak. The National Scientific Council on the Developing Child has written extensively about the impact that early experiences have on both gene expression and construction, which they refer to as the architecture of the brain (National Scientific Council on the Developing Child, 2010). Neurons to Neighborhoods (2000) addresses the link- age between environment and early experiences and the impact on healthy brain development. This seminal text conveys the importance of the ways developing brains acquire information and how the information is encoded, translated, understood, and expressed later in child development and behaviors. “Plasticity” is a term used to refer to as the brain’s ability to learn from experience. Research on brain development continues to focus on identifying the type and timing of various influences on early brain development. For example, trauma and toxic stress impact young children in different ways, which is likely influenced by the timing of the trauma, the type of trauma, and the protective influences a child has when recover- ing from the trauma. Shonkoff (2017) explains: Despite the widespread yet erroneous belief that people need only draw upon some heroic strength of character, science now tells us that it is the reliable presence of at least one supportive relationship and multiple opportunities for developing effective coping skills that are the essential building blocks for strengthening the capacity to do well in the face of significant adversity (p. 12). Resilience in early childhood is fostered in the context of caregiving relationships. Positive caregiving practices and environments serve as an important buffer in both supportive and challenging environments. Protective caregiving may include caregivers who are attuned and responsive to their child, positive discipline, environments that are supportive of learning and language, and playful child–caregiver interactions. When caregivers aren’t available, either physically or psychologically (e.g., parental mental health problems), to provide positive caregiving practices, children are impacted. In particular, children may receive less attention and lack the strong relationship bond that can buffer against adversity. 1 Introduction Assessment in Early Childhood 9

Development and Early Childhood Assessment

Language and Communication

Language and communication skills are always an important consideration to ensure accurate information is gathered during assessment. This is particularly true when working with very young children, given that language skills may be limited during this developmental period. Further, in contrast to working with older children, very young children may not have the cognitive or language abilities to answer direct questions, nor are their responses necessarily reliable due to their developmental level. Although there is evidence that foundational language skills (e.g., basic imitation) develop during early infancy (De Villiers & Davidson, 2016), the ability to express one’s experiences develops much later. Being able to convey one’s emotional experiences requires an understanding of emotions as well as the language or communication skills to share that information. Therefore, other forms of communication and information gathering are central to working with very, young children. In early childhood, communication often takes place in the form of behavior. For instance, an infant who is uncomfortable will cry or a toddler who is preverbal may point to something that he or she needs. While at times these behaviors may convey a clear meaning, other times they may be more ambiguous. The methods of communicating social-emotional needs, such as self-report measures, that are important for older children and adults are not useful in the early childhood period. Rather, understanding young children’s needs requires making inferences and relying on external reports (Zeanah & Boris, 2000). The challenge in using these methods is that there is a great deal of potential for miscommunication or misunderstanding. For example, a parent may inaccurately interpret their child’s behavior because of their own experiences. Parent report also relies on the perception and interpretation of their child’s cues and communication. For example, an exhausted and stressed mother may misperceive her infant’s crying as communicating hunger and respond by feeding the infant, when the crying baby may be expressing discomfort from a wet diaper. Communicative behaviors in infancy and early childhood may have many possible meanings, creating the potential to misinterpret what a child is trying to share. Assessment of very young children requires careful consideration of communication and the possible meanings of behaviors, caregiver reports, and how information for assessment is gathered and received. An additional complication is that some assessments may be confounded by language abilities. Although a toddler who is learning language may be able to share some of his or her experiences, what is shared may be limited by his or her communication skills. For instance, a young child may rely on the only two feeling words they know, even if neither word is truly able to capture their experience. Young children also struggle to understand temporal sense. For example, yesterday may feel like last week, and time is difficult for them to express verbally. Therefore, 10 R. Stein et al. assessors must be careful to consider whether they are actually capturing an understanding of a child’s emotional experience rather than a child’s ability to communicate effectively.

Motor Development

Purposeful motor movement is an alternative to verbal communication. A range of motor movements can convey important messages, from facial expressions to gestures. In addition, intentional motor activities are included in assessment, with the expectation that an individual can manipulate assessment tools (e.g., blocks). However, young children are still mastering motor skills, so motor abilities need to be taken into consideration. For instance, some assessment tools that rely on certain motor skills may actually assess a child’s motor ability, which may or may not be the aim of an assessment. While there are certainly ways to engage in assessment that reduce the expected motor demands, it is nonetheless important to understand a child’s motor abilities and their impact on assessment in order to ensure that accurate information is gathered.

Social-Emotional Development

The development of strong social and emotional skills is complex, but extremely important to think about because of their broad impact on other functioning and development. In particular emotional health in early childhood has been linked to better school performance and the related correlates (ZERO TO THREE). Children who struggle with challenges related to their social and emotional functioning have been shown to have fewer cognitive gains, in addition to having their interactions with others impacted. Children who struggle with self-regulation, self-soothing or express negative emotions through maladaptive behaviors tend to spend more time outside of the classroom (e.g., sitting in the hallway, suspension) and have fewer positive social interactions, which self-perpetuates (ZERO TO THREE). Foundational social-emotional skills and self-regulation are essential for an optimal developmental trajectory.

Contextual Factors Impacting Early Childhood Assessment

Considering the context in which the child lives and behaves is critical to accurately evaluating and describing a child. Individual variables of the child, caregiver factors, and cultural and environmental factors influencing early childhood assessment are outlined below. 1 Introduction Assessment in Early Childhood 11

Child Temperament and Personality

Social emotional development is influenced by biology, relationships, and the environment. Each of these contributes to a young child’s experience of and response to the world. Biologically, each child is born with a temperament that predisposes them to certain types of responses (e.g., tendency to be flexible versus inflexible). Biology lays the foundational blueprint for each of us. Some individuals are born with a tendency to be easy going, while others thrive when they have more routine. Temperament and personality are strongly affected by a child’s mood and regulatory state. For example, if a child is slow to warm up, a regularly scheduled 1 h evaluation may not allow enough time to get an accurate depiction of a child’s personality, but an evaluation that is scheduled for a larger block of time might allow for a very different picture of a child’s functioning and a larger slice of a child’s personality. Similarly, an evaluation that is too long or that includes a multidisciplinary team with multiple transitions and different evaluators, may elicit different qualities in a child who is slow to warm up versus a child who is extremely social.

Dyadic Considerations: The Early Caregiving Relationship

Relationships are the lens through which infant and toddlers first experience their surroundings; thus, relationships become a filter that can positively or negatively influence how very young children interpret their surroundings. The environment in which an infant is raised is an important contributor to their development. From the beginning, physiology plays a role in our experiences. For instance, a baby who is bigger when born may be able to take more food and may eat less often than a baby who is smaller at birth and may require many small feedings. In turn, these physical predispositions play a role in the types and quality of the child’s relationships. Caregivers respond in kind and bring their own emotional experiences to the physiologic predisposition of the child. Therefore, the caregiver of the larger infant may get more sleep and respond more predictably to their child’s feeding cues in contrast to the infant requiring more frequent feedings. Attributes of a child impact this caregiver–infant relationship. Infant development and an infant’s relationship with primary caregivers have been described as a reciprocal, serve and return (Shonkoff, 2017). Within their interactions with caregivers, infants seek interaction through verbal and nonverbal communication (e.g., babbling, gesturing, and pointing) and adults who are responsive return these serves with similar emotional engagement. Shonkoff (2017) describes that this serve and return behavior, continues like a game of tennis or passing a ball back and forth. This dyadic context for relationships illustrates the importance of considering caregivers in the developmental assessment of young children. Specific strategies and tools for dyadic assessment will be discussed further in this text (see Chap. 4). 12 R. Stein et al.

Environment and Culture

Outside of the context of the caregiving relationship, a child exists within a family, culture and larger society. These important ecological and environmental factors cannot be ignored in the evaluation of very young children. It is crucial to take into consideration the changing demographics of the United States, as this increasing diversity has led to heightened knowledge about ethnic and cultural variations. Culture influences every aspect of human development and is reflected in childrear- ing beliefs and practices designed to promote healthy development (Hughes, 2003). Culture affects many aspects of early childhood development. Cultural researchers have clearly documented that different cultures have different norms and expectations with respect to their children’s development (Rogoff, 2003). Some of these are parenting style, communication, ideals about safety, social communication (e.g., eye contact, body language, and nonverbal communication), parental control, independence, emotional responsivity, and cultural definitions of psychopathology, to name only a few. Cultural, racial, and ethnic identity, bicultural and intercultural families, and even the evaluator’s cultural identification can impact the assessment of a young child. Linguistic variables, a child’s primary language, and the family’s spoken language should also be carefully considered before beginning an evaluation with a young child. For example, many children raised in bilingual homes are exposed to only their native language at home, and exposed to English only outside the home. As children enter school, they become linguistically acculturated, but in early childhood sometimes do not understand or speak English fluently, depending on their exposure.

Goals of Early Childhood Assessment, Diagnosis, and Treatment Planning

Early childhood assessments typically take place in three broad contexts: medical, educational, and developmental/behavioral. Assessment procedures are employed for various reasons including screening and early identification, classification/ placement, diagnosis, and monitoring progress over time. Goals of an early childhood assessment can include the following: (1) assessing a child’s strengths to diagnose developmental delays or special needs; (2) screening to identify children needing further assessment to determine the need for health or other special services or supports; (3) determining eligibility for early intervention, special education and related services; (4) planning an intervention program, or monitoring a child’s progress; and (5) diagnosing early childhood mental health disorders. Considering the specific assessment goals is vital in determining what information needs to be gathered as well as the most appropriate tools. Each of these is briefly described below. Early childhood assessment in a medical setting often occurs in a primary care or specialty clinic setting. For example, child development may be screened as part of 1 Introduction Assessment in Early Childhood 13 routine pediatric primary care, or formally evaluated in the context of a neonatal follow-up, neurology, or cardiac clinic. Supplementary screening tools and caregiver questionnaires often accompany a formal developmental assessment. Typically the motivation for an assessment within a medical setting is to determine whether development is proceeding typically or to identify any problems that may be inhibit- ing typical development. Physical development and cognitive development (i.e., problem-solving and play skills) have historically been the primary focus of medi- cally based evaluations in early childhood, although there is an increasing awareness of the need to consider social-emotional development. The goal of assessment within a medical setting is usually to help determine whether additional care is needed (e.g., surgery, speech therapy, referral for Early Intervention) and to help connect a family to supportive services and community resources. Educational assessments in early childhood are often motivated by indications that a child is not learning at an expected pace or in a manner that is different from his or her peers. This may be indicated by an underlying disorder (e.g., trisomy 21), developmental difference (e.g., delayed language development), behavioral difficulties (e.g., hyperactivity, difficulty concentrating), or motivated by an early childhood educators’ observations or concerns. Assessment within the early childhood educational setting typically aims to help a child learn more effectively; specific goals of an educational assessment might include determining a child’s approximate development level, establishing an understanding of their strengths and weaknesses, identifying sensory sensitivities or differences, and developing a plan to provide support within the context of the classroom and community. Behavioral evaluations, or assessments in an outpatient mental health clinic settings in early childhood often take place because developmental, behavioral or psychological concerns have been identified. For instance, a family may seek clinical assessment after concerns for an Autism Spectrum Disorder arise or because their infant is crying excessively and medical concerns have already been ruled out. The goals of assessments in clinical settings are broad ranging, depending on the motivating question. Possible assessment goals within a clinical setting may include: trying to understanding a child’s learning, social-emotional functioning, development, or relationships with the goal of creating a treatment plan for intervention or support.

Infant and Early Childhood Assessment: Strategies and Tools

Screening

Developmental monitoring, surveillance or screening is recommended in early childhood to gather information about a child’s development by caregiver report. Standardized screening measures are administered by medical or mental health professionals in the context of medical and early care and education settings, and are used to track a child’s developmental progress over time. 14 R. Stein et al.

Table 1.1 American General developmental screening tools academy of pediatrics Ages and Stages Questionnaire (ASQ-3) screening recommendations Parents’ Evaluation of Developmental Status (PEDS) Parents’ Evaluation of Developmental Status- Developmental Milestones (PEDS-DM) Brigance Screens Developmental Assessment of Young Children Social-emotional screening tools Ages and Stages Questionnaire: Social-Emotional (ASQ-SE-2) Autism screening tools Modified Checklist for Autism in Toddlers (M-CHAT-R/F) Childhood Autism Spectrum Test Social Communication Questionnaire Maternal mental health screening tools Edinburgh Postnatal Depression Scale Center for Epidemiologic Studies Depression Scale (CES-D) Patient Health Questionnaire-2 (PHQ-2) Patient Health Questionnaire-9 (PHQ-9)

The American Academy of Pediatrics (AAP) issued a policy statement in 2006 outlining reco mmendations for developmental surveillance in pediatric primary care. They recommend conducting general developmental screening using evidence-based tools (see Table 1.1) at 9, 18, and 30 months, or whenever a concern is expressed by a provider or caregiver. In addition, autism-specific screening is recommended at ages 18 and 24 months, as well as screening for maternal mental health (AAP, 2006). Each developmental screening instrument includes instructions for caregivers on how to complete the measure, and for the evaluator on how to interpret raw scores. For some instruments, total raw scores in each domain are compared to preestab- lished cutoff points. Scores above the cutoff point mean the child is progressing as expected for his/her developmental age. Scores below the cutoff point mean a child may need further assessment, referrals or recommendations. Another critical component of screening is “closing the loop” to ensure appropriate and timely follow-up based on screening results. For example, if a pediatrician screens a child and uncovers that they are at risk for delayed language development, making a referral and following-up on the referral is important in ensuring quality care. 1 Introduction Assessment in Early Childhood 15

Standardized Assessment Tools

Standardized evaluation tools aim to measure behavior and development in early childhood using a uniform and measurable assessment protocol. Test items are administered in a structured and consistent format, and performance is scored in a standardized and norm-referenced manner. There are many standardized evaluations utilized to assess early childhood development (see Tables 7.1 and 7.2). In early childhood, it is important to note that standardized evaluations yield scores and often developmental or age equivalents. Test scores and other performance measures may be adversely affected by temporary states of fatigue, mood, or stress. Additionally, standardized test scores depend on a child’s cooperation and motivation.

Nonstandardized Assessment Tools

Nonstandardized or authentic assessment is an alternative to standardized evaluation in early childhood. Viewed by many early childhood professionals as an alternative approach to using standardized tests, this method of evaluation involves collecting information based on observation and/or interview. Often based in a child’s natural setting(s) while they are engaged in their typical daily activities as opposed to testing children in an artificial, decontextualized setting, nonstandardized assessments in early childhood often yield valuable data about a child’s development and functioning. Nonstandardized assessments can be structured or unstructured, but are often relational by nature. For example, observing a child in a classroom setting, data is gathered about their social and emotional development in the context of the setting, and relationships with teachers and same-aged peers. Similarly, a dyadic parent–child observational assessment reveals important information about a child’s attachment behavior, emotional-regulation, self-soothing capacities, and play skills. It also reveals information about caregiver capacities and behavior (often a critical component of infant and early childhood assessment). Nonstandardized assessment procedures (without structured protocols for observation) allow for evaluator judgment and opportunities to assess different aspects of a child or dyad in the moment. For example, an evaluator may choose to play with the child alone, assess the child’s capacity to separate from their caregiver, and observe the child in a play situation with their caregiver. This type of observational assessment can be done both a standardized and nonstandardized manner. It should be noted that in the field of IMH, there are both standardized and nonstandardized observational and dyadic assessments (as discussed in Chaps. 4 and 5). 16 R. Stein et al.

Overview of Chapters

A brief overview of subsequent chapters to help guide the use of this book based on specific reader goals and needs follows: Chapter 2: The art and science of obtaining a history in infant and early childhood mental health assessment. This chapter explains the importance of history gathering for understanding the problems of young children. It proposes a model/ process for gathering developmental, medical, family, environmental, and cultural history that differs from the medical history and physical (H & P) model of history taking. Chapter 3: Caregiver perceptions of the young child: assessment and treatment implications. This chapter explores the parent’s internal working model, their perceptions of the child, theory of mind, and the child’s world. It also examines how a parent’s history affects the relationship focusing on the impact of trauma, intergenerational transmission of parenting, and the parent’s clinical formulation of the problem. Chapter 4: Observational assessments of the dyad. This chapter builds on the previous one, discussing the importance of the relationship and relationship-based assessments. It covers seminal structured and semi-structured observational tools that can be used/adapted for clinical practice such as the ERA and Crowell. Chapter 5: Observational assessments of the young child. This chapter discusses the clinical tools that can be used in an office setting for the psychiatric assessment of a young child. It will discuss the importance of both observation and direct interaction with the child in structured and unstructured ways. It covers the Infant/ Toddler Mental Status Exam (ITMSE) in detail as the core assessment tool. It discusses other useful assessment tools such as the Disruptive Behavior Disorder Observation Scales (DBDOS) as adjuncts to the ITMSE. Attention is paid to concrete logistical issues such as office setup, toys, physical boundaries, and limit setting. Chapter 6: Assessing the inner world of the young child. This chapter addresses interviewing young children using tools such as the MacArthur Story Stems, or any other attachment assessment of the child’s internal working model, as well as describes how to use play to understand the young child’s view of their world. Chapter 7: Rating scales for social-emotional behavior and development. This chapter will cover the use of rating scales and screeners for behavior and cognitive/ developmental assessment of children from infancy through preschool. The chapter will also explain the importance of understanding the developmental level of the young child as part of an assessment. Chapter 8: Diagnosis in young children: the use of the DC:0-5™ diagnostic classification of mental health and developmental disorders in infancy and early childhood. This chapter will review the history of psychiatric diagnosis in children birth through five years. It will discuss the utility and shortcomings of the DSM-V approach and the use of the DC0-3R and DC0-5. It will offer an overview to the DC0-5 with recommendations about how to become proficient in its use and how to bill for services with these diagnoses. 1 Introduction Assessment in Early Childhood 17

Chapter 9: Psychopharmacologic considerations in early childhood. Discussion of the philosophy of medication use in treating young children and guidelines for assessment is included in this chapter. It provides a brief overview and introduction to treatment, appropriate consideration, and use of medications. Chapter 10: Constructing a joint clinical case formulation and treatment plan with families. This chapter highlights the importance of constructing a joint treatment plan with the child’s caregivers. It reviews ways in which to share feedback about each of the sections of the evaluation and obtain consensus and “buy-in” from the caregiver about the nature of the child’s difficulties and the appropriate treatments. It discusses how to handle parental resistance and defensiveness, as well as parental grief and/or denial.

Challenges and Rewards of Assessing Very, Young Children

Setting the affective tone in the assessment of very young children is often a critical element for providing accurate results and yielding positive outcomes for the evaluator, child, and family. There are many obstacles and factors that make developmental and psychological evaluation in early childhood difficult. Among the many challenges to assessing infants, toddlers, and very young children, some of the most significant factors include reliance on caregiver report due to limited verbal communication skills and children’s intrinsically unpredictable states. Because very young children do not have sophisticated verbal communication skills (even if they are developmentally typical), early childhood assessors rely heavily on caregiver report to corroborate behavioral observation and test data. Assessing caregiver accuracy and validity is one of many evaluator qualities (see Table 1.2) to enhance early childhood assessment. Furthermore, if information or a clinical interview is not obtained in advance of the assessment, and a caregiver who is not the primary caregiver brings the child, often information gathering is inaccurate or incomplete. For example the person who brings the child may be unaware of whether the child napped, or the concerns of the primary caregivers. Gaps in information can be det- rimental to the evaluation process and the outcome. Very young children lack the communication skills to explain themselves, making behavioral observations critical to comprehensive assessment, in addition to trusting caregiver report and evaluating its accuracy. Evaluators are often left guessing how a child behaves outside of the evaluation setting with little data to support their hypotheses. Additionally, young children’s moods are unpredictable and their personality and performance are all highly influenced by a myriad of internal and external factors, from dirty diapers to the weather. Their intrinsic unpredictability and ever-changing states, makes accurate, high quality early childhood assessment an art for even the most skilled early childhood professional. Please see Table 1.2 for a list of assessor qualities for optimizing early childhood assessment. 18 R. Stein et al.

Table 1.2 Evaluator qualities for early childhood assessment 1. Manage parental involvement and set expectations at the onset of the assessment 2. Minimize adult conversation/questions by gathering information in advance 3. Ask about the child’s day, routine, and mood before the assessment 4. Establish rapport and create a welcoming, emotionally safe environment for both the caregiver and the child (e.g., unstructured play first before a structured assessment) 5. Balance caregiver report with clinical observation 6. Go the child’s pace (administer standardized items quickly while accounting for slow processing speed and time for a child to warm up) 7. Match the child’s affective style (e.g., shy, slow to warm up versus high energy and inattentive) 8. Be flexible and comfortable improvising, even on standardized evaluation measures 9. Be creative about how to keep a child’s attention, especially as item difficulty increases 10. Have empathy and try to put yourself in the shoes of the caregiver and child

Despite these challenges, there are many rewards to assessing very, young children for the evaluator, child, and family alike. Under optimal conditions, early childhood assessment can be fun, playful, and create a warm and pleasurable environment for everyone involved. With accurate and adequate preparation, children often find evaluations feel like playing, rather than being tested. Caregivers often find that evaluations in early childhood offer another lens into the world of their child, providing a comprehensive and multidimensional perspective of the child they know well. Evaluations may also offer them a deeper look into the internal world of their child, explaining or contextualizing previously misunderstood behavior. For example, a developmental evaluation may reveal that a toddler who is having severe temper tantrums really has significantly delayed receptive and expressive language, making it difficult for them to understand their world or communicate their needs and yielding frustration. Contextualizing the tantrums within delayed communication development and recommending speech therapy may decrease the child’s tantrums and increase parental confidence and competence. Similarly, early detection and identification of developmental delays, sensory differences, problem- solving or play deficits, and making recommendations for early intervention and treatment can prevent long-term difficulties and pathology from persisting or worsening (Table 1.3).

Conclusions

Although this chapter is not exhaustive, it is designed to provide a foundation for the reader to understand infant and young child assessment. This volume, in totality, will allow an appreciation of the intricacies and skills needed to complete a thorough assessment of any infant, young child or family. With a foundational understanding of the origins and historical context of Infant Mental Health theory, in conjunction with strategies and tools for assessing the very young child, the reader will learn practical strategies for successful assessments. 1 Introduction Assessment in Early Childhood 19

Table 1.3 Structural recommendations for early childhood assessment Furniture Developmentally appropriate, adjustable, and supportive chair and table Seating for parents and family members Options for floor play (e.g., mats, blankets, Bumbo seat) Props for physical support (e.g., bolsters, blankets) Lighting Adjustable lighting that adapts to a child’s preference and sensory needs Play materials Offer a range of developmentally appropriate toys that are not part of the evaluation to assist with rapport building and distraction if needed Minimize Turn of computer, keep electronics out of sight distractions Keep both testing items and play toys out of sight and reach

References

AAP Policy Statement. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Itasca, IL: American Academy of Pediatrics. Bowlby, J. (1953). Childcare and the growth of love. London: Penguin Books. Bowlby, J. (1969). Attachment. New York, NY: Basic Books. De Villiers, J., & Davidson, T. (2016). Language development. In D. S. Blanchfield (Ed.),The Gale encyclopedia of children’s health: Infancy through adolescence, Vol. 3 (3rd ed., pp. 1576– 1583). Farmington Hills, MI: Gale. Fitzgerald, H. E., Weatherston, D., & Mann, T. L. (2011). Infant mental health: An interdisciplinary framework for early social and emotional development. Current Problems in Pediatric Adolescent Health Care, 41, 178–182. Fraiberg, S. (1980). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. In S. Fraiberg (Ed.), Clinical studies in infant mental health. New York, NY: Basic Books. Freud, A. (1983). CBE (1895–1982). Journal of Child Psychology and Psychiatry, 24, 333–338. https://doi.org/10.1111/j.1469-7610.1983.tb00114.x Holmes, J. (2014). John Bowlby and attachment theory. New York, NY: Routledge. Hughes, D. (2003). Correlates of African American and Latino Parents’ messages to children about ethnicity and race: a comparative study of racial socialization. American Journal of Community Psychology, 31(1/2), 15–33. Institute of Medicine. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: The National Academies Press. https://doi.org/10.17226/9824 Knudsen, E. I. (2004). Sensitive periods in the development of the brain and behavior. Journal of Cognitive Neuroscience, 16, 1412–1425. National Scientific Council on the Developing Child. (2010).Early experiences can alter gene expression and affect long-term development: Working paper no. 10. Retrieved March 7, 2015, from www.developingchild.harvard.edu Rathus, S. A. (2008). Childhood and adolescence: Voyages in development. Belmont, CA: Thomson Wadsworth. Rogoff, B. (2003). The culture and nature of human development. New York, NY: Oxford University Press. Sameroff, A. J., & Fiese, B. H. (2000). Models of development and developmental risk. In C. H. Zeanah (Ed.), The handbook of infant mental health. New York, NY: Guilford Press. Shonkoff, J. P. (2017). Breakthrough impacts: What science tells us about supporting early childhood development. Young Children, 72(2), 8–16. 20 R. Stein et al.

Shonkoff, J. P., Siegel, B. S., Garner, A. S., Dobbins, M. I., Earls, M. F., & McGuinn, L. (2012). The lifelong effect of early childhood adversity and toxic stress. Pediatrics, 129(1), 232–246. Weatherston, D. J. (2000). The infant mental health specialist. Washington, DC: Zero to Three. Winnicott, D. W. (1953). Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34, 89–97. World Association for Infant Mental Health, Tampere, Finland. (2017). Retrieved September 18, 2017, from https://www.waimh.org/i4a/pages/index.cfm?pageid=3289 Zeanah, C. H. (2009). The handbook of infant mental health. New York, NY: Guilford Press. Zeanah, C. H., & Boris, N. W. (2000). In C. H. Zeanah (Ed.),. Handbook of infant mental health Disturbances and disorders of attachment in early childhood. New York, NY: The Guilford Press. Zeanah, P., Stafford, B., & Zeanah, C. (2005). Clinical interventions to enhance infant mental health: A selective review. Los Angeles, CA: National Center for Infant and Early Childhood Healthy Policy at UCLA. ZERO TO THREE. (2017). Infant and early childhood mental health. Washington, DC: ZERO TO THREE. Retrieved September 18, 2017, from https://www.zerotothree.org/early-development/ infant-and-early-childhood-mental-health Chapter 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental Health Assessment

Gerard Costa and Carmen Rosa Noroña

Background

There is common agreement in the field of infant and early childhood mental health that the assessment of very young children’s emotional, behavioral, relational, and developmental difficulties should involve a multifaceted, multilayered, and multidisciplinary framework (Close, 1999; Lieberman & Van Horn, 2008; Thomas, 1998; ZERO TO THREE/National Center for Clinical Infant Programs, 1994). Such a framework allows for the exploration and identification of strengths, risks, and etio- logical considerations in the child, caregivers, the caregiver-child relationship, and the family’s ecological context. This context includes socioeconomic, cultural, and historical factors affecting the family’s functioning, and shaping the caregivers’ child development expectations and perceptions as well as child-rearing values and practices (Gilliam & Mayes, 2005; Lewis & Ghosh Ippen, 2004; Lieberman, 1990; Lieberman & Van Horn, 2004; Lieberman & Van Horn, 2008; ZERO TO THREE/ National Center for Clinical Infant Programs, 1994). Assessment also offers an approach to understanding and formulating, in collaboration with the family, the child’s and family’s difficulties as well as a pathway to early intervention, healthier functioning, and increased hope (Close, 1999; Lieberman, Ghosh Ippen, & Van Horn, 2015; Mares & Graeff-Martins, 2012). Fundamentally, in addition to determining whether or not clinical disorders are present, a comprehensive assessment should provide preliminary information about the child’s patterns of functioning in major areas of development (cognitive,

G. Costa (*) Center for Autism and Early Childhood Mental Health, College of Education and Human Services, Montclair State University, Montclair, NJ, USA e-mail: [email protected] C. R. Noroña Boston Medical Center, Child Witness to Violence, Boston, MA, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 21 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_2 22 G. Costa and C. R. Noroña language-communication, social-relational, emotional, motor, and physical), and the impact of the different areas assessed (family relationships, constitutional- maturational patterns, stress, interactive patterns, caregivers’ functioning) on the child’s vulnerabilities and strengths. It should provide guidance for the development of a treatment plan and preliminary intervention to address the child’s difficulties, the caregivers’ implicit and explicit expectations and to consequently enhance the caregiver’s sense of competence and reflective capacity and the child–parent relationship (Thomas, 1998; ZERO TO THREE, 2016). The ultimate goal is to support the child and his/her caregiver’s optimal development. It follows that treatment planning and intervention with young children and their families cannot be developed and implemented without a comprehensive understanding of the child’s functioning in all developmental domains, the child’s relationships, the caregivers’ functioning and the impact of the ecological context surrounding the child and his family or caregivers (ZERO TO THREE, 2016). “The process of assessment, of listening and observing, and of asking questions, allows clinicians and parents to begin to develop a clear and focused understanding of the core of the problem or problems underlying the family’s presentation.” (Mares & Graeff-Martins, 2012, p. 7, italics added for emphasis). Ideally the assessment process should integrate information from multiple sources and therefore have different components (see Chap. 10). These include the following: • Primary caregivers’/parents’/family’s interviews. • Observations of child’s play and interactions in different settings (home, childcare), child–primary caregiver relationships and patterns of interaction, family and parental dynamics. • Standardized or normed tests, scales, protocols. • Child developmental and sensorimotor assessments. • Reports from referring agency and other services or collaterals involved with the family (pediatrician, child-care provider) (Lieberman & Van Horn, 2008; Mares & Graeff-Martins, 2012; von Klitzing, Döhnert, Kroll, & Grube, 2015; ZERO TO THREE, 2016). Other sources of information may include written reports of past interventions or assessments, review of records and the clinician’s countertransferential response to the family’s and child’s presentation (Mares & Graeff-Martins, 2012). Developing a partnership with primary caregivers during the assessment process is essential given that: • Young children are unable to provide information on their difficulties. • They depend so much on their primary figures. • They perform better in the company of familiar adults (Gilliam & Mayes, 2005). • Development happens in the context of relationships (Lieberman & Van Horn, 2008; National Scientific Council of the Developing Child, 2004). Caregivers represent not only sources of information but also have a powerful impact on their children’s mental health (Gilliam & Mayes, 2005; Lieberman & Van 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 23

Horn, 2008). Coming in for an infant/early childhood evaluation can constitute a moment of great vulnerability for many families as fantasies and anxieties about their child being damaged and feelings associated with guilt, fear, and incompe- tence in the caregivers may arise. Therefore, every stage of the assessment process must contribute to the construction of a collaborative, informative, containing, nonjudgmental, and benevolent space (Lieberman, Ghosh Ippen, & Van Horn, 2015; Mâle, Doumic-Girard, Benhamou, & Schott, 1975) that facilitates the alliance between the practitioner and the family. The interview process is central in setting the tone for this space (Gilliam & Mayes, 2005; Mâle et al., 1975). As mentioned above the caregiver interview should be part of a multilayered and seamless approach in the assessment process; however, for the purposes of this chapter the interview will be discussed separately.

The Narrative Process

There is a fictional story in which a woman is walking down the street and witnesses a man suddenly fall out of a window. She immediately runs to him and asks, “What happened?” to which he replies, “I don’t know. I just got here!” There is much to learn about history-taking from this story—especially when the informants are infants, toddlers, young children, and their families. Like the woman who ran to the man, we practitioners usually “arrive” when something has befallen a child and family after some untoward event or a long history of events. Like the man who has fallen, the child or family may not fully understand what led them to “get here.” In fact, when the problem has to do with challenges in the infant–parent relationship, Trout (1989) notes that parents have cultural and intrapsychic barriers that make it difficult for them to “tell” the practitioner “where it hurts” and what befell them. The barriers are cultural because society places great emphasis on the importance of parenting, and parents often feel guilt and shame when they must seek mental health assessment and intervention for themselves or their children. Families experience stigma around mental health difficulties, notably as parents and in their children, who are the most intense “representations” of themselves. The barriers are also intrapsychic, because the reasons why a caregiver may struggle—a history of adverse experiences, victim of abuse and neglect, anxiety and depression, trauma, racism and discrimination, emotional and economic hard- ships—are not easily discussed. This is partly related to the difficulty we humans have in being objective about our own experiences. Gorden (1980/1987) identified the goal of interviewing as maximizing the “flow of relevant information” (1980, p. 88), but certain variables can serve to “facilitate” (p. 107) or “inhibit” (p. 88) that flow. Among inhibitors he identified, two are relevant here: “ego threat,” where information that may threaten a person’s self-esteem may be withheld, and “trauma” which can lead a person to avoid or repress the unpleasant retelling of frightening or overwhelming experiences. 24 G. Costa and C. R. Noroña

In the infant mental health history-taking process, the professional meets a family for the first time as he/she attempts to learn about them in the here and now (the “end”) by learning about the journey that lead them to us (the “beginning”). We encounter a family in crisis, and it is around that crisis that we meet them, not at their “best,” when they are fully functioning. In this regard, a helpful notion in history-taking is to view it as the start of crafting a principled, respectful narrative about the infant, child and family we hope to help. As noted earlier, this is a moment of great vulnerability, but also great opportunity—to be heard and supported. The interviewer, like staff in a hospital emergency room, can develop a skewed sense of human functioning when families are often met in crises. The history-taker must take stock of his/her inner landscape, a reflective process that will be examined. The goal at the end of the history-taking is a collaboratively developed formulation with the family about the central areas of concern and a strategy to move forward (see Chap. 10). This reminds us that the goal is not to gather as much information as possible, but to share what is needed to create an alliance, a shared understanding of, and empathy for the family’s experience, and a plan for next steps—further interviews, assessment, and/or therapeutic recommendations. Using an IMH perspective, Fraiberg (1980) spoke of three domains of interest: the developmental status of the child, the adequacy of the parent, and the nature of the relationship. Keep this in mind throughout the interview process.

The Caregiver/Family Interview and Taking a History

Despite the cultural and intrapsychic difficulties in identifying and sharing the nature of the family’s difficulties, much of the information regarding the infant and young child’s daily functioning and their relational, sociocultural, and historical contexts, must come from primary caregivers as usually these are the people who are most familiar with the child’s and family’s past and current functioning. To gather this information caregivers are interviewed at the beginning of the assessment process. Depending on the needs of the family, the setting, and the goals of the assessment, the initial interview can be conducted with the caregivers and the young child or only with the caregivers and can take more than one session. Interviewing primary caregivers or family members is usually one of the first steps and one of the core components of a comprehensive and effective infant and early childhood mental health assessment. These options will be reviewed in later sections. At a practical level the interview process allows the practitioner to: • Explore the caregivers’ explicit and implicit concerns including their understanding of the reason for referral, expectations of the provider, and the impact of the child’s difficulties on the caregivers, the relationship between caregivers, and the family. • Obtain a history of the child’s past and current functioning (including strengths and vulnerabilities) in the context of the family. 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 25

• Obtain a history of the caregivers’ family of origin and early childhood experiences to begin developing an understanding of how these have shaped their view of themselves and of their child’s behavior. • Gather a picture of the family constellation and their biopsychosocial functioning in the home, community, and their sociocultural context. • Gather family history on medical, developmental and mental health disorders that may be environmentally or genetically based which can aid in understanding the child’s symptoms. • Conduct an initial observation of the child and the caregiver interaction through unstructured play (King, 1997; Mares & Graeff-Martins, 2012; Thomas, 1998; Trout, 1989). As mentioned earlier, the goals of the interview and history-taking are not only to gather information but to form a therapeutic relationship where the child’s and caregiver’s difficulties are collaboratively understood by the practitioner and the caregivers, and there is progress in planning to address them. From the very early moments, relationship-building and information-gathering are mutually dependent (Seligman, 2005). “Whether a family is seen only once or the initial meeting is the first in a series of ongoing contacts, the process of developing a therapeutic alliance runs parallel to and determines success in eliciting facts of the history” (Mares & Graeff-Martins, 2012, p. 7). Taking a history should use a strengths-based approach where the focus is not only on the child’s symptoms and the family’s challenges but also highlighting and helping caregivers and the interviewer to identify areas of resiliency and adaptability in the child and family. Ten core skills, needed to support the history-taker, should be cultivated: • Allowing the caregivers to share their story from whatever point they can while maintaining a stance of benevolent neutrality (Mâle et al., 1975) where the practitioner suspends judgment or the desire to fix, protect, control, or “out-parent” the parent. • Using directive questions only as prompts to clarify. • Containing the amount of information shared to protect the caregivers’ and child’s psychological integrity and safety while validating their experience and story. • Listening for affect as well as for content, and noting shifts in the first when juxtaposed to the second (Trout, 1989). • Redirecting and reframing meanings to promote protectiveness, empathy, trust, and hope (Lieberman & Van Horn, 2004, 2005). • Providing well-timed developmental guidance (Lieberman & Van Horn, 2004, 2005). • Using self-reflection to increase awareness of the impact of the story on the practitioner, and of the practitioner’s beliefs and values on his/her stance and to increase the capacity to deeply listen rather than acting. • Being constantly aware of the tension between the need to gather information for clinical formulation and treatment planning and the family’s/caregivers’ sense of timing in sharing difficult information regarding themselves and/or their child (Lieberman et al., 2015). 26 G. Costa and C. R. Noroña

• Using clinical judgment to share information that the clinician might have gathered from other resources regarding the reason for concern (Lieberman et al., 2015). • Maintaining a calm but engaged reflective interest that can serve to curb intense affect in the family and difficulties in the child–parent relationship, and create a space for caregiver’s reflective thinking that can potentially reduce levels of stress and that can help to identify new strategies to address and manage challenges. These skills are not simply “knowledge” and “technique”-based, but involve a way of “being” with the family. This conceptualization of how the practitioner should be trained—what Costa (e.g., Costa, 2015; Costa & Mulcahy, 2015; Costa, Mulcahy, DiBella, Sullivan, & Haddock, 2016) refers to as “Formation”—addresses three interrelated “ways”: knowing, doing, and being. In this framework, “being” is emphasized as not only the most critical, and often least addressed, but as the aspect of the interpersonal process that infants, children, and families experience initially and most powerfully. Therefore, the interview is not guided only by understanding the family’s story, and being a skilled interviewed, but by creating a helping relationship. The open, reflective, non-judgmental, respectful, professional stance of the provider can communicate hope for the caregivers and transmit to them an increased possibility of having greater empathy and benevolence for their children and give new meanings to their challenging behaviors and symptoms (Lieberman et al., 2015; Mâle et al., 1975; Seligman, 2005). Caregiver–family interviews encompassing what has been described above can serve as brief interventions, in and of themselves, especially in cases where the family’s circumstances impede participation in extended assessments or treatment (Lieberman & Van Horn, 2008). The process of taking a history has been described as science and art. The way in which the practitioner conducts himself/herself must be guided by knowledge of the developmental sciences, but also by moment-to-moment judgements about where to lead, or not lead, the inquiry and when silence or pursuit is warranted. The unfolding process of the interview does not following a standardized course. In this initial part of the assessment process, how the interviewer responds to the needs of the child and the caregivers and to clinical questions and challenges that arise, will influence the family’s engagement in the remainder of the assessment and in treatment (Gilliam & Mayes, 2005; Lieberman et al., 2015; Mâle et al., 1975). The information gained during the interview process can help “the clinician and parents together to organize and understand the experience of the family in order to construct a narrative or ‘story’ and account of the family’s experience with the child.” (Mares & Graeff-Martins, 2012, p. 7). In this way, the family feels validated, heard, and consequently capable of caring for their young child and the process of taking a history can have a therapeutic effect. History-taking initial interviews represent the foundation of a process that ideally creates a space where the family and the practitioner co-construct, in time, a new understanding about the meaning and character of the child’s and family’s difficulties and a pathway for intervention and recovery (Mares & Graeff-Martins, 2012). 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 27

Artificial Distinction Between Taking a History, Conducting Assessment, and Treatment

The act and process of meeting a family for the first time and beginning to gather information, are the start of the therapeutic process. The process of conducting an interview and comprehensive evaluation in infant mental health, is recommended as best conducted over 3–6 sessions (e.g., Fraiberg, 1980; ZTT, 2016). Within this framework, the history-taking process is considered as the first encounter following the referral. Through the eyes of the infant or young child, child, and family, those practitioners with whom they meet for the first meeting(s) signal the start of engagement. In some practices and organizations, the same practitioner will meet the family, gather a history, conduct an assessment, and provide therapeutic services. In other organizations, the “intake” process in which identifying and background information are gathered, may be conducted by someone other than the treating clinician. One advantage of that process is that several team members can meet the family and share impressions, understandings, and insights and that the team “holds” each family. The principal disadvantage is that the alliance that begins to form when families begin to talk about themselves and tell their “story” becomes fragmented, and may feel impersonal. Organizations can develop procedures to minimize this by having clearly explained procedures and personal “hand-offs” when it is determined that a family move from the initial meetings to subsequent assessment and treatment phases. In this chapter the history-taking, assessment, and treatment phases are regarded as an integrated, seamless process. Most practitioners understand this process and recognize that empathic listening, necessary during history-taking, offers many families some therapeutic support in and of itself. The clinical interview constitutes the fabric of the history-taking process. While other chapters in this volume describe the comprehensive evaluation process, this chapter describes a framework, suggested practices, and strategies for taking a history in the field of infant and early childhood mental health.

Consideration on Trauma in the History-Taking

The multidimensional approach needed in the assessment of infants and young children is particularly relevant to the assessment of the impact of traumatic events. The child’s responses are influenced by developmental stage, overall functioning, availability of responsive caregivers, and environmental resources and stressors. Despite the prevalence of traumatic events in the lives of very young children, there is no consistent assessment protocol of child exposure. According to Lieberman et al., 2015, “early childhood mental health interventions do not usually include a systematic exploration and assessment of child exposure to traumatic events and continues to focus largely on enhancing the quality of the parent–child interactions and 28 G. Costa and C. R. Noroña promoting secure attachment” (p. 2). Reflecting principles of trauma-informed practice as well as the recommendations discussed in this chapter, the first interview is an ideal setting for sensitive exploration about exposure to traumatic events in infants/young children and their families. (Refer to Fig. 2.1, which provides suggested domains of inquiry regarding traumatic exposure in infants and young children in the context of history-taking.) Note that although Fig. 2.1 contains sections at the end on diagnostic impressions and clinical formulation, these are included as reminders of the practical and clinical benefits of these processes, but the history- taker likely will not have sufficient information and data to complete those sections.

Setting Up the Interview and History-Taking Process

First Contact: Introductions and Engagement

Prior to the encounter, either the practitioner or a colleague has likely made contact with the family and scheduled the appointment. Providers vary as to the number of visits that will be planned, and while a 3–6 session plan is recommended in the field of infant and early childhood mental health, some providers and organizations may adhere to a shorter time frame due to limitations in staff and financial resources. While providers vary in how the first meeting is “choreographed,” it is recommended that for the first meeting, the caregiver(s) and family, as well as others the family wishes to include, be invited to the meeting. If only one such meeting is allotted, it is suggested that the family determine who is to come, that the infant/ child be present, and that time be allotted to meet with the parent(s) alone, to explore sensitive material. However, in cases where it is readily apparent that sensitive material emerges, the practitioner can model a protective stance and request a separate time with the caregiver to explore the difficult material, whether by phone or in person. Additionally, if the referral material indicates that the family has experienced trauma, the first session should be arranged only with the primary caregivers. In matters of domestic violence, and the survivor wishes to bring the abuser to the session, it is recommended that the abuser and survivor not meet together. As a practical matter, and as a way of conveying the centrality of the infant–parent relationship, the practitioner should have “baby” items available and visible: infant toys, Handi Wipes, diaper-changing area, infant seat or even a crib (baby “décor”), etc., all signs that babies “are welcome.” Process aside, the first meeting is also a time when the practitioner will offer a brief overview of what will happen in the session, how it fits into what will come next, and what the goals are of all of the planned encounters. The anticipated outcomes are: understanding what brought them to services, and developing a collaborative plan for assessment (if needed) and intervention. 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 29

This "Infant-child-family profile" is adapted from an unpublished guide first developed by Gerard Costa, in 1997.

Date of Profile:

Completed by:

Principal Staff Member:

Instructions:

This is an outline of the areas of information to consider about our work with families. This should not be used as an interview guide or as an intake form, but as a way of conceptualizing the collection of information, and organizing our work, conversations and respectful sharing about an infant/child/family.

Identifying Information

Infant’s/Child’s Name______DOB______

Chronological Age______If Premature, Adjusted Age______(up to age 2 years)

Gender at birth ______Current Gender______

Address______

Name on Mailbox______Phone______

Geographical Markers (for home visit)______

Parent/Caregiver’s Name______Parent/Caregiver’s Name______

Gender at Birth_____Current Gender_____ Gender at Birth____Current Gender______

Address______Address______

Phone______Phone______

Involvement______Involvement______

Marital Relationship______

Living Arrangements______

Other Guardian (s)______Specify Relationship(s)______

Siblings/Children in Home: Note relationship to child (e.g .full, half, adoptive, foster, etc.)

Child Relationship DOB Mother/Father Residence

Fig. 2.1 Infant-child-family profile 30 G. Costa and C. R. Noroña

Race/Ethnic/Socio-Cultural Description (per the caregiver’s/parent description)

______

Primary Language(s) spoken in the home

______

Preferred Language/s:

Caregiver/s:

Child:

Special Ethnic/Cultural Considerations: (Gender roles, guidelines regarding eye contact or shaking hands, etc.) ______

Collateral Agencies (e.g. CPS, Educational, Early Intervention, etc.) ______

Reasons for Involvement and how the caregiver/family understands the reason for involvement

______

Source of Referral______

Contact______

Status of Infant/Child/Family

Reason for Referral/Presenting Problem

______

Prior Evaluations/Diagnoses -Multidisciplinary

______

Current Problem/Concern of Staff

______

Current Problem/Concern of Caregivers/Family (How they understand thereason for referral? Do they agree with it? What are they concerned about?) ______

Fig. 2.1 (continued) 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 31

Below is a list of common concerns in early childhood. Children’s developmental stag e should be taken into consideration for each of these items (e.g. it is developmentally appropriate for a 12 month old to have short attention span)

AREAS OF CONCERN

What brings child for What is caregiver most Intensity Frequency Consultation/Treatment concerned about? (Related to all (Related to all (Check all that apply) (Check only one) concerns in concerns in general) general)

☐ Not meeting expected ☐ Not meeting expected ☐ Problems have ☐ Once a developmental milestones developmental milestones increased over week time since last ☐ Relational concerns ☐ Relational concerns incident? ☐ 2-4 times/week ☐ Eating difficulties ☐ Eating difficulties ☐ Problems have decreased over ☐ Daily ☐ ☐ Sleep problems (e.g., Sleep problems (e.g., time since last sleep disrupted; sleep disrupted; incident? nightmares) nightmares)

☐ Intense crying/temper ☐ Intense crying/temper ☐ Problems Comments: tantrums, difficult to tantrums, difficult to remain the same soothe soothe since last incident?

☐ Upset by noise, smells, ☐ Upset by noise, smells, Comments: touch, tastes, open/busy touch, tastes, open/busy spaces spaces

☐ Self-harming/head ☐ Self-harming/head banging banging

☐ Excessive self- ☐ Excessive self- soothing/masturbating soothing/masturbating

☐ Excessively quiet and ☐ Excessively quiet and withdrawn withdrawn

☐ Space-out / ☐ Space-out / Detachment Detachment

☐ Intense separation ☐ Intense separation anxiety, overly clingy anxiety, over clingy

☐ Intense Fears ☐ Intense Fears

☐ Hypervigilant/ startling ☐ Hypervigilant/ startling easily easily

☐ Depressive mood/Very ☐ Depressive mood/Very sad sad

☐ Sudden mood changes ☐ Sudden mood changes

Fig. 2.1 (continued) 32 G. Costa and C. R. Noroña

☐ Aggression/ ☐ Aggression/

☐ Demanding/Controlling ☐ Demanding/Controlling

☐ Defiant/Not listening ☐ Defiant/Not listening

☐ Overly- ☐ Overly- compliant/submissive compliant/submissive

☐ Regressive behaviors ☐ Regressive behaviors

☐ Low ☐ Low attention/concentration Attention/concentration

☐ Overactive ☐ Overactive

☐ Reckless, prone to ☐ Reckless, prone to accidents accidents

☐ Somatic Complaints ☐ Somatic Complaints

☐ Other______☐ Other______

Comments: Comments:

Overall physical health of child (height, weight, integrity, illnesses, progress/regress, etc.)

______

Current Description of Child and Developmental Status

______

Level of Emotional Development (Impression)

______

Sensory Problems/ Special Sensitivities (Sensory-based difficulties/regulatory problems, etc.)

______

Fig. 2.1 (continued) 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 33

Trauma Exposure: The following are prompts to assist you in exploring with the family about child and family exposure to traumatic stressors. It is important first to explore what are the caregivers’/family’s perceptions and ideas about the words “trauma” or “traumatic exposure” and include their words/language as you are inquiring about potential traumatic stressors affecting the child and family. Also consider both direct witnessing of an event as well as “exposure”, meaning that a child may have been exposed to sounds, smells, movements, etc. associated with an event, or may have heard about an event that happened to other, particularly those close to him (e.g. an uncle being killed).

Has anything scary or unsafe happened to the child and/or the caregivers/parents/ or other family members with whom the child and/or the caregiver/s are close to?

______

Has the child ever witnessed a scary event in the neighborhood or at home?

(if the answer is yes, continue with the next section)

Yes______No______

These describe the nature of the traumatic event/s the child has experienced/witnessed:

a. Type of Traumatic Event :

☐ Child abuse (physical) ☐ Child abuse (sexual) ☐ Neglect ☐ Domestic Violence ☐ Community Violence ☐ School Violence ☐ Loss or separation of a loved one ☐ Animal Attack ☐ Serious illness; invasive medical procedures ☐ Racial trauma ☐Immigration trauma ☐ Natural disaster ☐ War/political-related violence ☐ Other______

b. Frequency of Exposure:

☐ Single Exposure (e.g. one experience)

☐ Chronic Exposure (e.g. different experiences or same type of violence repeated during a period of time).

☐ Complex: (e.g. chronic, interpersonal trauma; varied and multiple traumas; early onset; often by trusted caregivers)

1. If Single Exposure (Describe): (Suggested questions/prompts for the caregiver) a) What happened and where was the child? b) What do you think your child saw, heard or experienced? c) What was the child’s initial response? d) What do you think the worst part of the incident was for your child? e) How do you think your child understands what happened? (If I were to ask your child about the incident/that day, what would he/she said?). (This prompt would require the child to have language so you need to take into consideration the child’s developmental stage) f) Have you or anyone in the family have talked with your child about the incident/ that day? g) What have you told him/her?

Fig. 2.1 (continued) 34 G. Costa and C. R. Noroña

2. If Chronic/ Complex Exposure (Describe): (Suggested questions/prompts for the caregiver)

a) Age at time of first exposure? ______b) Duration of exposure? ☐ 6 months ☐ 1 year ☐ 2 years 3 years ☐ 4 years ☐ 5 years ☐ >5 years ☐ Don’t know c) What do you think was the most impactful /most difficult experience for your child? d) What do you think your child has seen, heard or experienced? e) How do you think it has impacted/affected your child? f) How do you think your child understands what happened? (If I were to ask your child about the incident that day, what would he/she say?). (This prompt would require the child to have language so you need to take into consideration the child’s developmental stage) g) Have you or anyone in the family have talked with your child about what you identify as the most difficult event in your child’s/ your family’s life? What have you told him/her?

How would the caregivers/family members like to be helped? What would the family members/caregivers like help with? (In their own words)

______

Pregnancy

Planned? (Be sensitive and aware of the fact that a pregnancy may be the result of rape perpetrated by partners, family members, or strangers)______

When discovered?______

Reaction?______

Abortion considered or Performed?

______

Level of prenatal care ______

Consider these areas of inquiry. Do not ask questions only, but be attuned of ways to learn about them:

- Prior pregnancies, miscarriages, losses - Parental Wishes - First feelings about pregnancy - Responses of other family members - Change in lives because of pregnancy - Body image changes - Childbirth education - Scares during pregnancy - Decisions about childbirth and delivery - Labor and delivery circumstances - Who was present during labor and delivery? - Birth experience - Name choosing conversations - Fantasies/special wishes/fears about baby (e.g., gender, appearance, attributes, etc.) - FIRST FEELINGS: How did baby seem? Who did the baby remind caregiver of? Who did the baby look like? ( Zeanah, Benoit, & Barton, 1993) - Homecoming - Reactions of siblings

Fig. 2.1 (continued) 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 35

- Joys/disappointments during first weeks - Health of baby - Early concerns/discovery about problems

Infancy/Early Childhood

NOTE: Consider the unique cultural context of the family and how that might lead to differences regarding developmental and behavioral expectations.

Principal Caregiver______

Other caregivers in early development______

Separations/ moves/ losses ______

Feeding and Eating routines:

-Breast-fed/formula -Difficulties/disappointments regarding lactation and feeding -Response to feeding routines -Growth patterns -Special circumstances -Eating/digestive problems -Preferences/sensitivities Sleep routines:

-With whom did child sleep? -Overall pattern of sleep/wake cycle -Routines for sleep -Special objects/persons for sleep -Sleep problems/nightmares/night terrors -Schedule

Emotional Issues:

-Attachment qualities -Socialization/Peer Relationships -Play and imagination -Language/communication -Problems in self-regulation -Self-help -Aggression/Impulse problems -Depression/Mood -Relatedness -Attention/Activity -Destructive -Physical/Sexual/Emotional Abuse -Toileting -Fears/anxieties -Comfort/soothing patterns; Coping style -Preferences-persons, objects, activities -Transitions -Reactions to separations -Temperament/Style -Range of Emotional Expressions

Fig. 2.1 (continued) 36 G. Costa and C. R. Noroña

Child’s strengths/protective factors:

______

Parent as Caregiver and Infant-Parent Relationship

Parental Emotional Well-Being

______

Level of Attunement -(Reciprocity, mutual signaling, “Match”, “Fit”)

______

Nature and Quality of Infant-Parent Relationship (Mutual satisfaction/joy, “games”, moment-to moment “dance”)

______

“Language of Interaction” -(Touch/movement/position, Vocal, Verbal)(Trout, 1989)

______

Preferred Emotional Theme(s) for Parent (e.g. more comfortable with nurturance vs. discipline)

______

Strengths and Protective Factors

______

Environment and Family Context

Nature and Adequacy of housing and living arrangements/socio-economic circumstances including history of changes of socio-economic status due to separation, divorce, immigration

______

Contact with Grandparents/Extended Family/Others in “family circle” including transnational relationships (via social media, narratives)

______

Fig. 2.1 (continued) 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 37

Ethnic/Socio-Cultural Considerations

______

Legal/Immigration Issues

______

Family Background (3 Generation Genogram)

Grandparents

Parents/aunts/uncles/cousins

Child/siblings

Family Themes (Cycles over generations: e.g. abandonment, abuse, family roles/reputations, stories, history of oppression/inequity/racism, immigration/displacement, historical trauma, etc.)

______

Family Myths/Beliefs/Rituals(Multigenerational family “stories”)

______

Religious/Spiritual Beliefs/Practices/Affiliations

______

Support Systems and Strengths

______

Fig. 2.1 (continued) 38 G. Costa and C. R. Noroña

Summary

Diagnostic Impressions (DC:0-5/ICD-10/DSM 5)

______

Integrated Clinical Formulation

______

Recommendations

______

Note: Figure 2.1, the “Infant-Child-Family Profile” was adapted from the “Infant-Child-Family Case Profile” developed by Gerard Costa, 1997, 2010,and the “Child Witness to Violence Intake Assessment Form” developed by Michelle Acker,Carmen Rosa Noroña, Marta Casas and the Child Witness to Violence Project (CWVP), 2000, 2009, 2013.

Fig. 2.1 (continued)

Setting the Therapeutic Frame

This first session should include legal and practical information. A central aspect of this session is to clarify and establish the legal, practical, and administrative parameters of the process. Prior to conducting the interview, it is important for the provider to share with the caregivers how the information they provide will be used. The provider should also discuss confidentiality and its limits, mandated reporting requirements, child’s and caregiver’s rights to privacy and its limits, and consent to provide services and exchange information with collateral agencies. Consent forms and releases of information and other pertinent paperwork to protect the caregivers’ and child’s rights (including the caregivers’ consent for their and their child’s assessment) should be explained thoroughly by the provider and if caregiver is in agreement, dated and signed. Policies and mandates regarding these issues may vary from state to state. If the caregivers/family has limited fluency in English or identifies another language as their primary language, the forms should be presented to the family in this language. Offering linguistically appropriate translation services to clients is a mandate in health-care organizations receiving federal funding (US Department of Health and Human Services, 2001) and organizations in general should strive to uphold these standards (Fontes, 2005; St. John, Thomas, & Noroña, 2012) given the cultural and linguistic diversity of families with young children in 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 39 the USA. The diversity among individuals and families in society is also reflected in a move away from binary views of gender and family structure. This is reflected in the “infant–child–family profile” (Fig. 2.1), where information about caregivers is not categorized as binary (mother/father). Similarly, the gathering of information about an individual’s gender reflects the LBGTQ (lesbian, bisexual, gay, trans- gender, and questioning) community’s insistence on respecting diversity and individuality. The provider should review with the family the reason for referral, explore their perceptions and ideas about the reason for referral, what they know about the services being offered, whether or not they have prepared the child for the visit and what the child has been told. The provider then should clarify any misconceptions or answer any questions the caregivers may have about the services and provide clear and simple information about what the assessment process (including initial interviews) will entail, where it will take place, who will participate in it and how long would it take. The provider furnishes information on fees and in collaboration with the caregivers establishes a schedule for the sessions. If the young child is part of the first interview, the provider shares developmentally appropriate information about the reason for referral and her role (e.g., “Your mommy and you are here today because mommy is concerned about you because she says that you are afraid all the time and that you are having a hard time staying at school (child care) when mommy leaves for work. She thinks that you are having a hard time because you are missing daddy. My name is _____ and I am a clinician/provider/doctor/psycho- therapist which means that I am someone who help kids and their parents with their worries and their big feelings so they can feel better and understand each other better. Mommy and I are going to see each other a few times and I might see you again too so we can understand how to help you feel better”).

Reason for Referral

During the interview, the provider explores with the caregivers their perceptions feelings and ideas about the referral. King (1997) notes that a key element early in the interview is to clarify the social context and reasons for referral, discerning who is concerned about the child and why. It is important to determine if the referral originated with the caregivers or with other adults in the child’s life (e.g., pediatrician, early intervention provider) and whether or not the caregivers agree with the referral.

Presenting Problem

The caregivers’ interview not only provides information about the child’s functioning and the caregivers’ attitudes towards the referral and the assessment process but also helps to unveil the meaning and impact of the child’s symptoms on the family. 40 G. Costa and C. R. Noroña

The meaning, function, and clinical implications of the symptoms might be different depending on the child, family, and the sociocultural context. Therefore, it is important to explore the caregiver’s/family’s perceptions of the child’s behavior and motivations (Seligman, 2005): How do the family members understand and describe the child’s current problem? (Note: make note of their words in describing the problem) What are the attitudes of the caregivers, others and the child towards it? What is the emotional experience in the child and family members? How much distress is it causing? Do family members need to make significant accommodations to manage the child’s symptoms? In order to determine the degree of functional impairment that the current problem is causing on the child, it is important to determine: When did the child’s difficulties appear? Have they happened before? Was there any event that precipitated the difficulties? Why is the family seeking help now? Did they seek help in the past? What have they tried and was it helpful?

Family/Caregiver History

The infant and young child’s mental health and overall functioning cannot be considered outside the context of the primary relationships and the ecology of the family (Lieberman et al., 2015; ZERO TO THREE, 2016). Therefore, in order to understand the child’s and family’s difficulties, strengths and vulnerabilities it is important to first pay attention to and understand the unique outcomes and narratives, for each child and family, that result from the interplay between (1) the history and quality of relationships in the immediate family, (2) the history and quality of relationships of the primary caregivers’ families of origin, and (3) current and past sociocultural, political, and historical factors relevant to the child, the caregivers, the caregivers’ families of origin and cultural groups (Lieberman et al., 2015; ZERO TO THREE, 2016). Moreover, for the process of taking a history (of child– caregiver relationship, family relationships, and overall child and family functioning), to be truly inclusive of all families and respectful of each family’s unique story, it should be rooted in a diversity-informed framework (St. John et al., 2012). This approach allows the practitioner an in-depth exploration and reflection of how the cultural and socioeconomic context, the experiences of systemic and structural inequities and historical trauma have influenced the family’s identity, quality of relationships, and overall functioning (Comas-Diaz, Lykes, & Alarcón, 1998; Lewis & Ghosh Ippen, 2004; Lewis, Noroña, McConnico, & Thomas, 2013). The sociocultural and historical context is related to the child and caregiver functioning, the quality of the caregiver–child relationship, and the child and caregiver experience of secondary adversities, trauma, and also healing (Lewis & Ghosh Ippen, 2004). 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 41

Family’s Sociocultural and Historical Context

The expression of infant and young children’s behavior, developmental skills, attachment styles, and emotional life are shaped by their sociocultural context (racial and ethnic membership; socioeconomic status; culturally determined goals for socialization, caregiving practices and caregivers’/family system of values and beliefs), and the ecological and historical factors in which children and the significant people in their lives are embedded (Ghosh-Ippen, Noroña, & Lieberman, 2014; Lewis 2005; Lewis & Ghosh Ippen, 2004; Lieberman, 1990; Noroña, 2011; ZERO TO THREE, 2016). Ecological factors refer to aspects in the neighborhood, community, and larger society (including structural inequities and experiences of oppression, discrimination, and racism) that can affect children and their families/ caregivers. These are particularly important for children and families who have been marginalized due to race, ethnicity, religion, disability, poverty, gender identity and other diversity factors (Lieberman et al., 2015). Historical factors may involve past experiences of mass migration and/or displacement, war, and political trauma which could be part of historical trauma experiences for a group that may persist as part of the family’s “story.” Historical trauma is defined as “a cumulative emotional and psychological wounding over the life span and across generations, emanating from massive group experiences” (Brave Heart, 2003b, p. 7) caused by a traumatic event or a complex set of traumatic events that have impacted a community or entire population. Often the traumatic events were deliberately and systematically targeted by a dominant population to a segment of society as a result of a specific membership criteria of that group (race, ethnicity, nationality, belief, gender, sexuality, etc.) (Hooker & Czajkowski, 2007; Lewis et al., 2013; National Child Traumatic Stress Network, 2012, 2016; Noroña, Flores, Velasco-Hodgson & Eiduson, 2018; Sotero, 2006). “Historical trauma experiences exist on a continuum that include experiences from colonialism, systematic discrimination based on a diversity characteristic … to political violence, genocide and generations of structural inequality” (Duran, Duran, & Brave Heart, 1998; Eyerman, 2004; Healey, 2013; Hooker & Czajkowski, 2007; Sotero, 2006 cited in Lewis et al., 2013, p. 12).The effects of these experiences if not addressed, can be transmitted across generations and have a continuing insidi- ous impact at the individual, family, societal, national, and transnational levels (Hooker & Czajkowski, 2007; Lewis et al., 2013). One of the essential aspects of historical trauma is that “the magnitude of the trauma experience derails the population from its natural, projected historical course resulting in a legacy of physical, psychological, social and economic disparities that persists across generations” (Sotero, 2006, p. 94) and that affect the targeted group and those who were bystanders. As highlighted before, the lasting wounds of the trauma history of an identified group may be expressed at the individual, family, and community levels. At the family level these may be manifested through parent–child relationships in a multiplicity 42 G. Costa and C. R. Noroña of ways that can affect young children’s outcomes currently and for generations to come (Lewis & Ghosh Ippen, 2004; Lewis, Noroña, McConnico & Thomas, 2013; Sotero, 2006). These may include (1) “specific developmental expectations and socializations patterns [e.g., distrust anyone outside your family circle] that may be no longer adaptive” (Noroña et al., 2018, p.13); (2) the intergenerational transmission of trauma which may involve mechanisms such as (a) secrecy about the historical trauma events or conversely retelling of events; and (b) attachment relationships characterized by patterns of abuse and neglect and intense levels of stress (Lewis & Ghosh Ippen, 2004; Lewis et al., 2013; Noroña et al., 2018; Sotero, 2006). At the community level the impact of historical trauma may be manifested through (1) internalized oppression where members of the oppressed group “inter- nalize the beliefs or stereotypes created by the aggressor group (Taylor & Grundy, 1996)” (Lewis et al., 2013, p. 14); (2) “ongoing community exposure to oppression and inequities including racial trauma, discrimination, and fear (Ghosh Ippen, 2018)” (Noroña et al., 2018, p. 13); (3) systems of care and institutions where insid- ious patterns of injustice get reproduced with individuals, children, and families (Noroña et al., 2018). Historical trauma’s legacy persists in sociocultural contexts fraught with poverty, racism, discrimination and oppression. Incorporating an understanding of how historical trauma shapes present day interactions between cultural groups is a critical growing field of infant mental health (…). As we attempt to partner with families, to support them in raising their young children, we [must] begin by acknowledging that historical trauma and ongoing oppression and racism are connected to current struggles for many multicultural groups (Ghosh Ippen, 2018, p. 7). The responses to historical trauma vary across sociocultural contexts (Lewis & Ghosh Ippen, 2004; NCTSN, 2012) and the perception of what is traumatic (and therefore its impact on child, family, and community functioning) also differs by group and individual (Lewis & Ghosh Ippen, 2004; Noroña, 2011). We cannot assume that a group or an individual would be traumatized as a result of historical wounds. However, due to the pervasive and destructive nature of the legacies of historical trauma, it is essential to thoroughly explore not only the child’s and family’s sociocultural background and exposure to traumatic events as part of an infant and early childhood assessment process, but also the cultural group exposure to potentially traumatic events. The first interview and taking-history process provides the ideal setting to begin this exploration. (Figure 2.2 offers guidelines to explore or start a conversation on the historical trauma and race and ethnicity related experiences and narratives of family.)

Relational History of Family Members

Parenting a child can represent a powerful trigger for memories, feelings, and thoughts in the caregiver about his/her own upbringing (e.g., Fraiberg, Adelson, & Shapiro, 1975). Many aspects of parenting are unconsciously determined by how 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 43

Guide to Explore the Socio-Cultural Context, Historical Trauma and Oppression Using a Diversity Informed Lens

1. Suggested Areas to Explore with Immigrant Families:

i. How do individuals/ family identify racially, ethnically, culturally, socio- economically ii. How do individuals identify in terms of their gender and what are their preferred pronouns? iii. Where did individuals/family come from? What part of the world? iv. Geographical context (rural area, urban) in the home country v. Ethnic, racial, cultural group in the home country vi. Languages/dialects the family/individuals spoke in the home country vii. Degree of involvement of the individual/family in traditional indigenous culture (Brave Heart, 2001 a, b; Brave Heart,1998) viii. Role of cultural factors (beliefs, traditions, rituals) in providing emotional, social and informational support of functioning as coping mechanism (Brave Heart, 1998, 2003 b.; Lewis & Ghosh-Ippen, 2004; Noroña, 2011) ix. Socio-political context and relevant historical facts in the home country x. History of colonization, slavery and oppression that may have affected the family’s /individual’s group or community. What has the family’s cultural and racial/ethnic group experienced/endured? a. History of acts of mass violence (genocide, ethnic cleansing)? b. History of wars and internal armed conflict? c. History of mass losses and displacement? d. History of survival and resiliency? i. How these events were/are processed in the family and in the group? (Brave Heart, 2001 a, b; Brave Heart, 2003 b) ii. Are there any cultural factors (beliefs practices) that served as buffers/source of strength, meaning-making or that helped cope with the events? (Brave Heart, 1998; Lewis & Ghosh-Ippen, 2004; Lewis, Noroña, McConnico, Thomas, 2013) iii. Are there any cultural factors that served as impediments in coping with the events? e. How did they get to the host country? f. What motivated/forced them to leave their country of origin? g. Family’s description of the immigration process. h. Did family members reside in refugee placements? i. Assess for potentially traumatic events prior, during or after migration (immigration trauma) (Perez-Foster, 2001). j. Employment and educational/skill status in country of origin? k. What is their environment/ecological context like now? i. Legal involvement/concerns ii. Immigration status; fears related to documentation; separation from family members/children iii. Perceived experiences of discrimination or microaggressions (based on race, ethnicity, immigration status, gender identity and expression, faith, disability) and how the individuals/family have processed them iv. Access to services for the individual/ family members and employment v. Housing and health care status vi. Income/cost of meeting needs vii. Protective factors

Fig. 2.2 Family’s socio-historical-political and cultural context 44 G. Costa and C. R. Noroña

2. Suggested Areas to Explore with all Families (can apply to families who might be second or third generation immigrants) a. How do individuals/ family identify racially, ethnically, culturally, socio- economically b. How do individuals identify in terms of their gender and what are their preferred pronouns? c. Where did individuals/family come from? What part of the country? Where did the family of origin came from? d. Geographical context (rural area, urban) where they come from e. Ethnic, racial, cultural group background f. Languages/dialects the family/individuals spoken in the family: present and past g. Degree of involvement of the individual/family in traditional indigenous culture (Brave Heart, 2001 a, b; Brave Heart, 1998) h. Role of cultural factors (beliefs, traditions,rituals) in providing emotional, social and informational support of functioning as coping mechanism (Brave Heart, 1998; 2003 b.; Lewis & Ghosh-Ippen, 2004; Noroña, 2011) i. Socio-political context and relevant historical facts for the family: Past and present j. History of colonization, slavery and oppression that may have affected the family’s /individual’s group or community. What has the family’s cultural and racial/ethnic group experienced/endured (Brave Heart, 1998; Lewis & Ghosh-Ippen, 2004; Lewis, Noroña, McConnico, Thomas, 2013) i. History of acts of mass violence (genocide, ethnic cleansing)? ii.History of wars and internal armed conflict? iii. History of mass losses and displacement (generational boarding school history)? iv.History of survival and resiliency? v. How these events were/are processed in the family and in the group? (Brave Heart, 2001 a, b; Brave Heart, 2003 b) vi.Are there any cultural factors (beliefs practices) that served as buffers/source of strength, meaning-making or that helped cope with the events? (Brave Heart, 1998; Lewis & Ghosh-Ippen, 2004; Lewis, Noroña, McConnico, Thomas, 2013) vii. Are there any cultural factors that served as impediments in coping with the events? k. What is their environment/ecological context like now? i. Explore instances of perceived discrimination and microaggressions and how the individuals/family have processed them ii. Legal involvement/concerns iii. Access to services and employment iv.Housing and health care status v. Income/cost of meeting needs vi.Protective Factors

(Brave Heart, 2001, a.b.; Brave Heart,1998.; Pérez Foster 2001; Lewis-Fernandez & Diaz, 2002, Lewis & Ghosh-Ippen, 2004; López, 2009; Noroña 2011; Lewis, Noroña, McConnico, Thomas, 2013)

This form was developed by Carmen Rosa Noroña (2011, 2012, 2013, 2018) for training on immigration trauma.

Fig. 2.2 (continued) 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 45 the caregivers were parented and, as discussed above, these intergenerational patterns are in turn shaped by sociocultural and historical factors including traumatic events targeted to different generations in a cultural group (Lewis et al., 2013). Therefore, parents’ or primary caregivers’ perceptions, potential distortions, attitudes, and expectations of the child need to be carefully assessed as they can reveal the caregivers’ own early relationship histories (see Chap. 3) and how these early relationship histories were influenced by the family’s context. By exploring the caregivers’ family history and perceptions of their own early relationships, insight can be gained regarding the mental representations that each primary figure has of the child and of themselves. This insight can help identify possible risks in the caregiver–child relationships and prevent the intergenerational transmission of patterns of abuse and neglect (Chu & Lieberman, 2010). As highlighted previously, it is central to also understand the role that the family’s past and present sociocultural context and the family’s cultural group’s history have played in shaping those representations.

The Interview Setting

The initial interview can take place in different settings and in various models of service delivery (home-visiting, early childhood programs, mental health outpatient services, child welfare services). Caregivers are often interviewed with their infant or toddler present and history-taking often occurs in more than one session, depending on the case and the context of the assessment process. It is recommended that the interview process includes a child–caregiver/family session and at least one session with the caregivers alone (King, 1997; Lieberman et al., 2015). Broadly, each of these sessions targets different but interconnected domains where different pieces of information are gathered and the provider–family working relationship is hopefully fostered. To review, the initial session with the family or child–parent session provides an opportunity to: • Explore the reason for referral, and the caregivers’ and the child’s (when developmentally appropriate) understanding of the referral and presenting problem. • Explore hopes and fears related to the assessment process. • Understand expectations of the caregivers about themselves, their child and the family’s experience with mental health services in the past. • Provide information about the agency and the provider’s role. • Explain the assessment process. • Discuss confidentiality, reporting requirements and obtain caregivers’ consents. • Establish a therapeutic contract (scheduling, number of sessions, payment, expectations and responsibilities) with the caregivers and the child. • Begin taking a history (e.g., developmental history). • Observe the parent–child behavioral and affective interactions (most important). 46 G. Costa and C. R. Noroña

A second session with the caregivers can focus on: • The parents’ family history and history of relationships. • Exploring sensitive matters with the caregivers (e.g., the parental trauma history) that cannot be discussed in front of the child. • Addressing issues of safety and stabilization. • Clarification of any questions or concerns the caregivers may have. The domains suggested for each of the interview sessions will be discussed in the section on the “what” of the interview.

The “How” of the Interview Process: Guiding Principles

The Practitioner’s Stance and Interpersonal Processes: The Power of Affect and Relationships and the “How” of History-Taking

The forces that lead families to mental health services vary greatly, and at times may include involuntary requirements to participate, such as a referral by child protective services or through a court order. While these circumstances pose particular challenges to the process, families often experience ambivalence and anxiety even when they have made the decision on their own to seek help. In all circumstances, practitioners need to be aware of the interpersonal forces that are at play in beginning a therapeutic alliance. The history-taking process involves the first set of encounters around mental health concerns and experiences with the practitioner and must first “feel safe” for families. When individuals feel safe, they are more likely to use higher, level “executive” processes in sharing information and responding to inquiries (Siegel, 2010). While the family “brings” their own feelings and beliefs to this encounter, so does the practitioner, but the practitioner is principally responsible for guiding this process. In adopting the “stance” that will promote the accuracy and experience of the process, the following eight principles are offered as guidelines for the history-taker: • The process of history-taking occurs within the context of a relationship. While the “content” of the interview will necessarily include facts, events, people, dates, times, and locations, the interview is less about collecting data, and more about forming a personal helping relationship with the family and their infant, toddler and/or child. Costa (2006) cautioned against the practice of infants and families becoming “objects” of study not “subjects.” He commented about the danger of prematurely “diagnosing and pathologizing” and cautioned against the adverse consequences when “…(f)amilies are viewed as ‘having’ certain problems or characteristics rather than ‘being’ who they are in their journey of growth and adaptation.” 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 47

One implication of this relational context is the recognition that “information” derived is jointly constructed. Different interviewers will almost certainly derive different “data,” so that the history-taking process cannot be regarded as resulting in “objective data” or facts, but as the product of the interaction of the practitioner and family. This is not to dismiss the validity of the information derived, but it is reminder that both the family members and the interviewer influence the flow of information and what is shared by the family. As will be examined shortly, subtle shifts in the interviewer’s demeanor or response may unconsciously and inadvertently lead the family to disclose or fail to disclose information. This understanding requires a capacity for self-observation and reflectivity in the practitioner. Collectively, what emerges is the recognition that the history-taking experience is a collaborative process, and that the more families share that experience, the more likely the information that is gathered will be accurate and meaningful, and the greater the likelihood that families will become engaged in subsequent therapeutic supports. • Cultivate self-awareness, introspection, and reflectivity, and understand the ways in which our subjective experiences can influence our affect, gestures, and the process of engagement. This also entails cultivating our capacity to “listen” not only with our ears and eyes, but with our “bodies.” The interpersonal neurobio- logical processes mean that the professional may “sense” stress or anxiety in his/ her own body, and the task becomes discerning whether the source of this stress is within the interviewer, or in something being felt from and with the infant or family. This principle is directly addressed when the practitioner is engaged in regular reflective practices (e.g., Heffron, Ivins, & Weston, 2005; Shahmoon- Shanok, 2009). Linked to reflective practice and increased self-awareness, tenet number one of the Diversity-Informed Infant Mental Health Tenets (St. John et al., 2012; Thomas et al., 2019) urges practitioners to avoid replicating systems of oppression when serving families, by engaging in a continuous, intentional, and critical self-exploration of the impact of their own history, experiences, sociocultural background, and professional training in shaping their values, beliefs, and implicit biases and hence interaction patterns with families. • Be particularly attuned to your own affect, gestures, movement, pacing, and vocalizing. Infants, children, and families will first and foremost attend to non-verbal communications and they will begin to form, often without awareness, feelings about the safety and trustworthiness of what follows. Movements and pacing are particularly important: shifts in posture, looking at or turning away from the family, and waiting for responses before continuing to talk are all ways that families “feel” and know of our interest (or not) in hearing their story. Moments of respectful silence can mean a great deal to families. Often the time pressures of the clinician’s or organization’s schedules may lead the interviewer to “rush” 48 G. Costa and C. R. Noroña

these conversations, or conduct interviews in a “question-answer” fashion, which may be experienced as an interrogation. As a rule of thumb: go as fast as the family prefers, not as fast as you can. • The power of observation, “wonder,” and tolerance of discomfort. Trout (1985) formulated a framework for observation, “language of interaction” (visual, touch/kinesthetic and vocal/visual modalities) in which he offers the practitioner insights into the “alternate ways” that infants and families communicate to us about the nature of their lives through their interactions. In this framework, the practitioner attends to the many ways that infants and families communicate, and observation of interactive transactions among the infants, children, and caregivers is one such messaging system. In fact, Hirshberg (1993) argues that what is more important in the clinical interview is what the infant and parent are “doing” while they are “saying,” rather than simply attending to what is being said (p. 176). It is critical that the practitioner suspend premature judgment and interpretation about the meaning of the interactions, but instead engage in “wondering” about the many meanings an observation may yield. This need for caution also extends to avoidance of judgments and “reputations” conveyed by other professionals and systems that may accompany the referral. This requires the history- taker to come to learn about and honor the stressors faced by the family and the varied ways that the infant and family have adapted, without judging and prematurely intervening. One difficult outcome of this restraint is the need to tolerate uncomfortable feelings. Caution about judgement and impressions that follow a family does not mean we ignore information, but rather we engage in a thoughtful, principled, and careful process of coming to know the family, and reframing our view of “problems” as attempts at adaptation. • Embrace an “adaptation” and “strengths-based” framework. This emerges from the view that gathering information about the journey that brought the family to the practitioner, is best viewed as a journey of “adaptation” to the events, stressors, circumstances, and interpersonal relationships they have encountered. Recalling the earlier discussion about the crisis nature of seeking mental health services, both the practitioner and the family may expect that the history-taking is only about identifying the problems—and the past difficulties and failures. Yet even the most challenged families have moments of deep love and care that occur, and that alongside the most adverse human experiences, infants and children can have moments of regulated, engaged, loving, reciprocal humanity. The history-taking process offers the family a way of sharing their full range of human experiences, and when the practitioner explores and validates their strengths and adaptations, the family will more likely find themselves engaged in resolving all that brought them to the practitioner. • Be prepared with areas for discussion but be available to follow the family’s lead. In practice, history-taking is an “organic” process, and while the practitioner should have a general plan to follow, it is important to follow the family’s 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 49

lead. Costa and Sullivan (2009) describe a reflective activity, “Practicing Conversations” (p. 163) in which the practitioner can imagine with colleagues how a particular conversation, especially one that may address trauma, loss or emotionally charged material, could proceed. There will also be moments in the process where the practitioner will have a strong emotional, even visceral reaction to what is shared and discussed. In those moments, the need for a reflective partner is most critical. • Understand and cultivate “self-regulation.” Professionals will not be able to prepare for every conversation, but can practice sustaining “calm” and self-regulation. The capacity to monitor, understand and not be overtaken by internal states was referred to by Siegel as “mindsight” (Siegel, 2010). Shanker (2016) offers a comprehensive framework to address the complex domains of “stress” that are always present in the clinician’s mind and body, and offers ways to cultivate sustaining regulation. • Recognize the limitations of history-taking and establish an “end” to the session. While families differ greatly with regard to providing information and discussing their lives and history, the practitioner needs to pace the session in such a way that the family does not feel overwhelmed by the review of their “story” by conveying to them that there will be more opportunities to cover what was missed. This “titration” of information aims at averting an experience where the family shares “too much” and goes “more deeply” than the history-taking process requires. Hirshberg (1993) reminds practitioners that the “…gathering together of a number of disjointed facts … is … less productive … than the careful analysis of some small detail or single experience that embodies or instanti- ates the core problem or difficulty.” (p. 174). The aim of history-taking is to gather enough information with the goal of understanding and planning. It is critical to keep that goal in mind, however interested one might be in pursuing certain lines of inquiry.

Validating Experiences and Meaning-Making

In gathering information during the clinical interview, listen to how families describe the events in their lives, and avoid correcting or recasting their ideas and terms into more clinically accurate language. It is important in the early stages of coming to know an infant, child and family, that families are encouraged and supported to speak about their “story” in their own words. Families, may for example, attribute intentionality to a 6-month-old infant, such as “she cries just to annoy me,” or about a 9-month-old, “He’s just like his father when he gets mad, and I just ignore him.” These statements can be very alarming to the practitioner and while there is an obligation to intervene or respond in cases where present or imminent injury or abuse are suspected (addressed in a later section), the primary task of the history gathering 50 G. Costa and C. R. Noroña is to create a “safe space” where the family can begin to allow themselves to be known and heard. In such cases, a useful strategy in listening to families is the periodic simple, slow, and thoughtful restating of what you have heard—using their own words as much as possible. Additionally, listen for the family’s effort to make “meaning” of all they have encountered. As families feel heard and experience no shame or criticism (which can be engendered by intrusive questions and hash demeanor), and experience a safe, caring interest, the likelihood increases that difficult material will be shared, and recommendations for subsequent clinical services will be accepted. Listen as well for the parents’ “reflective functioning.” Fonagy, Steele, Moran, Steele, and Higgitt (1991) introduced “reflective-self-function” (p. 203) as an essential human capacity to understand behavior in light of underlying mental states and intentions (see Chap. 3). Slade (2005) applied this notion to “parental reflective functioning” in which she described the parent’s capacity to hold the child’s mental states in mind. Within the context of observations and interactions in the history- taking, does the parent demonstrate an ability to reflect on their own experiences and inner life as well as the ability to imagine the infant’s or child’s experiences through his/her eyes? Throughout the history-taking process, note the parent’s reflective capacities, including how this capacity may be supported by the empathic listening and reflection by the practitioner that occurs during the interview process.

Parenting as a Relationship Not a Skill

Mental health practitioners working with infants, children and parents bring their own experiences—in their own development and their many professional encounters with families—into the work. This was considered above and referred to in discussing the need for reflective practices, and supervision, as essential requirements to the work. Considering parenting as a relationship not a skill has great meaning to the history-taking process. Most notably, it is essential for the practitioner to reframe the parenting relationship as one that does not just involve “knowing” (knowledge) or “doing” (skills), but “being.” In this framework, Fraiberg (1980) would remind us that while parental adequacy and the infant’s developmental and emotional well-being are essential targets of care and intervention, the primary “patient” in infant mental health is the “relationship.” In the next section, the “what” of the history-taking process will be described and guidance will be provided about the domains of the history-taking that are designed to support the practitioners inquiry into the nature of how the “relationship” has come to be what it is when the infant, child, and family “got here.” It is important to address the possibility that when the practitioner first encounters the infant, child, and family—particularly when the contact was precipitated by a traumatic event—the provider may need to assess whether or not the family requires immediate intervention—meaning that the process of engaging in a clinic setting will be deferred as the family receives urgent attention. Accordingly, the 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 51 clinician should include a safety screen, especially when the possibility of personal, family, or community violence or danger exists.

The “What” of the Interview Process: Domains to Be Addressed

The “infant–child–family profile” (Fig. 2.1) was provided earlier as a way of considering the many “domains of inquiry” in wondering about the forces that have brought the family to services. This is meant as a respectful guide in exploring the family and the parenting journey. In this section, a number of these domains will be reviewed in an effort to create a flexible guide for the practitioner to use in organizing the historical journey of the family. Recognize that not every domain will be explored and remember that the history-taking is not aimed at creating a complete history, but rather a jointly constructed narrative that contextualizes where the family is in the present. The practitioner must always keep the family’s cultural context in mind to ensure that what is best understood as a cultural difference is not regarded as a disturbance or pathology. Furthermore, many families, particularly families representing groups considered “minority” groups based on race/ethnicity, immigration status, disability, gender identity, or the intersection of some of all these variables, might have encountered legal and political discrimination and stressors that provide the context for their presenting difficulties. As mentioned previously in these instances when professionals encounter families with experiences of intergenerational/historical trauma and oppression, a diversity-informed lens is needed. Figure 2.2 provides areas of inquiry emerging from such a lens. Throughout this section, keep in mind that the guides in Figs. 2.1 and 2.2 and the areas discussed below represent important areas about which practitioners informed by infant and early childhood mental health, must “wonder” as they come to know a family. None of these domains is meant to be explored through a “question– answer” process as might occur in more structured interview guide or in a formal interrogation. The number of domains and the emotional meaning that are embedded in most, make it clear that this is not a list that will be explored in one setting or session, but rather represent a “pool” of areas that might be explored in the time allotted for the history-taking sessions. Selected domains of inquiry are reviewed below.

Pregnancy, Birth, and Infant/Child Information

It is possible that prior to the history-taking session, demographic information (age, race, ethnicity, caregivers’ current relationship) will be known. Even when this is available, it is important for the interviewer to review and verify that all of the information is accurate. 52 G. Costa and C. R. Noroña

Using an infant mental health framework, gathering information about pregnancy, childbirth and the first several months of life are particularly relevant. This includes, pregnancy and birth history, developmental history/milestones and concerns, becoming a parent or caregiver by birth or adoption or foster care placement, planned or unplanned pregnancy, relationship with partner at time, decisions about birth and breastfeeding, and early eating/feeding experiences. Other areas include, first feelings on discovery of pregnancy, experiences during pregnancy, highlights, scares or worries, prenatal care, circumstances of delivery, including those present, type of delivery (vaginal or Cesarean-section), complications or worries, first feelings on seeing the newborn/the adopted child, name-choosing conversations, and homecoming (see also Chap. 3) Medical and developmental concerns should also be noted.

Current Members of the Household and Other Significant Family Supports

Those who are considered “members” of a family are not only defined by blood, marriage, or co-location but also by their importance to the family’s support system including transnational relationships, so it important to understand those who live in the household.

History of Significant Caregivers, Moves, Changes, Separations, Losses, Traumas, etc.

The nature of early experiences are organized through relationships, and experiences with a range of early caregivers, disruptions or losses of important relationships should be described. Events that resulted in separations (e.g., infant child or parental hospitalization, military service, incarceration, separation and divorce, deportation) or trauma (child maltreatment, family violence, disaster, traumatic separations, etc.), are important historical events in the developmental trajectory of the infant, child and family. Listening for these, and reacting without judgement and with empathy are important elements of the interview.

Educational, Skill and Employment History

This is an area where not only the developmental/educational needs and experiences of the infant and child are recorded (early intervention, preschool disabled services, etc.) but where the formal education and specialized training of the parents could be 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 53 explored, including areas of interest and avocation. Prior difficulties in training and employment would also be explored. Gaps, frequent changes and disruptions in education and employment would be important to note and may be helpful in later clinical formulation. It’s important to inquire about the parents’ own educational journey, including developmental, learning and special education needs as this can relate to their expectation and experiences with their young child’s educational journey.

Access to Services

Under this domain, respectfully inquire about the family’s ability to seek and secure services that might be needed—including health, educational, child care, housing, financial, social support, transportation, food and other services, Consider in this area, access to services in their geographical region, affordability of services, availability of services that meet their linguistic, cultural, and religious practices. Importantly, discern if the quality of services (e.g., school system, child care that is “rated” or accredited”) are available or restricted in their areas. This is a sensitive area and families may not self-identify their own school and community as poor.

Involvement of Collateral Agencies, Including Child Care and Education/Special Education

Often families, particularly those with many risk factors, may be involved with other educational and social service agencies, including early intervention and special education services, legal services, immigration services, foster care system, welfare and Medicaid services, other mental health providers, home visitation services, unemployment agencies, child care and after-school programs, and others. Noting these will help prevent duplication of services and promote coordination of care.

Current Health/Dental/Mental Health Care and if One, a “Medical Home”

Health care varies widely based on the financial resources of the family and geography. An integral part of the family’s well-being is the availability and engagement of health providers. Many communities are promoting a transformation of pediatric and primary care practices into “medical homes.” The US Department of Health and Human Services promotes this public health practice approach to providing 54 G. Costa and C. R. Noroña comprehensive primary care for children, youth, and adults, called the “Patient Centered Medical Home (PC-MH)” (Scholle, Torda, Peikes, Han, & Genevro, 2010). The PC-MH is an initiative to redesign primary health care, in which healthcare settings facilitate partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. In this model, the primary care physician is regarded as the coordinating “hub” for all care that is provided to the family. If a family is engaged with a primary-care physician, the history-taker should gather information about the provider, including whether the family or provider regards the practice as a PC-MH. Similarly gather information about dental and mental health services in which the family members are engaged. This section reminds the practitioner of the larger context of health care in which our work with the family is embedded.

Legal Involvement and Concerns

Consider in this domain any involvement the family might have in legal/judicial systems. This might include involvement of child protective services (with the assignment of a public defender, guardian ad litem, CASA caseworker—court appointed special advocate), custody litigation, educational advocacy for their child (e.g., filing complaint or engaged in due process hearing to dispute an educational plan), or any criminal or civil legal initiative. These are regarded as additional stressors that require emotional, cognitive, temporal, and financial resources.

Immigration Status/Concerns About Documentation and Fears of Deportation

This is an area of particular importance in geographical areas with high concentrations of immigrants. In taking a history, recognize that families with fears about their status and deportation may be very guarded about direct inquiries, and practitioners need to provide clear assurances about confidentiality and non-discrimination for services based on legal status. This may affect the ability for a family to meet the costs of services, so a candid discussion will be required. This is also an area where “fact” and “fear” may merge. While families may share actual events and concerns about their immigration status and government authorities, listen too for fears that are expressed or experiences the family members share from their encounters with neighbors, strangers, in schools, child care centers, faith-based organizations, and their larger social communities. In particular, listen for concerns about family separation due to detention and deportation, discrimination and how that might affect their expectations and beliefs about mental health services. While listening to these concerns the provider can offer assistance with information, resources and with 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 55 family preparedness plans in case of detention and deportation. In this way and in the face of the unknown, families can gain a sense of control and make informed decisions and plans regarding their children (Noroña, 2017).

Concrete Needs: Safety, Housing, Food, Clothing, and Financial Concerns

Among the “categories of helping” in infant mental health, is the need to attend to “concrete services” (e.g., Lieberman et al., 2015; Weatherston & Tableman, 2003) such as safety, shelter, housing, food, health care, and transportation. The task in history-taking is not in directly addressing the needs but recording these as part of the family’s profile and when unmet, as sources of likely stress. This also recognizes the need to address the lower, more basic needs as a way of support higher level needs, including “self-actualization” (Maslow, 1954) and promoting family engagement in the assessment process. (Lieberman et al., 2015) It is important to consider the family’s ability to meet their needs and financial obligations. There is a significant literature linking families in poverty with greater challenges, and more barriers in overcoming those challenges when compared to families at higher socioeconomic levels (Farah et al., 2006; Swafford, Wingate, Zagumny, & Richey, 2015). Under this domain, respectful inquiries need to occur regarding safety. This may refer to family safety (in-home conflict, abuse, violence) and community violence in schools, playgrounds, and neighborhoods where a family lives. Quality and safety of housing is also important: adequate, clean, warm, dry, and maintained space (compared to overcrowded, leaky, rodent and insect-infested, poorly heated quar- ters). Housing affordability is often a significant barrier for families.

Protective and Risk Factors

This is a section in which particular risk factors, not yet identified, could be included. Some risk factors are evident and identifiable by families, and others may be such an integral and common part of everyday life that a family may not identify them. It is important NOT to impose one’s beliefs and perspectives onto the family narrative. Throughout the interview, listen carefully for experiences and events which likely pose risks to families and infant/child and family well-being. Risk factors can be present within families and in communities, so consider a wide lens in discerning the context of the family’s life. Consider the ten ACE (adverse childhood experiences) factors extensively examined for nearly 20 years in over 50 studies (e.g., Felitti et al., 1998). These are emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance 56 G. Costa and C. R. Noroña abuse, household mental illness, parental separation/divorce, and incarcerated household member. The greater the number of ACE factors, the more likely the individual will have negative physical and mental health outcomes, and ultimately early death. Of significant value are the presence of familial and community “protective factors”—those forces that serve as “resilience” forces to counteract risks. These include the positive and secure relationships that exist within families and their extended social network, social and community groups with which the family identifies, and those known to the child and family from whom they derive support— such as faith communities, civic groups, parent–school associations, theatre groups, libraries, boy/girl scouts, and transnational relationships, as well as cultural practices, rituals, and referents.

Family, Cultural, and Religious Values and Beliefs

Under this domain, listen for the many ways in which the family is guided by long- held values and family, cultural, and religious beliefs. The context of development and of the family’s unfolding life has a profound influence on a wide range of our practices and beliefs. Here is a non-exhaustive list of domains organized by our socioeconomic, cultural, and familial context: expression of affect, dress and customs, language and gestures, interpersonal space and behavior—including eye contact, hand-shaking, behavior between men and women, art, music, movement and dance, diet and food choices, historical context and origins, their “legacy,” historical and personal “myths” or “narratives,” religious beliefs, values, and world views— including belief in God, evil, afterlife, notions of equality, personal choice, freedom, beliefs about role of government, and methods of social justice—including forms of government, laws and punishment, gender roles, family structure, marriage and community, views about and treatment of authority, medical care and health practices; regard for seeking and acceptance assistance, parenting and child-rearing beliefs and practices—including discipline practices, sleeping practices, and belief in importance of achievement and autonomy. In listening to the family’s story, listen for these domains, but first recognize the inherent filters that your own socioeconomic status, culture and beliefs may impose on you. The practitioner must become aware of the ways in which his/her own beliefs can alter their ability to identify and honor views that differ from their own. So, in summary, while engaging in history-taking, listen for: • Religious/spiritual beliefs and customs. • Child-rearing practices and developmental expectations. • Views of the health-care system. • Perceptions regarding mental health issues and illness. 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 57

• Perceptions of what is traumatic (views about using the words like trauma, traumatic, and traumatized to describe own or loved ones’ experience). • Perceptions regarding loss, grief, emotional pain and recovery from it. • Ideas on origins and meanings of “symptoms” (e.g., What words does the family use to describe the infant/child/family difficulties?).

Exploring the Parent’s “Internal” Representation of the Infant/ Child

This domain, unlike the other sections of the framework for the history-taking described in this chapter, will entail the interviewer asking a set of structured questions of the parent, if time permits and there is an opportunity to interview the parent(s) without the infant/child present (see Chap. 3 for a more in-depth discussion). Zeanah and Benoit (1995) (Benoit, Zeanah, Parker, Nicholson, & Coolbear, 1997) developed a structured interview to examine parental perceptions/representations of their infants, named, the “Working Model of the Child Interview” (WMCI). The interview which typically occurs over a period of an hour, contains 19 questions, some with multiple parts and are respectfully and slowly explored with prompts. Many of the domains covered in the “Pregnancy, Infant, Child Information” section above and addressed in Fig. 2.1 are represented in the WMCI questions. Drawing from the WMCI and related domains, if time and circumstances permit, the interviewer can pose some or all of the ten questions below, and record impressions about the way in which the parental responses offer a glimpse into the way in which the parent “represents” the infant/child. This is not intended to meet the validity and reliability of a well-trained WMCI interviewer, but instead is designed as an informal way of discerning the nature of the parental perceptions of their infant/child. 1. What was your first reaction on learning you were expecting? 2. How was it for you when you brought your child home? (i.e., after birth, adoption, or after a separation). 3. How did you choose his/her name? 4. How would you describe your child’s temperament or personality? 5. How would you describe your relationship with your child? 6. What do you like about him/her? 7. Who does he/she look like? 8. Does he/she remind you of anyone? 9. What does your child do when he/she is having a hard time? (i.e., disobedient, not listening, defiant). 10. Name five adjectives that describe your child. 58 G. Costa and C. R. Noroña

“Proper” Goodbyes and Reflections on the Interview Process

Proper Goodbye

A “proper goodbye” with the family is crucial, as they transition to the next phase of the intervention process. Inherent in the clinical interview is the formation of a relationship around the nature of the forces that brought the family to seek help. From this relationship-based framework, aside from the “content” of the material that was shared by the family and “listened to” by the practitioner, the “process” of being together represents an opportunity for the family to experience a “relationship” that may affirm or challenge their “models” of what relationships are like. A fundamental truism about the field of infant mental health is that attachment and loss are central organizing principles in the unfolding of human development. While many families come to the interview with experiences of warm, consistent, attuned, predictable and loving experiences, others will arrive with unfavorable experiences about relationships—unavailable, inconsistent, hurtful, and abandoning. The notion of a “proper” goodbye means that the practitioner has an opportunity—even an obligation, to ensure that as the history-taking process ends, the family experiences the transition as one characterized as predictable, caring and as leading to a continuation of care in accord with the mutually agreed-upon next steps. In this regard, as the clinical interview comes to an end, the practitioner can support the process by ensuring the family that the evaluation process will continue. By providing the family with contact information should any questions arise or should they need to share new information, by following-up with promises to be in touch or schedule any next steps, even by checking with the family should there be a delay or change in the plan—all of these steps support the family’s emerging belief that the interview is the beginning of the helping process—that they will not be forgotten or ignored, and that help is on the way.

Reflections of the Interviewer’s Experience

Throughout this chapter the need for self-awareness and reflectivity on the part of the interviewer has been highlighted. As the interview ends, and the practitioner prepares the family for the next steps in the clinical plan, it is important that the practitioner reflects on his/her own experience of the interview process. The practitioner could consider: • Based on the family history and observations, what is at stake for the children and family if the risk factors are not effectively addressed? • What was learned about the parent’s/caregiver’s own childhood and upbringing? What factors might be operating that make it difficult to engage the family? How can reflective practice to help the clinician empathize and promote engagement? 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 59

• When the family was doing well in the past, what was different? • The clinician should reflect on “What is “going on“ inside of you? What could help better manage and “use” those feelings to the benefit of the clinician and the family’s? • The clinician should wonder who they represent this mother/family? • Who is this child/parent/family to the clinician? Collectively, these will help the practitioner better “use the self”—awareness of the clinician’s inner experience—to discern whether interpretations of what was learned are being unduly influenced (confirmed or disconfirmed) by the clinician’s subjective experience. The history-taking is the first experience of the helping systems. How it begins and how it ends make an enormous difference in how the family experiences the process, and can influence their decision to engage in the intervention plan.

Case Vignette

Paquito and His Mother Ana L.

This vignette is based on history-taking over the course of two sessions. During the second session, a developmental screening and observation of the mother and child was conducted and videotaped. These observations and clinical impressions represented the transition to the assessment phase and would more appropriately be considered in the evaluation section.

Background

Identifying Information and Description of Presenting Problem from Referral

Ana L. is a 25-year-old native of Guatemala, who was adopted at birth by non- Latino parents in the USA. Paquito is a male infant, born in the USA, aged 12 months, adjusted age 10 months due to prematurity. The mother and child live in a women-and-infants’ shelter. Paquito is the first child born to Ana and her fiancé Frank, aged 27. The child’s pediatrician referred the child and mother to the program for an assessment due to concerns related to the mother’s parenting ability (difficulty responding appropriately to his emotional and developmental needs and keeping him safe). At the time of the referral Ana and Paquito had an open case with the Department of Children and Families (state child protection agency). DCF became involved with the family after the shelter filed a formal complaint of neglect because 60 G. Costa and C. R. Noroña

Ana had left Paquito unattended in the shelter’s living room, resulting in an injury which she did not address. She initially came to the interview because in her eyes DCF, her pediatrician, and the shelter were forcing her to do so. She did not understand why providers thought that she needed support parenting Paquito, and she described her problems as caused by Paquito’s behavior and by not having enough financial support and no housing.

History of Presenting Concerns

During the intake Ana stated that her problems with Paquito began when they moved into the shelter when Paquito was 2 months old. She reported feeling exhausted and overwhelmed as a result of her living situation and of caring for Paquito who often cried inconsolably and had colic and reflux. She denied depression, domestic violence, substance abuse, or suicidal ideas or attempts.

Social and Family History

Ana came to the USA at age 2 months from Guatemala with her adoptive parents, Linda and Paul L. Ana was their first and only child. Her adoptive mother, Linda, is 51 years old and her adoptive father is 55. Ana knows little about her family of origin or what led her parents to place her for adoption. She was told by her adoptive parents that her mother was a 15-year-old girl who lived in a very poor village in Guatemala and that the girl’s parents could not afford to raise her. Ana’s adoptive mother, Linda, told Ana that her mother was very pretty, and in the only picture she had of her mother, Ana could see how much she looked like her. When Ana said this, she smiled sadly. When Ana became pregnant, she and her fiancé, Frank moved from the basement of his aunt’s house into an apartment with friends, and then once she gave birth, briefly to an apartment with Frank, where she remained until she was forced to move into the shelter. Frank’s small jobs and the public assistance for Paquito were not enough to support them and pay for the rent.

Family History and Cultural Considerations

Ana reported that she was born in Guatemala in an indigenous community and adopted at birth by North-American parents. She stated that she had tried to track her biological mother on the internet, but her search did not yield any information. Her adoptive father, Paul, reportedly left the mother for another woman when Ana 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 61 was a newborn. She saw the adoptive father a few times when she was a young child but has little memory of him and she described a conflictual and ambivalent relationship with her adoptive mother. While she reported that they still speak frequently, she said, “We clash a lot.” She explained that she was not close to her adoptive mother while growing up and that her adoptive mother had been physically and emotionally abusive towards her and blamed her for the adoptive father’s abandonment “and for everything that is wrong with her life.” Ana lived in the Western part of the USA where she met Frank. They remained together after high school graduation. After Frank lost his job, she followed him to the East Coast in search for new opportunities. They lived in the basement of his aunt’s house, and when she became pregnant with twins, they moved into the apartment of Frank’s cousin. She suffered a fetal loss of one of the twins (a girl) at 12 weeks. She was admitted to the hospital at 30 weeks gestation for bed rest. Soon after she gave birth to Paquito, she and Frank had to leave the cousin’s’ apartment, as they lived in public housing and were concerned about compromising the cousin’s lease. Ana moved to an apartment with Frank and when Paquito was discharged from the NICU at 7 weeks. They lived together for only 2 weeks, when they were evicted for non-payment of rent. Ana and the baby moved into a women’s shelter and Frank moved in with other friends. He broke up with her when Paquito was 5 months old. Regarding social supports, she has no friends or family in the area. She received a crib, diapers, and other resources through her connections/relationships with providers at the Federally Qualified Health Center (FQHC) and through nurses who befriended her at the hospital where she gave birth. Weekly visits at the FQHC with the social worker and the nurses from the hospital appear to be her main source of support.

Family Psychiatric/Medical History

Ana stated that her memories of growing up were filled with fights and being hit by her mother, and many episodes of her mother being sad and often crying. At other times, when her mother seemed happy, Linda would tell Ana how much she loved her and she would tell stories of what it was like when she returned home from Central America with Ana. Ana recalled that her mother would take pills and saw a doctor for what Linda described as “the blues,” and “her moods.” She also recalled that her mother would always drink wine and that Linda had almost no friends and had no contact with her own parents who lived on the West Coast. No information is available about her biological family, but she is aware that in the area where she is from there were massacres against indigenous people like her biological family. 62 G. Costa and C. R. Noroña

Child Medical and Developmental History

Ana reported that her pregnancy with Paquito was planned. The pregnancy was complicated, which was very stressful for Frank and the host family. She began to attend a nearby FQHC for prenatal care. At 12 weeks gestation she began to bleed again and she was rushed to the nearby hospital where she discovered that she was pregnant with twins. She lost one of the fetuses, a girl. She delivered the surviving male infant via C-section at 31 weeks, more than 2 months premature. She remembered that his “APGAR” scores were 6/7, and that he was immediately placed in an incubator because he was having difficulty breath- ing. He weighed 2 pounds, 14 ounces. He required oxygen briefly after birth and stayed in the NICU for 7 weeks, with no further complications. Ana could not settle on a name for the child, and until 5 weeks of age she called him “the baby.” The child received Early Intervention Program (EIP) services after discharge from the NICU for generalized low muscle tone. The EIP worker reported that the child was approximately 4 months delayed in all areas of development, with a chronological age of 8 months and an adjusted age (for prematurity) of 6 months. At the time of the referral Paquito was in the care of his mother. Ana did not want him to attend day care. She said that she did not trust sending the child with strangers and said that she wanted to be a stay-home mom until he was ready to go to preschool.

The Interview Process

Behavioral Observations

Ana L. and her son Paquito were transported to the clinic by a van from the Women and Infant shelter. Ana held Paquito while wheeling a small stroller. Ana was bilingual Spanish/English but reportedly preferred speaking English. The interviewer entered the waiting area and introduced herself to Ana, and welcomed her to the program. The interviewer shared with Ana that she knew Ana is bilingual and highlighted that Spanish-speaking providers are available, if Ana chooses to have a bilingual provider. The interviewer asked Ana to introduce her to the child and she said hello to Paquito, still in his mother’s arms. Paquito looked at the interviewer and leaned closer to his mother, but when prompted by his mother, he first looked and then turned his head away and began to scream and kicked his legs. Ana immediately told the child to be quiet and made an angry face, saying that Paquito is so difficult. The interviewer spoke with Ana about this “new place” and suggested moving to a nearby family-friendly interview room equipped with developmentally appropriate toys. The interviewer offered Ana a seat and asked if she would like to place the child in the infant seat on the playmat near her chair or hold him. Ana quickly placed Paquito in the seat, kissing his head, and offering him the large 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 63 rubber ring with a mirror. Paquito looked at his mother and smiled, and immediately began to shake the ring and using both hands placed it in his mouth. The interviewer explained the reasons for referral and the interview process and gathering of information. She paused for any questions or comments and then showed and read each release of information and confidentiality form with Ana, answering any questions before asking Ana to sign the forms. The interviewer told Ana of the “confidentiality” of the information shared, and noted that in rare circumstances, such as if Ana were at risk for hurting herself or others, she (the interviewer) would be required to inform authorities, but even if that happened, the Infant-Parent Mental Health program would remain helpful. Ana looked at the interviewer and shrugged her shoulders, to which the interviewer noted that this must be making Ana feel worried, and that she hoped Ana would soon come to feel comfortable. The interviewer began respectfully to explore the events that led Ana and Paquito to come to the clinic. Ana immediately spoke angrily about the staff at the shelter who contacted the protective service agency which led to an investigation and then referral to the Infant-Parent Mental Health Service. Ana stated that she did not need help but Paquito did. She reported that she hoped that Paquito would allow her to have more time for herself. She described Paquito as active, “hard-headed,” “stubborn,” “needy” and as having a “mean streak” at times. She said that Paquito has difficulties with separation, is hard to comfort (did not quiet, crying intensely, difficulty calming), and a difficult temperament (becomes upset easily and is very sensitive to noises and lights). She said that Paquito has become more like his father (physically), but his personality is like her own—“all or nothing.” He likes things to happen right away and has a “dark side.” She even described herself as “mean,” stating that she could be “a bitch.” The interviewer observed that as Ana was speaking, Paquito was looking at her and mouthing the toy. The interviewer wondered aloud about what Paquito might be feeling. Ana looked at the baby and said that he sometimes cries when she is upset and she wondered if babies could “sense” that something was wrong. The interviewer commented on how remarkable babies are but how terrific that Ana noticed such things. During the interview session, Paquito remained mostly quiet while he teethed and shook the rubber ring; at times he gestured to his mother and offered the ring but Ana would miss his attempts to get her attention. Only when he “fussed” or cried, Ana would reach down to pat his head or place a pacifier in his mouth, and on a few occasions, she would pick him up to hold him, mostly when she seemed sad by the nature of the events in her life that were being discussed. The interviewer explained that she would like to ask some questions about Ana’s life, and again reminded her that she could ask any questions she might have, and that she need not answer any questions she could not or did not want to. The following is a description of the interview. 64 G. Costa and C. R. Noroña

Pregnancy, Birth, and Early Life

The interviewer asked about whether or not she had thought about becoming a mother when she was younger, and Ana immediately smiled and said that when she was in high school, she always dreamed of having a little daughter. She explained that she always hoped that she would have a baby who would love her and who she could love in a way she always wanted to be loved. When asked about her own parents, she explained that while she only saw one picture of her birth mother, a teen- age girl in Guatemala, she imagined that she wished that she had not given her daughter up for adoption and wondered if she was “forced to.” She then described her relationship with her adoptive mother, Linda, as “okay now” but said that her mother drank a lot and would hit her often as a child. She said that she did not know “which mother” she would come home to after school and when she had the chance to leave with Frank, she did. Ana said that she wanted a baby with Frank and was surprised when she became pregnant. When she was hospitalized with bleeding during the pregnancy, she was so frightened of losing the baby. When she learned she was carrying twins, and there was fetal demise of the female twin, she said that she cried when she learned that the surviving child was the boy. The interviewer validated her feelings of loss and asked about her first feelings when she gave birth to Paquito. She said that the baby was immediately taken to the NICU and she did not see him for 24 h. The interviewer noted that just as she said this, she leaned down and touched Paquito’s head and he smiled and kicked his legs, which led Ana to smile. She visited Paquito at the NICU as often as she could, about 3–4 times a week, but did not hold him until he was 4 weeks old. When asked how that felt, she looked worried saying that he was so small that she was afraid she would hurt him. Paquito was discharged after 7 weeks (38 weeks gestation) and was brought back to the cousin’s home. Two weeks later, she, Frank, and Paquito moved into their first apartment, only to separate and move into the shelter 2 weeks after that.

Current Members and Household

Ana described her living arrangements at the shelter as horrible. She and Paquito share a room which cannot be locked, and money, clothing, and diapers are often stolen. When the interviewer asked if the supervisors in the shelter know about these events, she laughed and said that they do not care. She has made one friend in the shelter, another young mother with a baby girl close to Paquito’s age, whom she hopes to live with when they are forced to leave the shelter in 18 months. When the interviewer inquired about others in her life with whom she feels close and who she sees as supportive, Ana mentioned her wish to be with Frank again, “when he can support us.” She also mentioned the FQHC social worker, Kaitlin and the nurse at the hospital who helped her get diapers and formula, Rebecca. She said that she speaks with her mother often by phone and sometimes by “FaceTime,” but that she has not seen her mother since she moved up north. 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 65

History of Significant Caregivers, Moves, Separations, Trauma

As the interviewer showed interest in her early life, Ana appeared to feel more comfortable and spoke about her early adoption and life with her adoptive parents. The Interviewer asked if Ana ever thought about her birth family and Ana shared her unsuccessful efforts to learn about them on the internet. She said that she feels she looks like her birth mother and like the indigenous people in that area of the country. When the interviewer asked about places she had lived, she said that her adoptive mother moved four times after her adoptive father left them because she could not pay the rent. After high school, she remained living with her mother and began working. When she met Frank and became pregnant, she moved with him to the north, where she had lived in several places before landing at the shelter. The interviewer asked about any times in her life when she felt frightened or when something “scary” or “terrible” happened. Ana paused for a few moments, as the interviewer remained silent and waited patiently, looking at Ana, but not staring. She then shared that once when she was 13, her adoptive mother was drinking with a guy she met at a bar and took him home. Her mother fell asleep. The man entered Ana’s room and entered her bed. He began to touch her and she screamed at which point, her mother ran in and screamed at the man, hitting him with the lamp on her bed stand, and he fled. Her mother asked if he had sex with her and she said no, then left the room to go to bed. The interviewer asked if she and her mother ever spoke about what happened and she said no. The interviewer listened with silence and compassion and wondered if she had ever told anyone before. She said that when she first met Frank years later, she told him and he wanted to go to her home and beat her mother. As Ana recounted these events, she looked frightened and she picked up Paquito and held him on her lap facing her. He looked at her and placed his head on her chest and then grabbed her nose. The interviewer commented on how Paquito was attuned to her and on how frightening that must have been, and Ana quickly regained composure, and said that “she had to get tough” when she was growing up, and now take care of her baby.

Educational Skills and Employment History

When the interviewer asked about her education, she said proudly that she had graduated high school and was a really good biology student. She said that she thought of applying to a BSN program in college but her mother could not afford that. Her school guidance counselor suggested community college, but she decided to work instead so she could have money. She described several jobs in the local area, including as a retail clerk at a clothing store in a mall in her hometown which she held for several years before meeting Frank. When the interviewer asked about work, she said that she cannot work now because she has to take care of Paquito. When she said this, she placed Paquito back in the infant seat and he began to fuss and cry, to which she replied, “See what happens? He is always wanting my attention! How can I work?” 66 G. Costa and C. R. Noroña

Access to Services

The interviewer asked Ana about income, health care, clothing, and transportation needs. The family was enrolled in Medicaid health care which is accepted by the FQHC and the hospital. Ana then asked if she had to pay for the visit today and the interviewer explained that Medicaid covered the services. She said that the shelter provides food and that she tried to save money, but her small savings were stolen at the shelter; she now carries all her money with her. She also said that a Medicaid “livery service” covers transportation to the FQHC and hospital and that she walks with Paquito in the stroller and she uses her money to pay for buses if she needs to go to a store that is not in walking distance.

Involvement of Collateral Agencies

The interviewer asked about agencies from which Ana and Paquito receive services and she mentioned the FQHC and the hospital. Asked about the shelter, she expressed the feeling that it was a place to live but she does not like it there and does not feel safe. The interviewer asked about any meetings, workshops, or programs there and she remarked that she sometimes goes to a “parenting” program they have, but that she does not need help as a parent. The interviewer noted that she and Paquito receive services from the Early Intervention Program (EIP) and she smiled and said that her provider is named Ryann, and that she visits her and Paquito at the shelter twice a week to “play” with Ana and Paquito. She said that Paquito “loves” Ryann and that she shows Ana some exercises that will help strengthen Paquito’s “trunk” since he has “low tone” because he was born prematurely. The interviewer commented on how wonderful it was that Ana knew so much about Paquito’s development and she smiled, stating, “He’s my son and I have to learn all I can to help him grow.” The interviewer noted that the referral to this program was a new one for her and was made by DCF. Ana, again expressed anger at the referral and at the staff at the shelter. She said that the DCF Caseworker, Tamara, was very nice when she first met Ana, but that she does not trust DCF. Ana remarked that when Tamara mentioned the “Infant-Parent Mental Health Service” at the hospital, she said that she did not need “no mental health counseling” but agreed since she and the baby could come together. When the interviewer asked if she was “okay” with this “interview and learning your history,” so far, with asking “all of these questions,” she smiled and said, “It’s okay, I guess. I don’t mind your questions and Paquito seems to like it here.”

Current Medical/Dental and Mental Health

The interviewer asked about health care and Ana again spoke about the FQHC and the hospital services, where she and Paquito receive care. She said that a pediatrician at the FQHC sees Paquito for regular “well-baby” visits and when sick. She 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 67 volunteered, with evident pride, that he is “up to date” with his immunizations, and that he is a healthy baby. In asking about dental care, she said that Paquito had been on “amoxicillin” for an ear infection when he was 9 months old and that neither she nor Paquito are currently taking any medication.

Legal Involvement and Concerns

In asking about this area, Ana said that she is not involved “with the law or the cops and want that to stay that way.”

Immigration Status and Concerns About Documentation and Deportation

Ana is a US Citizen as both of her adoptive parents are US citizens. She said that when she lived briefly in the home of Frank’s cousins, the female partner was an undocumented immigrant from Mexico with a young child who was concerned about being deported and separated from her child. The fear of drawing attention to her family and their public housing unit was partially the reason why Ana and Frank moved.

Concrete Needs, Housing, Safety, Food, Financial Needs

In asking about housing and daily needs, Ana looked concerned and said that all she does is dream about having her own apartment. She must leave the shelter after 18 months, and she noted that was less than a year away. She hopes that she can get help in locating housing, and while she has discussed living together with her friend from the shelter, she also hopes that Frank “finds a job that can support us as a family.”

Protective and Risk Factors

The interviewer reflected that the history of separations and moves, the poor quality of familial relationships, the current separation from her fiancé, and the absence of a larger social supports must make it hard to handle stress. The interviewer also noted that Ana did have “protective factors,” including supportive with the FQHC, the hospital and EIP systems, and an identified friend at the shelter. Ana too, appears bright and verbal and was engaged throughout the interview, suggesting that she is capable of working towards helping herself and her child. 68 G. Costa and C. R. Noroña

Family, Cultural, and Religious Values and Sociocultural Context

Ana said that her birth family was reported as “Roman Catholics” but that her adoptive parents were not religious. She stated that Frank was Catholic and that his family is “religious” and go to church regularly. She and Frank began to go to a Catholic church after she lost the female twin. When she asked the priest there if her newborn son could be baptized, he asked if she was “Baptized and Confirmed.” When she said that she was not, the priest said that Paquito could be baptized but that she would have to attend “RCIA” (adult education) classes. She agreed but stopped going after Paquito was baptized. She regards herself as a “Catholic but not very religious.” The interviewer asked if she would like to become part of a faith community, Ana paused and said that she thinks it would be nice to have a group to belong to that “care for each other,” but that she did not like the many “rules” that Catholics have. The interviewer also explored Ana’s beliefs about therapy, play, developmental expectations, and hopes and concerns for her child. Ana shared that she values education and also would like for Paquito to become less dependent on her as this would make him stronger in life. This part of the session was also an opportunity to explore with Ana aspects of her identity. Ana shared her confusion and pain about being an indigenous woman from Guatemala but having lost the connections with her roots. She reported feeling rejected in the USA for her appearance, being asked often by strangers, “Where are you from?” which often makes her feel like not belonging anywhere. The clinician validated Ana’s experience.

Exploring Parent’s Internal Representation of the Child

Using the guide described earlier based on the “Working Model of the Child” interview (Benoit et al., 1997; Zeanah & Benoit, 1995), the interviewer asked Ana if she could talk with her about being a parent and about her relationship with her baby. She asked, “What do you mean?” to which the interviewer replied, “I’d like to ask you some questions about what it was like for you to learn that you were pregnant and other questions about Paquito.” Ana agreed. The interviewer asked questions focusing mostly on areas that had not yet been addressed in the interview. The questions and responses are summarized: 1. What was your first reaction on learning you were expecting? “I was unhappy because I wanted a baby girl and I was hoping I would have a daughter. 2. Follow up question about the loss of the twin and pregnancy with her son. “I was afraid that I was going to die and when I heard that my little girl died, I cried so much and I did not want to be pregnant anymore. I did not want a son because sons become like their fathers but as I felt better, I thought it would be okay.” 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 69

3. How was it for you when you brought your child home? “We had a crib that we got from hospital nurses and Paquito was so small that I was so afraid he would die. We were at Frank’s cousin’s apartment and Frank had to work that first evening home. I called my mother and cried to her. She told me that being a mother is hard work and that I had to get used to it. I stayed up all night and felt so alone.” 4. How would you describe your relationship with Paquito? “I love him but he is so hard to comfort. When he cries I try to hold him but he keeps crying and when I yell at him to stop, he cries more. I am not sure what he wants from me. I thought it would be different to be a mom ... When he falls asleep, he is so cute and I hold and I feel like he is so beautiful.” 5. What do you like about him/her? “He is so cute. When he smiles at me, he makes me happy. I know he loves me and I know he will never leave me. I like to feed him too. He loves to eat.” 6. Name five adjectives that describe your child. Ana paused and then slowly said, “He is cute … he is a devil … he’s so spoiled … he’s happy, and …he’s always so needy. He is stubborn and all or nothing, like me”. At the end of these questions, the interviewer asked Ana if she had any questions or would like to add anything that was not discussed. Ana wondered if everything she said was a secret and wanted to know if her family’s information would be shared with anyone. The interviewer reminded her that everything she shared was confidential and that no one would ever be told any of the interview, unless she gave permission to do so. The interviewer reminded her that the only time she would ever need to share information was if Ana was in danger of hurting herself or others, including her son, and of course, that was not the case. The interviewer told Ana that she was very happy to meet her and she told her about the Infant-Parent Mental Health Services that were available to her at the program and explained the next steps in receiving services, if she decided to return. She wondered if Ana would interested and would agree to meet with the staff here so they can see how they might be able to address her concerns about Paquito. Ana again stated that she does not have any problems but that she would like for Paquito to get help and she wondered if she could come for a few sessions only “to see how they went.” The interviewer explained that she could come to as many sessions as she would find helpful and Ana consented to continue services. She smiled warmly and shook Ana’s hand, and by then Ana had picked up Paquito, who was sleepy and whose eyes began to close as he lay his head on his mother’s shoulder. The interviewer quietly said goodbye to Paquito and patted his back. She then walked Ana and her baby to the waiting room where the van driver was already waiting. 70 G. Costa and C. R. Noroña

Interviewer’s Impressions Based on History

Ana presented as an talkative, engaging and bright young woman who despite not having a choice regarding coming to the program, and the possible fears associated with the referral, was open to the interviewer and to exploring services for her child. She has limited social supports and a tenuous relationship with her fiancé. Her own history of adoption, emotional and physical abuse, separation and loss suggest that Ana might feel insecure and uncertain if people close to her will keep their promises and not abandon her or hurt her. Her own unmet needs and relational trauma may make it difficult for her to read her child’s cues and understand and meet his needs as she often sees Paquito as demanding more attention than she can give. She expressed the wish that he will love her in the way she wished to be loved by her parents She seems to misperceive his behaviors, assigning to them the intentionality of adult behavior. She has difficulty understanding his behavior through a developmental lens. In addition, Paquito’s developmental needs and resemblance to his father might represent a painful reminder of vulnerability and of Frank’s loss and rejection. Anna’s responses to the questions based on the “Working Model of the Child” questions reveal her sadness about losing her daughter, and her “projections” onto Paquito of possible damage, rejection and vulnerability which appear to interfere with her ability to understand his behavior though a developmentally appropriate lens. Her own adoption, abandonment by her adoptive father, and ambivalent relationship with her adoptive mother pose potential risks to her relationships with her son and others. Her wish for a more meaningful relationship with Frank also suggests her reliance on others who appear unable to be with her in a secure, loving way. Finally, while Ana appears less introspective about her own needs and has difficulty adopting a “reflective stance” in imagining the world through her “son’s eyes,” she appears bright and capable of insight when she is engaged in a helping relationship that provides her with a sense of control or choice and when life’s stressors are manageable. The interviewer found herself liking this young woman who, despite her struggles and limited support, conveys a wit and intelligence that will be beneficial to her and her son. One potential threat to the work is that the assigned practitioner must recognize that Ana and her baby may activate the “need to be taken care of” or possible frustration with the mother when she misperceives the child’s feelings and behaviors and dismissed his needs and cues. This can interfere with helping Ana identify and develop her own capacities to grow and parent her son.

Diagnosis and Formulation/Plan

Paquito is a 12-month-old (10 months corrected for prematurity) boy, the son of a 25-year-old mother, Ana and a 27-year-old father Frank. Paquito is a small boy but reported as healthy, receiving early intervention services due to generalized low muscle tone and developmental delay. His mother Ana describes him as “stubborn” “needy” and “demanding.” During the interview sessions, Paquito remained in an 2 The Art and Science of Obtaining a History in Infant and Early Childhood Mental… 71 infant seat while his mother often attempted to use his pacifier and rocking of the seat to quieten him whenever he vocalized to get her attention or to express his wish for comfort. Paquito did not make attempts to explore the space or the toys in the room nor Ana attempted to place him on the floor. Ana and Paquito live in a women’s shelter, and there is diminishing contact between them and Paquito’s father, Frank. They have limited income and limited social supports. There is a history of separation, loss, and abandonment and maternal emotional and physical abuse in Ana’s life, including loss of a female twin early in her pregnancy with her son. The infant–parent relationship needs further exploration, but it appears that Ana is overwhelmed by her losses, trauma, external stressors, including instances of discrimination, and loneliness and while she “needs” the love of her child, she often misreads or misses his cues and opportunities to engage him in an attuned, consistent, and reciprocal relationship. This appears to result in little interpersonal engagement and stimulation for Paquito, and little opportunity for Ana to experience and enjoy motherhood. Paquito presents developmental delays and although his capacity to initiate and “demand” attention are undeveloped, he makes continuous attempts to engage his mother and usually gets her attention only when he cries or tantrums. Ana seems committed to Paquito and to care for him, but her traumatic experiences, losses and grief, limited support systems, and her unfolding abandonment by Paquito’s father are contributing to a possible underlying depression, and emotional unavailability which affects her ability to recognize Paquito’s emotional and developmental needs. Her own emotional needs are clear and she has little opportunities for them to be met. A developmentally based intervention, such as “Circle of Security” and relationally based developmental guidance, or a thoughtful, reflective, and trauma-informed infant–parent psychotherapy such as child–parent psychotherapy is recommended for this dyad. Diagnosis: Axis I: Global Developmental Delay (DC:0-5™, DSM-5). Adjustment Disorder—related to relational/environmental stressors (DC:0-5™; DSM-5).

Summary

A thoughtful, principled, caring, and informed interview and history-taking represents a family’s first experience of the helping systems. This chapter offers the practitioner guidelines on the “how” and “what” of this process when families of infants, toddlers, and young children arrive for understanding and intervention. How it begins and how it ends make an enormous difference in how the family experiences the process, and can influence their decision to engage in the intervention plan. This chapter offers a conceptual framework, guidance, and a detailed structure for conducting an initial interview and history-taking, guided by principles of infant and early childhood mental health. The critical importance of the practitioner’s 72 G. Costa and C. R. Noroña affective and interpersonal stance is emphasized as these are the first ways that caregivers and family members experience the “helping professionals.” Additionally, the need for families to feel “safe” in the experience of being “held” and “listened to” is critically important, as information will not be shared when individuals feels fearful and judged. The chapter offers domains of inquiry throughout the range of life experiences in the family, and useful templates to customize inquiries regarding special circumstances, particularly trauma and human diversity. Finally, a case vignette and the use of the multiaxial system of the DC:0-5™ diagnostic manual are offered as illustrations of the interview process. The interview and history-taking are described a “co-constructed” processes and the goal of these are not to gather ALL information possible, but instead to identify enough information upon which to create a “narrative”—a kind-of “first person” account of what life has been like for this family caring for an infant/child—in order to develop a provisional clinical formulation and statement of the problem, and recommendations on ways to help. More information will always be discovered as the work continues, and information first gathered will almost always be modified as the practitioner and family come to know each other in a therapeutic relationship. What is most important is that the family experiences the history-taking as respectful, safe, and one in which they feel listened to, as they share what is often the most difficult material to disclose.

Acknowledgement No conflicts of interest to report.

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Amy Dickson and Shannon Bekman

Introduction

For many very young children who present for assessment, the key to treatment may lie in their relationships with their caregivers. One of the most important aspects of assessment is understanding the caregivers’ relationship with the child. Standard child clinical assessments cover several important topics such as the baby’s weight at birth, any medical complications and the attainment of developmental milestones (see Chap. 2). An infant/early childhood clinician, however, knows that this does not capture the full picture of the child. Donald Winnicott reminds us all that “there is no such thing as baby” (Winnicott, 1975), meaning that any child is a product of their environment and to ignore this environment is to miss the bigger picture of who this child has become. These relationships are not predicated on just the baby’s characteristics. The caregiver’s capacity to understand the child and their needs is referred to as reflective functioning, while meeting those needs is referred to as sensitivity. Caregivers with better reflective functioning have been shown to have children with improved attachment security due to better parental sensitivity to the child’s needs (Fonagy, Steele, & Steele, 1991). Caregivers who can recognize how their feelings and projections impact their parenting, and who see their child as a unique individual with his/her own needs and personality, will have a healthier relationship with their child and be better able to support this child’s development. Conversely, caregivers can unconsciously place negative projections on their child, such as the young mother who had a violent relationship with the child’s father.

A. Dickson (*) Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA, USA e-mail: [email protected] S. Bekman University of Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 77 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_3 78 A. Dickson and S. Bekman

When discussing her child’s screaming, she sees signs of her son also becoming violent and his assured eventual incarceration as he ages—even though he is only 9 months of age. To understand these relationships more fully, a clinician must assess the caregivers and their influences from the past and the present. This understanding should include learning about the caregiver’s view of their child and of parenting. Subconsciously, every individual develops an “internal working model” of how they relate to others in their environment. As defined by John Bowlby, the internal working model is a cognitive framework comprising mental representations for understanding the world, self, and others. Infants initially experience their world through the lens of the caregiving environment. For infants, their internal working models stem from the relationship with their primary caregiver (Bowlby, 1969). An infant who is loved by a calm caregiver trusts that when they are hungry and cry to be fed, they will be fed. When caregivers respond sensitively and consistently, infants come to trust the adults in their environment to care for them and meet their needs. When this well-cared for infant must separate from their primary caregiver, say to attend care outside of the home, they carry with them the belief that other adults will meet their needs. For example, an infant will signal hunger by crying at daycare and believe this will be met with a response and eventually food. Internal working models change based on new information. If a once responsive caregiver stops responding as in the case of a depressed or substance-abusing parent, the infant may stop signaling that they are hungry as they do not expect comfort or care. Critical to understanding the caregiver’s relationship with the child is assessing both the caregiver’s and the child’s internal working models. While infants cannot share verbally how they view others, a well-trained clinician can infer much about these working models and the relationship by observing the caregiver–child dyad. An infant who freezes and stills with a wide-eyed expression when they hear a certain voice is communicating that they are frightened by that person and perceive them to be a danger. While the young child’s working models are mainly shaped by the responsiveness of their environment, the caregivers’ working models of the child are more complex. A caregiver’s view of a specific child is influenced by memories of their own parenting, their hopes and fears for this child, whom the child resembles and what is triggered in the caregiver when they look at the child. A host of influences from the past and the present, including experiences, thoughts, and emotions all influence how this caregiver will respond to a particular child. Fortunately, there are several avenues to assist the clinician in understanding the various influences that are affecting the caregiver’s relationship with and working model of their child. Simply engaging in the process of exploring the caregivers’ view/ understanding of the child, a clinician can prompt caregivers to uncover memories and feelings of which they were not consciously aware. This can begin the process of working with caregivers to move to a more reflective and emotionally available place where they can better meet the child’s needs. A key aspect of understanding parenting is understanding the current stressors on the caregiver, the caregiver’s functioning in their environment, their past and present traumas, the caregiver’s views of their child, and the caregiver’s own memories of their childhood. 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 79

When working with difficult to engage caregivers, such as court referred caregivers or caregivers who must seek services for their child to be returned to school/nursery, interviews focused on the caregiver’s perception can open the door to establishing a working relationship with their clinician. This may help set the stage for a collaborative therapeutic relationship in which the caregiver understands that the therapist is interested in the caregiver’s thoughts and views as the expert in their situation, and will work with the caregiver to try to understand the challenging behavior and help the caregiver figure out a solution. Parenting is the product of many different influences. Caregivers bring into the moment their own experience of being parented and their individualized perceptions of each child, all of which is impacted by cultural values and current environmental influences and stressors (Ayoub, Fisher, & O’Connor,2003 ). Was the child the product of a planned pregnancy or an unplanned one? How does one parent feel about the other? How does a grandparent caring for a child feel about the parents? How does the foster parent feel about the biological parents? How is the caregiver’s family and support system reacting to this addition, are they supportive or condemn- ing? How does the caregiver feel about the sex of the child? How do their feelings about the fetus/infant change if they are sick throughout their entire pregnancy? Can they handle this child with the other stressors in their lives? All of these influences set the tone for how the caregiver feels about the child even before the child arrives (Benoit, Zeanah, Parker, & Nicholson, 1997). Then, their early interactions with the child may change these initial feelings and/or intensify them. A parent who initially feels unprepared to have a child and is anxious and worried as to how they will parent, may fall in love with the small infant and begin to feel pride in their role as the infant’s provider who works hard to keep the child healthy and safe. Conversely, an infant may be born resembling the perpetrator who assaulted the mother and she finds herself struggling to look at, hold, or bond with her baby. Mothers who have so desperately wanted a child are shocked when they experience postpartum depression and they do not feel a strong bond or love for their child as they struggle to cope with their current depression. Furthermore, cultural influences predominate and impact the representations of the child and how caregivers relate to the child. A caregiver’s culture may encompass their ethnicity, religion, identified sex/gender, their age group, etc. but it is also largely influenced by their own family’s culture of parenting that has been passed down to them and the culture of the community in which they live. Culture impacts the ways caregivers respond to an infant’s cues and how the caregivers perceive their role in the infant’s life. A young parent may instinctively go towards their infant who is crying only to be admonished by the elder relative with whom they live not to pick up their child as they will spoil them. Thus, while some knowledge about a caregiver’s culture can be accessed consciously and declaratively, for example in interviews (see Chap. 2), much culturally guided knowledge exerts its influence through internalized rules that govern how we find meaning in routines and social interactions, silently, without reflection and without awareness (Vaisey, 2009). There is much debate how one’s culture impacts an individual’s attachment style and internal working models. Some theorists postulate, like Bowlby, that attachment 80 A. Dickson and S. Bekman is universal and exists across all cultures. Others discuss differences noted in some populations, such as lower income African-Americans who may have a harsher style of interacting to breed toughness, an advantage in a harsher community environment, or the Japanese value of collectivism over individual’s needs (Agishtein & Brumbaugh, 2013). Venta, Munoz, and Bailey (2017) caution against assessing working models if the interviewee is not being addressed in their native language as they may not be able to fully express their thoughts and perceptions as well as they would in their native language. It is always important for the clinician to understand the various influences of a caregiver’s culture and incorporate that into their understanding of how the caregiver views the child. Many of these influences will be spontaneously brought up during a formal assessment, such as the Working Model of the Child Interview or the Angels in the Nursery Interview, and some may need to be asked more thoroughly in the clinical interview to gain a more comprehensive picture. In understanding parenting and the dyadic relationship, it is also critical to explore the caregiver’s own trauma history. This can be done through an unstructured clinical interview, or in a more standardized manner by using a questionnaire like the Life Stressors Checklist—Revised (Wolfe, Kimerling, Brown, Chrestman, & Levin, 1997; available from http://www.ptsd.va.gov), the Life Experiences Survey (Sarason, Johnson, & Siegel, 1978) or one of numerous trauma screeners such as the Trauma Symptom Checklist (Briere & Runtz, 1989), or the Trauma Symptom Inventory-2, Caregivers who have a personal trauma history may struggle with the unconscious projections from their past or memories of their traumas at the hands of others that influence how they currently respond to others in their environment. Caregivers may or may not be aware of how their past affects their current relationships and approach to their environment. Infant clinicians refer to those unconscious memories as “ghosts in the nursery” (Fraiberg, 1975). Learning about and understanding the impact of those “ghosts” is part of the assessment of the caregivers internal world and parenting experience. Those who have been the recipi- ent of less than optimal caregiving bring those memories and lack of nurturing and appropriate parenting skills into this new relationship. For example, if a caregiver was often beaten as a child for any minor infraction, their reflex as a caregiver may be to hit their child when frustrated as they have internalized this response. Any caregiver who blurts out an old adage from their parent (that they strongly disliked hearing as a child and swore they would never utter to their progeny) understands that these memories live within us and surface at times of high emotion. To refrain from hitting their child takes reflection and work to establish a healthier response system. If the caregiver is capable of refraining from hitting the child when angry, but still cannot be emotionally available to their child and meet their needs, the caregiver may feel this is an acceptable compromise as they are providing less harmful care than their own caregivers provided to them and may see little wrong with their behavior. This is indeed a positive step, but a child with a caregiver who is emotionally unavailable does not develop a healthy sense of self and can begin to act out behaviorally while they suffer emotionally. This child may not learn that they are worthy of love and care and they have great difficulty understanding emotions and expressing their needs appropriately to others. 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 81

Children’s behavior can also “trigger” caregivers’ trauma responses, in that a behavior by a child can cause an extreme or inappropriate reaction from the caregiver as the caregiver is overwhelmed by emotions from their past and reflexively responds, often in a defensive manner (Schechter & Wilheim, 2009). For example, when toddlers hit to express their displeasure as they do not yet have the words to share their feelings, caregivers can be triggered by their memories of intimate partner violence in their past and can overreact to this behavior by harshly disciplining the child, or can conversely become afraid of their small child and withdraw from them. A caregiver with an abuse history experiences the swatting from their toddler in a very different manner than a parent who has never been abused. They may become scared of their child, or strongly dislike them and be unsure why. In treatment, this caregiver will hopefully uncover that the child has triggered memories for their past that caused these strong emotions and reflexive behavior on their part. Many caregivers have children so they can be loved by someone. For many young caregivers, having a baby may fill an emotional void for them and lead to poor boundaries. They may speak of their infants as their best friend and someone they can talk to about their problems. The dyad may experience difficulty when the infant begins the normal developmental stage of individuation and begins walking and starts to venture away from their caregiver. Caregivers with histories of neglect or fragile emotional states often see this as a rejection instead of a cause for celebra- tion that the child is progressing developmentally. Conversely, there are many caregivers who do not breastfeed because of a history of sexual abuse. Caregivers can also become overprotective of their child when their child reaches the age that their abuse began. Thus understanding caregiver ghosts, working with them and banish- ing them is an integral part of the assessment and treatment process in infant and early childhood mental health. To address difficulties in the caregiver–child relationship, Child–Parent Psychotherapy is often utilized (see Chap. 10). This evidence-based treatment involves a caregiver and a child in the room together with the clinician exploring how to read the child’s cues and meet the child’s physical and emotional needs. The caregiver explores with the clinician their own ghosts and what they hope for their child and their relationship. Some caregivers enter the clinical environment with their child and can speak freely about their prior traumas as they have dealt with them or explored these in a previous course of therapy. These caregivers do well in this form of dyadic treatment as they begin to explore the impact of their previous experiences in their role as a parent. Other caregivers have never disclosed their trauma history, or they have disclosed, but were not supported or have never received any treatment to help them process their experiences. These caregivers will have more work to do in their treatment with their child as they begin the important process of exploring the impact of their past traumas on themselves and then how this translates to their parenting. Caregivers may also have “angels” in their nursery (Lieberman, Padron, Van Horn, & Harris, 2005), benevolent figures who made them feel loved and cared for and who represent warm memories. If a caregiver’s mother sang them to sleep each night and they recall this with fondness, this new caregiver is likely to continue this 82 A. Dickson and S. Bekman tradition with their baby. Phrases long consciously forgotten can be triggered by their child and resurface. This can be positive when a caregiver recalls a pet nick- name, a fun game, or a phrase of encouragement, or negative when a caregiver recalls comments negating the child’s importance or worthiness of care. Sometimes, these memories need to be drawn out and recalled to encourage warmer interactions with their child. It has been shown that recalling the angels can mediate some of the impact of the ghosts by helping parents access their own experiences of feeling protected (Narayan, Ghosh Ippen, Harris, & Lieberman, 2017). A study of the “Angels in the Nursery” interview, found that mothers with very low angel memories and higher levels of childhood maltreatment had higher levels of adulthood Post Traumatic Stress Disorder (PTSD) symptoms. However, mothers with high levels of childhood maltreatment did not show significant PTSD symptoms when these mothers were able to recall even fleeting memories of kind and nurturing caregivers (Narayan et al., 2017). Thus, even transient memories of feeling loved and cared for can impact a caregiver’s ability to be a more nurturing parent and can mediate the amount of distress they feel when with their child. If a mother had significant ghost memories, but also significant angel memories, Narayan et al. found these mothers to still have high levels of warmth, though they also had high levels of negative affect. Thus, in order to fully understand a child’s behaviors, one must view that child within their environment. Of central importance is the child’s relationship with their caregivers and to understand that relationship, one must access the unconscious internal working models, both angels and ghosts, that the caregivers have of the child. Although this chapter focuses on the caregiver’s perception of and relationship with the child, in addition to these assessments, it is also important to note that attention should be paid to assess the caregiver’s own general functioning. Many young children’s behavioral issues are linked to their caregiver’s wellbeing. A depressed parent is often emotionally unavailable to their child. A psychotic caregiver can be frightening and unpredictable and it is difficult for a child to build a pattern of responding in this chaotic environment. A caregiver who is homeless or in a violent relationship has additional challenges that may prevent them from being able to fully meet their child’s needs. However, this chapter will focus on assessments of the caregiver’s internal working models, while noting that a thorough interview should also include assessments of the caregiver’s trauma history and emotional well-being (see Chap. 2). The following sections highlight caregiver’s representations by focusing on the several semi-structured interviews. The model of relationship evaluation guiding the interviews reviewed in this chapter is attributable to Stern-Bruschweiler and Stern (1989). The model highlights the need to assess not only overt caregiver– infant interactions, but the caregiver’s representations of their infant. Several tools that specifically assess the caregiver’s internal representations will be reviewed. Some of the assessments are part and parcel of specific infant mental health interventions (e.g., Circle of Security Interview) and others are stand-alone, intervention- neutral instruments that can be used as part of an assessment that informs any infant mental health treatment. 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 83

Adult Attachment Interview

The Adult Attachment Interview (AAI; George, Kaplan, & Main, 1984, 1985, 1996) was designed to assess an individual’s “overarching state of mind with respect to attachment” (Main, 1995, p. 437), by probing how individuals think and feel about their own childhood attachment experiences. Prior to 1985, the field of attachment was focused on assessing the observable manifestations of attachment behaviors in infants during the Strange Situation Procedure (SSP; Ainsworth, Blehar, Waters, & Wall, 1978). However, the methodological contribution of the AAI and its use of narrative discourse analysis enabled researchers and clinicians to empirically study the internal world of mental representations of adolescents and adults. This “move to the level of representation” (Main, Kaplan, & Cassidy, 1985) extended attachment theory to become a lifespan phenomenon (Steele & Steele, 2008). The AAI was designed to consider and evaluate what Bowlby had theorized and termed “internal working models” (Bowlby, 1973). Internal working models are mental representations or templates that tend to operate largely outside of conscious awareness and serve as guides within relationships. They are useful in appraising and guiding behavior by using the knowledge of past events in dealing with the present and future. These mental templates represent a person’s attachment history, expectations of relationships, and complementary views of the self. Internal working models have been referred to as the “unthought known” (Bollas, 1987; Powell, Cooper, Hoffman, & Marvin, 2016) because our ways of being together in relationships are encoded in our minds and bodies in the earliest weeks, months, and years of life before verbal memory is established. The unthought known operates out of procedural memory and thus individuals are unaware their behavior and experiences in relationship are being guided by very early memories of relational experiences. In this same vein, Main has described the AAI as designed to “surprise the unconscious” (Main, 1995, p 437). Because internal working models operate outside the scope of conscious awareness, individuals are unable to verbally report upon them. The elegance of the AAI is its ability to tap these mental representations of self and other that operate outside of awareness. The questions in the AAI take the adult back to highly emotional events in early childhood, times when the individual’s attachment system was likely activated, and offers a test of the extent to which one can remain coherent and collaborative when thinking and reflecting upon these emotionally charged memories.

Format and Administration of Interview

The AAI is a structured interview composed of 20 questions (and follow-up probes) that explores how adults and adolescents think and feel about their childhood attachment experiences. It asks individuals to describe their childhood experiences with primary caregivers, share their thoughts and feelings about the influence of their 84 A. Dickson and S. Bekman childhood experiences on their adult personality, and reflect on the reasons caregivers may have behaved the way they did when the individual was a child. Other interview questions focus on the present day, inquiring about the nature of current relationships with the interviewee’s parents/caregivers. The AAI also includes questions that probe for experiences of trauma and loss occurring throughout an individual’s lifetime. It ends by asking what the interviewee wishes for his or her children’s future (or imagined children’s future) and what he or she would want his /her children to learn from his/her parenting. (Main, Hesse, & Goldwyn, 2008). The interview typically takes one hour to administer and is audio-recorded for later verbatim transcription and classification. Responses to the interview questions are coded according to a technical manual (Main, Goldwyn, & Hesse, 2003) that results in classification of an individual’s “state of mind” with regard to attachment into one of five categories: secure-autonomous, dismissing, preoccupied, unresolved/disorganized, or cannot classify. The AAI is different in that one’s classification is determined by the coherence and clarity of the interview narrative as opposed to its manifest content. As stated by Van Ijzendoorn & Bakermans-Kranenburg (1997, pp. 138), the AAI “was a simple but revolutionary shift in attention from the ‘objective’ description of childhood experiences to the current representation of these experiences, and from the content of autobiographical memories to the form in which this autobiography is presented.” This is contrasted with interview formats that emphasize an interviewee’s direct report of family experiences, be it positive or negative, and drawn conclusions or predictions based on the reported childhood experiences. From the perspective of the AAI, assignment into an “organized” state of mind classification has no direct or consistent link to a speaker’s stated life experiences (with the potential exception of having very high scores on ‘loving’ subscale, described below) in the same way that a speaker’s report of negative life experiences does not dictate an insecure or unresolved/disorganized classification. It is the overall coherence that determines classification; this is of particular importance to psychotherapists because while life history is immutable, coherence can change (Main et al., 2008). As Wallin (2007) notes, it is one’s stance of the self toward experience that predicts attachment security better than the facts of personal history themselves.

Brief Explanation of AAI Classification and Scoring

As noted above, there are there are five major AAI attachment classifications. These include the three original “organized” classifications: secure/autonomous, insecure/ dismissive and insecure/avoidant as well as two categories that were later added: unresolved/disorganized and unorganized/cannot classify. Beyond these five major classifications, the three organized categories of the AAI are divided into 12 sub-classifications. Scoring of the AAI includes three methods of transcript analysis. The first method involves reading and coding transcripts with attention to the “probable experience scales.” These five 9-point scales have coders rate an interviewee’s 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 85 inferred experiences of loving and unloving behavior as experienced with each parent during childhood. Next transcripts are coded on eight 9-point scales describing language usage as it pertains to “state of mind with regard to attachment.” These continuous scales include the “coherence of transcript” scale, which has proved to be of primary importance and is most closely identified with adult security and predictive of infant security (Main et al., 1985). The third and final reading of transcripts involves a “feature analysis” in which coders classify AAI transcripts into the best fitting organized classification and subclassification, even if later it will be determined that the transcript is not organized. Further details about the specifics of the AAI scoring and classification of transcripts are beyond the scope of this chapter; however, several excellent introductory resources exist (see Hesse, 2008, 2016; Main et al., 2008). Formal training in the analysis of the AAI is available to clinicians and researchers and occurs during two- week long intensive institutes facilitated by one or two certified trainers. Trainings are offered throughout the United States, as well as in Canada, Mexico, Europe, Asia, and Australia. In order to become certified, upon completion of the 2-week intensive training, one must pass a reliability check across 30 transcripts with certified trainers; this process usually takes 18 months. Further information about AAI certification and trainings can be found on June Sroufe’s website, www.attachment- training.com.

Empirical Research on AAI

We highlight the AAI in this chapter because it has attracted widespread attention from clinical psychologists, psychiatrists, clinical social workers, and other mental health professionals and is a uniquely valuable clinical instrument. It is particularly salient to the infant and early childhood mental health field because of its predictive power with regard to quality of children’s attachment classifications. When administered to caregivers, each of the five major adult attachment classifications has repeatedly and systematically been associated with the attachment classification of the child of the interviewee. Parents rated as secure/autonomous on the AAI tend to have babies classified as secure in the Strange Situation procedure (SSP); parents classified as dismissing in the AAI tend to have children classified as avoidant in the SSP and parents rated as preoccupied in the AAI tend to have babies classified anxious/resistant (Van IJzendoorn,1995 ). Additionally, research has demonstrated well-established associations between parents rated as disorganized/unresolved or unorganized/cannot classify on the AAI and their children being classified as disorganized in the SSP (Van IJzendoorn, 1995; Madigan et al., 2006). In addition to a caregiver’s AAI status being linked to their children’s SSP attachment classification, a recently published longitudinal study demonstrated that first- time mothers’ AAIs collected during pregnancy predicted their first-born children’s reflective functioning as scored from the AAIs of their first born children 17 years later (Steele et al. 2016). 86 A. Dickson and S. Bekman

The previously emphasized point that negative or traumatic early childhood experiences do not predestine one to an insecure or disorganized state of mind, is supported by the concept of “earned security” (Phelps, Belsky, & Crnic, 1998; Roisman, Padro’n, Sroufe, & Egeland, 2002; Sroufe, Carlson, Levy, & Egeland, 1999). Earned security is a subclassification of secure/autonomous AAI status reserved for speakers who experienced adverse or highly unfavorable childhood experiences, but have nevertheless achieved a secure state of mind. This earned secure status may be achieved through experience in a warm, loving romantic relationship or a course of psychotherapy. These nurturing experiences serve to positively reorganize an individual’s internal working model of self and other. Saunders, Jacobvitz, Zaccagnino, Beverung, and Hazen (2011) have demonstrated that speakers with an AAI subclassification of earned-secure are just as likely as speakers with “continuous” security to have infants coded as secure in the SSP.

Working Model of the Child Interview

Following in the footsteps of Mary Main’s work on the AAI, and the knowledge that a caregiver’s early experiences in life profoundly affect how an individual perceives, interprets, and experiences relationships with others, Zeanah and colleagues developed the Working Model of the Child Interview (WMCI, Zeanah, Benoit, Hirschberg, & Regan, 1994). The WMCI is an hour long semi-structured interview designed to assess caregivers’ internal representations of their infant or young child. Unlike the AAI which assesses a caregiver’s overall attachment representations of self and other, the WMCI assesses parents’ child-specific internal representations and subjective experience of their young child and their relationship. Zeanah notes that the WMCI was grounded in the knowledge and evidence that parents develop highly specific and different representations with each of their children (Zeanah, Keener, Stewart, & Anders, 1985). The interview was designed to be administered to parents of children ages birth through 5 years of age, but also is frequently administered to caregivers during pregnancy and a prenatal version has been developed for this purpose. It can be administered to biological parents, kinship caregivers or foster parents, with slight modifications to some questions. It requires no special equipment, although audio or video recording is recommended, especially for clinical use in which video replay with the caregiver may be helpful. When administering the interview, ideally the child should not be present, so as to ascertain a caregiver’s internal representation, rather than having responses be influenced by the child’s contemporaneous behavior. It should be noted some practitioners have found it helpful to have an infant present during the interview to help elicit a caregiver’s memories. However, we caution against practitioners allowing young children to be present who have developed receptive vocabulary, as one would not want them exposed to potentially hostile representations that may arise in the course of an interview. Additionally, it should be highlighted that when working clinically with multiple caregivers, the interviews should be conducted separately. 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 87

The interview begins with a developmental history of the infant and the parent’s relationship with the infant. Initial questions ask about pregnancy, probing for whether it was planned or unplanned, how labor and delivery proceeded, the parent’s reaction to first seeing the infant as well as the family’s response to the birth of the infant. Following inquiries about developmental milestones and the parent’s early sense of the baby’s intelligence, the interview asks about daily routines, and both the baby’s and parent’s reactions to any early separations. Then, very similar to the AAI, the WMCI asks the caregiver to provide five adjectives to describe the baby’s personality and provide specific memories to support the selection of each adjective. A later question asks the parent to provide five adjectives to describe their relationship with the infant and again provide specific memories to support each adjective choice. Questions that follow ask who the child reminds the parent of, and how the child and is both like and unlike each of the parents. Caregivers are asked to reflect on what pleases and displeases them about their relationship with their baby and how they expect that to change over time. Later questions ask caregivers to report upon infant behaviors that are challenging for them and how they react when the child is physically hurt, emotionally hurt or sick. Drawing again from the AAI, the interview asks caregivers how they perceive their relationship with their child has affected their child’s development. The interview ends by asking caregivers to think about their young child as an adolescent and an adult and what their hopes and fears are for these times in the child’s development.

Scoring

There is a scoring system that is used for research (Zeanah, Benoit, & Barton, 1996); however, it should be noted that formal scoring is not required when the WMCI is used clinically for assessment or treatment planning purposes. Nevertheless, knowledge of the scoring criteria described below can be helpful in clinically understanding the content of the interview. Scoring begins with six anchored, 5-point, rating scales that are used to characterize the qualitative features of the caregiver’s representation of the infant: richness of detail, openness to change, intensity of involvement, coherence, caregiving sensitivity and acceptance. These scales are less about the content of what the caregiver is saying and more about the narrative features of their responses (similar to the AAI). This is followed by two anchored, 5-point scales assessing the content features of the caregiver’s representation: infant difficulty and fear for safety. Secondary scales are then rated that assess the degree to which various affective tones color the caregiver’s representation of the infant (e.g., joy, anger, anxiety, indifference, disappointment or other expressed emotion). Following examination of these continuous qualitative and content scales, representations can then be classified categorically. This typology of representations was heavily influenced by scoring of the AAI and Strange Situation Procedure attachment classifications. In the original scoring system, narratives can be classified asbalanced, disengaged, or distorted. More recently, Crawford and Benoit (2009) adapted the original scoring system, which was created prior to the full 88 A. Dickson and S. Bekman conceptualization and validation of the infant disorganized attachment classification, to include a disrupted scale and category that is linked to infant disorganized attachment. WMCI narratives achieve a classification of balanced when caregivers can comfortably describe strengths and weaknesses in their child while maintaining empathic appreciation of their child’s emotional experience. They value their relationship with their child and the child’s individuality. These caregivers demonstrate coherence throughout the interview by providing clear, collaborative responses to interview questions with rich and detailed descriptions of the child. Finally, their representations about the child are open to change as new information and experiences of the child become available. Disengaged representations are characterized by a lack of emotional engagement with the child. An emotional distance from the child is conveyed through answers that are unelaborated and demonstrate a poverty of detail and description. This may be communicated through generic responses describing the child as “normal,” “typical,” or “just like any other kid.” The importance of the relationship is often minimized and in extreme cases the influence of the parent on the child’s development may be perceived as nonsignificant. Lastly, distorted representations are characterized by internal inconsistencies within the representation in which the caregiver is either preoccupied by other concerns, bewil- dered and anxiously overwhelmed by the infant or self-involved and insensitive to the infant as an individual. Descriptions of the infant are likely to be incoherent, confused, contradictory, or even bizarre and as a result the caregiver may have difficulty maintaining their focus on the infant in the interview. These caregivers’ responses tend to lack appreciation of the child’s experience and they may look to the infant for care or concern in an appropriate way. Benoit’s addition of the disrupted classification was heavily informed by the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE, Lyons-Ruth, Bronfman, & Parsons, 1999) which is a behavioral coding scheme that assesses frightening or frightened caregiver behavior that is disorganizing to young children during caregiver–child interactions. The authors of the WMCI disrupted scale translated these frightened or frightening behaviors into frightened or frightening discourse characteristics that can be gleaned from a caregiver’s WMCI narrative. The five dimensions that are coded include those analo- gous to the AMBIANCE: affective communication errors (e.g., reporting or describing a failure to respond to a child’s distress cues, or over the course of the interview contradicting something said related to the infant), role boundary confusion (e.g., when asked WMCI questions about the infant, the interviewee repeatedly references the self), fearfulness/dissociation/disorientation (e.g., during interview caregiver uses a frightened, tense, ghostlike or stammering voice; or speaks of infant as though he/she was an inanimate object), intrusiveness/negativity (e.g., describes response to infant that includes pushing, restraining or grabbing; or describes infant in a way that is mocking/teasing) and withdrawal (e.g., describes an interaction where the infant’s need for contact is dismissed; or describes an interaction in which the caregivers directs the infant away from herself via toys). For example, in the course of a WMCI, a caregiver may describe an incident in which her infant was 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 89 crying in distress, motioning with his arms to be picked up and the caregiver redirects the infant to play with toys instead of meeting infant’s need for physical contact.

WMCI/Infant Attachment Concordance and Empirical Research

In the decades since its inception, the WMCI has been used extensively in clinical settings and rigorously evaluated in research (Vreeswijk, Maas, & Van Bakel, 2012) establishing it as a valid and useful clinical and research instrument. Its usefulness is most clearly demonstrated in the studies showing links between the WMCI classification and infant’s attachment classification as measured by the SSP. Research findings show that WMCI representations of balanced, disengaged, distorted and disrupted systematically correspond to infant’s attachment classifications of Secure, Avoidant, Resistant and Disorganized, respectively (Benoit, Parker, & Zeanah, 1997; Crawford & Benoit, 2009; Zeanah et al., 1994). These associations are true when the WMCI is administered during pregnancy as well as when the child is 12 months of age. The three original WMCI classifications also distinguish clinical groups from nonclinical groups (Benoit, Zeanah, et al., 1997; Coolbear & Benoit, 1999; Vreeswijk et al., 2012; Zeanah & Benoit, 1995). In their review of the empirical research conducted using the WMCI, Vreeswijk et al. (2012) found that balanced representations were more common among nonclinical mother–infant dyads whereas disengaged and distorted representations were more prevalent when either the mother or infant was experiencing a medical or psychiatric problem. The studies encompassed in Vreeswijk’s review included mothers of infants diagnosed with Failure to Thrive, sleep disorders, prematurity or who were otherwise referred to an infant psychiatric clinic. The mothers in the clinical groups included those with major depressive disorder and those experiencing interpersonal violence. Specifically, in nonclinical populations, approximately 53% of caregivers were shown to have balanced representations whereas in the clinical groups, most representations were classified as disengaged and distorted (Vreeswijk et al., 2012). Although the vast majority of empirical research with the WMCI to date has examined mothers’ internal representations of their infants, more recent work has begun to include fathers. Hall et al. (2014) demonstrated that fathers’ early representations of their infants as assessed with the WMCI not only predicted the future quality of fathers’ behavior, but that it predicted the infant’s interactive behavior. They showed that fathers’ balanced representations were more strongly correlated with favorable behaviors in fathers and infants. Fathers with balanced representations displayed more sensitive and less intrusive or withdrawn behavior with their infants as compared to fathers with unbalanced representations. Furthermore, infants of fathers with balanced representations also scored higher on measures of cognitive development than infants of fathers with unbalanced representations and father’s interactive behaviors were shown to mediate this effect. In addition to the associations with infant or caregiver behaviors, WMCI representations of balanced, disengaged, distorted and disrupted are associated with AAI 90 A. Dickson and S. Bekman classifications of Autonomous/secure, Dismissing, Preoccupied and Unresolved, respectively. More recently, Madigan, Hawkins, Plamondon, Moran, and Benoit (2015) showed in a mediation analysis that the WMCI fully accounted for the association between AAI classification and infant attachment classification. They further noted that a postnatally administered WMCI did not add to the prediction of infant attachment, over and above that explained by a prenatally administered WMCI. Given the systematic and consistent links between WMCI classification and infant attachment classification, the WMCI should be considered as a tool to be used not only in treatment planning with clinically referred infant–parent dyads to identify particular areas of struggle, but it could be used as a screening instrument for pregnant women and/or their partners who could benefit from early perinatal intervention before the arrival of a child who without intervention could be predicted to have a disorganized attachment classification at 12 months based on the caregiver’s prenatal WMCI.

Circle of Security Interview

The Circle of Security Interview (COSI; Powell et al., 2016) will be briefly described here as it will be discussed in greater detail Chap. 4. It is a parent perception assessment that is administered as part of the larger Circle of Security Intervention (COS). COS is a relationship-focused intervention that aims to enhance young children’s attachment security by improving caregiver relational capacity, including caregiver reflective functioning. Prior to a caregiver’s beginning the COSI intervention, the caregiver–child dyad complete a caregiver–child interactional assessment that is videotaped for later review with the caregiver. The dyadic interactional assessment is a modified Strange Situation Procedure (Ainsworth et al., 1978) which involves brief separations of caregiver and child, followed by reunion. The COSI protocol modifies the SSP by including two additional episodes, a reading and clean up. At the end of the SSP, books are brought in and the caregiver is asked to sit on a couch and read to the child for 3–4 min. This is then followed by cleanup of the toys. The COSI is completed following the interactional assessment with only the caregiver present and is filmed for later review by the clinician. The COSI is a clinical interview comprised of 25 questions and follow-up prompts and takes approximately 1 h to administer. Its questions heavily draw from the AAI and the Parent Development Interview (PDI: Aber, Slade, Berger, Bresgi, & Kaplan, 1985; PDI-R: Slade, Aber, Bresgi, Berger, & Kaplan, 2004) and this is reflected in the caregiver capacities it assesses, described below. The PDI is another clinical interview that assesses caregiver representations of the child, the caregiver–child relationship and oneself as a parent, though not reviewed in this chapter as it was initially used predominantly for research. However, a PDI-R is an adapted version that can be used clinically and comes in four different versions. Readers are directed to Slade et al. 2004 for further information. The COSI begins somewhat neutrally by asking the 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 91 caregiver to talk briefly about where the child was born, whether the caregiver has any other children and to talk about the caregiver’s support system. Following this, the caregiver is asked to reflect on various aspects of the caregiver-child interactional procedure, including probes about the caregiver’s emotional experience of various episodes of the procedure, and the caregiver’s perspective on their child’s emotional experience to the various episodes including: separations (e.g., “You were asked to leave the room two times. What do you think that was like for him/ her each time? What was that like for you each time?”), reunions (e.g., “You came back into the room two times. What do you think that was like for him/her each time? What was that like for you each time?”), and clean up (e.g., When you asked him/her to pick up the toys, could you describe what happened?” What do you think that was like for him/her? What was it like for you?”). Following these questions about the interactional procedure, the interview includes inquiries derived from the AAI (and reminiscent of the WMCI), including asking the caregiver to choose five adjectives that describe their relationship with their child and offer specific memories that support selection of each adjective. Later questions ask what brings the most joy as a caregiver to the child, as well as what causes the most pain or difficulty. Probes then ask about fears as a caregiver to the specific child, and how the caregiver handles various moments of parenting challenges. It concludes with having the caregiver reflect upon themselves as a young child, the parenting they received and what the caregiver hopes their child will learn from his/her experiences in relationship with them.

COSI’s Assessed Caregiver Capacities

The questions are designed to assess specific aspects of a caregiver’s capacities and perceptions of their child including: the coherence of the caregiver’s narrative; positive and negative attributions of child and self; what the caregiver values in relationship (e.g., intimacy vs. hierarchy); reflective functioning; empathy for self, the child and others; the caregiver’s primary defensive strategy (known in COSI as a “core sensitivity”) from one of three categories: esteem sensitive, safety sensitive, and separation sensitive. The Circle of Security book (Powell et al., 2016) elaborates extensively upon this assessment and the core sensitivities. They also offer trainings throughout the world on the COS intervention, which includes administration and clinical conceptualization of the caregiver’s responses in the COSI. Training opportunities are listed on their website, www.circleofsecurityinternational.com

The Insightfulness Assessment

Much like the COSI, the Insightfulness Assessment (Oppenheim & Koren-Karie, 2009) is a procedure that first involves structured interactions between the caregiver and the child. The assessment is then completed when the caregiver watches the first 92 A. Dickson and S. Bekman two minutes of each videotaped segment with the interviewer and then is asked specific questions to assess their sensitivity in reading their child’s cues. The Insightfulness Assessment (IA) was developed to assess Ainsworth’s concept of a caregiver “seeing things from the child’s point of view.” Ainsworth firmly believed that caregivers who were able to see the infant as a separate individual from themselves with their own thoughts and needs and who were able to accurately read those needs and then meet the infant’s needs, would have children with more secure attachments to them. Hence, caregivers who were insensitive to their child’s cues and needs would have children who were insecurely attached to them. Oppenheim and Koren-Karie stated that caregivers who could talk coherently about the motives of their children’s behavior, accept these motives, be able to provide a nice multifaceted conceptualization of their child, and be open to what the child’s behavior in the segments suggested would be more insightful about their children and their children would relate more adaptively and in a more secure manner towards them. The Insightfulness Assessment is accomplished by a caregiver and a child being videotaped in three interactions that display caregiving, play, and teaching behaviors. Afterwards, the caregivers are shown the first 2 min of each of the segments and are asked what their child is thinking and feeling in each segment. The caregivers are asked if this is typical behavior for the child and how the caregiver felt while watching the video. Caregivers are asked if they are surprised by the child’s behaviors, if the behaviors were concerning or if the behaviors made them happy. Following this, the caregivers are asked to describe the child’s main characteristics and to portray their relationship to the child. This assessment has been used with children as young as 6 months and up to 18 years (Oppenheim & Koren- Karie, 2013).

Coding for the Insightfulness Assessment

Coding for the IA was based on Ainsworth’s four scales that encompassed the qualities of mentalization she was examining: sensitivity vs. insensitivity to the baby’s signals, cooperation vs. interference with the baby’s ongoing behavior, physical and psychological availability vs. ignoring and neglecting, and acceptance vs. rejection of the baby’s needs. Ainsworth believed that caregivers who showed interest in their child, who were free from projecting their own needs and thoughts onto the child due to their anxieties, who were able to read their child’s unique cues, and who took interest in discussing their child were more likely to have securely attached children. Like many of the internal working model assessments, the IA is coded not based on the specific stories provided, but on how the caregivers speak about the child. The video segments are not watched by the coders who only look at the transcripts of the interviews. This is based on Main’s concept that the coherence of how the caregivers talked was more critical than the specific memories (Main et al., 1985). Interview transcripts are rated on ten scales: insight into the child’s motives, openness, complexity in description of the child, maintaining focus on the child, 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 93 richness of descriptions, acceptance, anger, worry, separateness from the child, and coherence of thought. Based on these assessments, an interview can be categorized into one of four classifications: positively insightful (PI), one-sided (Os), Disengaged (De), or Mixed (Mx). Oppenheim and Koren-Karie hypothesized that PI caregivers were more likely to have children classified as secure, Os caregivers would have insecure-ambivalent children, De would have avoidant children and Mx caregivers would have insecure-disorganized children. Studies with low-risk families bore this out aside from the Mx caregivers having disorganized children as the sample size was small and the risk of the families was low (Koren-Karie, Oppenheim, Dolev, Sher, & Etzion-Carasso, 2002). Paternal insightfulness was also assessed in joint interactions with the mothers. If both parents were insightful, the interactions with the child were coordinated, if only one of the two caregivers was insightful, the interactions were conflictual, and when neither parent was insightful, the interaction was disordered (Marcu, 2013). There was also empirical support for utilizing the IA with caregivers of Autistic and Intellectually Disabled children (Feniger-Shaal & Oppenheim, 2012; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009). These researchers also found that insightfulness explained the variance in attachment beyond that accounted for by sensitivity. In looking at intervention studies that assessed if insightfulness increased, caregivers who were able to improve their insight in regard to their child had children who improved behaviorally and were more secure (Muzik et al., 2012; Oppenheim, Goldsmith, & Koren-Karie, 2004). Thus, the IA provides further evidence that how a caregiver thinks and feels about their child gives the interviewer cues as to how the caregiver will relate to their child and how their child will function in their environment.

Angels in the Nursery Interview

The assessment tools highlighted thus far have assessed either a parent’s overall attachment representations or their mental representations of a particular child, with an arguable emphasis on identifying “ghosts in the nursery”. The AAI can and does assess benevolent influences in one of its later interview questions; however, the Angels interview does so more persistently. In contrast to identifying early relational experiences of fear and helplessness, the Angels in the Nursery Interview (“Angels Interview,” Van Horn, Lieberman, & Harris, 2008) targets a caregiver’s early childhood experiences of having received particularly benevolent care characterized by intense shared affect in which the parent felt nearly perfectly understood, accepted and unconditionally loved (Lieberman et al., 2005). These are benevolent experiences that are believed to bestow a core sense of worth and security to an individual. Lieberman and colleagues contend that just as ghosts may lead caregivers to unconsciously reenact experiences of neglect and abuse with their own children, angels can be protective and growth-promoting forces that an individual draws upon to interrupt the cycle of maltreatment. Similar to ghosts, these benevolent experiences can be unconsciously transmitted from one 94 A. Dickson and S. Bekman generation to the next and should be assessed in the beginnings of infant and early childhood mental health interventions to assist the clinician in promoting helpful therapeutic change in a dyad. The clinician’s possession of knowledge of a caregiver’s angels can be particularly helpful in the treatment of early childhood traumatic stress, where ghosts are likely to run rampant. The clinician can incorporate angels as powerful allies and therapeutic agents infusing knowledge of these benef- icent experiences into treatment to help a maltreating caregiver find empathy for their young child and rediscover their principal role as their child’s protective shield (Lieberman et al., 2005). The Angels interview is a brief, semi-structured interview that consists of seven questions and standardized follow-up prompts that takes 10–20 min to administer. While a coding system exists (see Ghosh Ippen, Narayan, Van Horn, et al., 2015 for manual) and is used in research, administering the Angels Interview without formally coding it can be very clinically meaningful. Like the AAI, the Angels interview can be recorded for later review, however unlike the AAI, verbatim transcription is not necessary so long as the clinician takes detailed enough notes to be able to remember the content of the interviewee’s angel memories clearly enough. Unlike the AAI which asks pointedly about one’s mother and father, the Angels interview does not direct the interviewee to describe memories with a specific caregiver; rather, the interviewee is free to recount memories with any special caregiver, be it an extended family member, sibling, foster parent, or other special figure. The first five questions inquire about childhood memories of benevolent experiences (e.g., “Do you remember a time when you were little when you felt especially loved, understood or safe?”) and query for specific sensory experiences associated with the shared memory (e.g., “Do you remember any smells, sights, sounds or other sensations that are connected with the memory?”). Follow-up questions probe for additional loving memories with same caregiver and whether there are additional loving memories with other special persons. The last two questions were adapted from the AAI and are asked only if the interviewee has been able to identify benevolent early memories. Specifically, these last two questions inquire about how, if at all, the interviewee uses the just recalled loving memories to inform their own positive parenting of their children (e.g., “As we work together, is there anything about these memories that you want to use in raising your child, to help you bring that kind of feeling to you and your child?” and “If I were to see your child 20 years from now, what would you like him/her to tell me about you?”). An example of an angel memory is offered below, with the characteristic sensory perceptions illustrated: When I was a little girl, I can remember going to my grandmother’s house when my mother occasionally had to work on the weekends. My grandmother would make me applesauce from scratch, which she knew was my favorite. She let me help her peel the apples and stir it on the stovetop. I can remember the smell of the cinnamon, and the warm gooey taste in my mouth. I loved those weekends with my grandmother. Although the developmental psychopathology literature is clear on the considerable benefits of having even just one safe, supportive, loving relationship in the promotion of resilience (Sroufe, Egeland, Andrew, & Carlson, 2005; Masten, 2014), empirical research on the clinical usefulness of the Angels Interview in infant 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 95 mental health interventions is just emerging. Narayan et al. (2017) examined whether childhood memories of benevolent caregiving experiences as assessed by the Angels in the Nursery Interview protected against heightened levels of adult psychopathology in high-risk mothers. Results showed that benevolent memories of having received safe, loving care, termed “angel memories” moderated the relationship between childhood maltreatment and adult PTSD symptoms, demonstrating a protective effect. This work lends initial support to the notion of explicitly retrieving angel memories in the course of clinical work and using them as allies against the intergenerational transmission of trauma between high-risk mothers and their young children. Further research will need to explicitly link increased access to memories of benevolent early childhood experiences with positive changes in caregiver–child relationships.

Clinician Assisted Video-Feedback Exposure Sessions

Clinician Assisted Video-feedback Exposure Sessions (CAVES; Schechter et al., 2006; Schechter et al., 2015) is both a research assessment measure and experimental intervention developed by Schechter and colleagues. Their research explores the mental representations of mothers who have experienced interpersonal violence- related PTSD (IPV-PTSD). Specifically, Schechter’s studies have documented how mothers with histories of IPV-PTSD can experience their young children’s routine, developmentally normative intense displays of distress including helplessness, frustration, despair, and anger as triggers to their own posttraumatic stress symptomatology, reminding them of their interpersonally violent perpetrator’s rage and behavioral dysregulation. Schechter and colleagues have described how IPV- PTSD with its implicit self-directed, self-protective focus and inherent dysregulation of affect and arousal, “hijacks” a caregiver’s ability to be emotionally present for her child, accurately read and respond to a young child’s cues of fear or distress and instead redirects her attention to her self-preservation rather than to ameliorating her young child’s distress. Schechter developed this assessment/ brief intervention to help these traumatized mothers tolerate the ‘trauma associated mental states’ in their children and support the mothers to accurately read and respond to their young children’s emotional cues (Schechter & Rusconi, 2014). As such, this clinical assessment/intervention targets specifically for change these distorted maternal mental representations of a young child’s personality, intentions and behaviors and the mother’s associated behavior toward the child. The method of video-feedback was chosen because it allows the caregiver to focus on moments of affectively triggering parent–child interactions from a safe, regulated distance with support from a clinician. The Clinician Assisted Video-feedback Exposure Session (CAVES) intervention uses four selected 30-s excerpts from a previously recorded parent–child interaction procedure: a modified Crowell Play procedure which includes a free play (10 min), first separation/reunion (5 min), clean up (5 min), structured joint-attention task 96 A. Dickson and S. Bekman

(5 min), and second separation/reunion. The four chosen clips are presented to the mother (without child present) in the following order and represent (1) an optimal moment of parent–child play (i.e., containing the most joy, spontaneity, joint attention and mutuality), (2) a moment of separation without mother present (i.e., child alone in playroom), (3) a moment of reunion upon mother’s return, and (4) a moment of suboptimal play. During the video review, the clinician highlights strengths demonstrated by the mother in the dyadic interaction with her child and fosters the mother’s reflective functioning capacity by asking her to describe what her child might have been thinking or feeling in each of the selected moments. As detailed by the Schechter et al. (2006), specific probes to ask following each video excerpt include the following: “Tell me what happened there. Tell me the story of what happened in that moment. What do you think was going on in your child’s mind? … In your mind? What were you feeling then? What were you feeling as you were watching the moment with me? What was your child feeling? Why do you think I chose this moment for us to watch?” The clinician then asks one of the content items from the WMCI (discussed earlier in this chapter), “Please choose 5 words (adjectives) to describe your child’s personality.” If a mother’s attributions of her child have changed from how she previously described her child (in earlier visits with clinician), the clinician asks the following prompts: “What changed?” Do you think that your child changed or that your feelings changed in relation to your child?” Additional queries include: “Whom does your child remind you of in this excerpt?” “Does this moment remind you of any specific moments in your own life?” “On a scale of 1–10, one being the easiest, and ten being the hardest, how was this moment to watch and why?” CAVES has shown promising preliminary outcomes including a significant reduction in the degree of negativity of mothers’ attributions toward their young child following the three session CAVES protocol, for mothers with IPV-PTSD as compared to a community sample (Schechter et al., 2015). This assessment/ experimental intervention may be useful not only as a means of assessing the capacity of a traumatized caregiver to make a shift in her reflective capacity to see a child more sensitively, but also as a potential catalyst to further and deeper psychotherapeutic caregiver–child work.

Cultural Considerations

It is important to note that in each of the caregiver interviews, the caregiver has opportunities to help the clinician understand the caregiver’s own cultural history and how that impacts their parenting. Culture impacts parenting both directly and indirectly. Certain parenting techniques and beliefs can be passed down among generations and can range from traditions with positive implications, such as the entire extended family getting together to welcome the birth of a child to negative implications as in a female child not being valued by the family and provided fewer emotional and tangible resources. All individuals are impacted by their race, gender 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 97 preference, and ethnicity in addition to the cultural values based down to them by the individuals who influenced them throughout their life. If a young parent has been admonished not to pick up their crying infant as it will spoil them, this belief will likely come out in the interviews and early on in treatment. The clinician needs to be mindful that these initial interviews may draw out some, but not all belief systems. It is vitally important that the clinician work to understand the various influences that guide and shape an individual’s parenting. The clinician also needs to be mindful of how their personal beliefs may differ and how to convey respect for the caregiver’s experiences, beliefs, and values while supporting and encouraging the caregiver to reflect on how those may impact their caregiving and their relationship with their child.

Case Study

Intake/Background Information

Roberto is an 18-month-old, Hispanic male. He was referred by Department of Child and Family Services to a community mental health clinic with his biological mother, Sofia, due to “aggressive” behavior at daycare. In addition, Roberto’s mother is concerned that he is a “bully” and would like help managing his behavior. An initial intake was conducted with Roberto’s mother who was a fluently Spanish/English bilingual speaker having been raised in the United States since infancy. Roberto was born full-term, and there were no medical complications during the pregnancy or the delivery. However, Sofia reported that she felt very stressed and received minimal support during the pregnancy. Sofia reported that Roberto had always been a difficult child, and was hard to soothe, ever since he was a newborn. She also stated that he hits her and hits and pushes other children at daycare. He also throws toys and gets “very angry, very quickly.” Roberto’s mother further reported that Roberto cries in his sleep, and she believes he is having bad dreams. Additional concerns include sensitivity to loud noises, startle response and appearing “on edge.” The doctor insists that Roberto is healthy and there is not a medical cause for his behavior. Sofia initially denied that Roberto had been exposed to any traumatic events. However, over time, as she began to trust the clinician and develop more rapport with her, Sofia acknowledged ongoing intimate partner violence between herself and Roberto’s father, which had ended several months prior when Roberto’s father was incarcerated. When asked further, Sofia disclosed that Roberto’s father hit her repeatedly in front of Roberto, and on one occasion choked her. As per her report, Roberto would cry and appear to freeze during these episodes of violence, and would then be very clingy towards her for several hours afterwards. Currently, Roberto lives alone with his mother, as his father is incarcerated. During the week, he is in day care throughout the day and spends the mornings and evenings with his mother. His grandmother, Sofia’s mother, 98 A. Dickson and S. Bekman helps her daughter take care of Roberto and is an important caregiver for Roberto. Sofia’s own father left the family when she was a teenager. He was violent with Sofia’s mother. Sofia did not report any other siblings or family members as support. This was Sofia’s first attempt at seeking professional help for her son. To gather a better understanding of Roberto’s needs and the relationship with his parents, as well as to inform treatment, an assessment of the parent–child relationship was conducted with Roberto and each of his parents. In addition to the relationship assessment, an ideal comprehensive assessment with a young child would also include a developmental assessment/screening, an observation in the child care setting, as well as interviews with other caregivers, such as his teachers. For the purposes of this case study, only the parent–child working model assessments will be described in more detail.

Parent–Child Relationship Assessment with Roberto’s Mother

Parent Perception of the Child Interview: Working Model of the Child Interview (WMCI)

Sofia was initially excited to be pregnant with Roberto, but then felt stressed during the pregnancy. Sofia did not go into more detail at the time that the stressor was related to Roberto’s father’s treatment of her. Sofia was happy to see her beautiful baby and Sofia’s mother welcomed the baby into the world as well. However, Sofia began to struggle with Roberto soon after his birth as he was a fussy child who was difficult to soothe. In describing Roberto’s personality, Sofia chose the following adjectives: mean, strong-headed, independent, and funny. Sofia could not come up with a fifth adjective. When asked about “mean,” she specified that Roberto threw things at her and did not listen to her on purpose. The interviewer asked Sofia to try to recall a specific incident in which this occurred and Sofia stated that the night before Roberto wanted a specific food and when she stated that was not what they were eating for dinner, he threw his cup of water at her head. Sofia described that Roberto is “independent” because he likes to do everything by himself, and does not like to play with her. She added proudly that Roberto could do everything her 3-year-old nephew can do, and did not need her help. Sofia’s specific incident involved Roberto pulling the stool up to the sink, attempting to get his own glass and fill it with water. When asked who Roberto reminded her of, Sofia instantly answered, “His father,” and added, “because of his anger.” Sophia stated that she is afraid Roberto inherited his father’s temper, and will not learn how to control it. She added, “He’s going to do some damage with his temper, just like his father.” Sophia described their relationship with the following adjectives: frustrating, fighting and caring. Again, Sofia had difficulty coming up with five adjectives. She stated that she and her son are always in a fight, but also that they both care about each other. When asked for a specific example, Sofia stated that everything she asks Roberto to do ends up in a fight. She recalled that when she attempted to dress 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 99

Roberto to go to day are that day, he kicked his shoes off and yelled at her as she attempted to put on his socks. Sofia used this example for both frustrating and fighting. When asked for an example of how their relationship is caring, Sofia stated that Roberto could be sweet and just the night before had hugged her when she leaned down to kiss him goodnight. When asked for a favorite story, Sofia struggled at first and then was able to recall a time she and Roberto had fun at the local park and he laughed while she chased him around. When asked about her fears for Roberto as an adult, Sophia stated, “I hope he doesn’t need anybody…that he stays independent. You can’t trust people, you can only trust yourself.” She added that she hopes that he will not get into trouble so that she does not have to “bury him at a young age.” In addition, throughout the interview, Sophia reported that she wants Roberto to listen to her more, and that the most difficult behavior for her to handle is his aggression and his crying. She made several connections between Roberto and his father, especially in regards to the negative attributions including the aggressive behavior. When discussing challenging behaviors, Sofia expressed that she did not know what to do to manage Roberto and everything she tried did not seem to have an impact. Sofia acknowledged with sadness that at times she feels like giving up in her role as Roberto’s parent and that Roberto does not like her and is intentionally distressing her. However, Sofia also expressed hope that Roberto would not be a violent man like his father and would have a happy life as an adult.

Angels in the Nursery Interview

Sofia completed this interview after completing the Working Model of the Child Interview. When asked about a time Sofia felt especially loved, understood or safe as a little girl, Sofia paused, and then replied that she had always felt safe with her grandmother. Sofia described a memory of a time she was baking with her grandmother, and described how she used to stand on a chair so she could reach the table, and her grandmother would let her stir the dough with a big wooden spoon. Sofia softened and smiled as she was telling the story, and then added that whenever she was around her grandmother, she felt like nothing bad would ever happen to her.

Parent–Child Relationship Assessment with Roberto’s Father

Parent Perception of the Child Interview: Working Model of the Child Interview (WMCI)

During the initial evaluation phase with Sofia and Roberto, Roberto’s father, Robert, was incarcerated due to the intimate partner violence. He was then released from jail and wanted to join the therapy when the clinician reached out to him. The clinician scheduled Robert to come in and complete a Working Model of the Child Interview. 100 A. Dickson and S. Bekman

Robert presented with restricted affect, but he was cooperative and answered questions to the best of his ability, gaining more comfort once he felt that the clinician was treating him respectfully and without obvious judgment. Robert’s interview was characterized by his expressed warmth for his son. Robert was excited to learn of Sofia’s pregnancy and had many positive hopes for his son that he would have a better start in life than Robert had experienced. Robert recalled his son’s birth in great detail and shared his pride in his son. Roberto’s arrival triggered Robert to think about his recent lifestyle choices and he vowed to do better for himself and for his son. When asked about specific details in Roberto’s development, Robert acknowledged that Sofia did most of the caretaking while he worked and then he missed much of his son’s development while in jail. When asked what he would change if he could go back, Robert initially stated “many things” and shook his head sadly. He then discussed spending more time with his son and not letting his son see the arguing between Robert and Sofia. Robert recognized that his absence in his son’s life while he was incarcerated was a setback for Roberto. At this time, Robert did not discuss in great detail the impact on his son of witnessing the intimate partner violence, but he alluded to the “arguing” being a negative influence. Robert used all positive words in regards to his son and expressed positive hopes and dreams for his son’s development and future. His favorite story of his son was just that his son existed and Robert spoke of thinking about his son often. Robert did not see any of his son’s behaviors as difficult, and placed all of his son’s behaviors in a developmental framework, stating that he was just a baby and was learning how to behave. Robert briefly mentioned issues with Roberto’s mother, but made no mention of the intimate partner violence or its impact on Roberto.

Angels in the Nursery Interview

When talking about his past, Robert spoke warmly and often about his grandmother who always had positive hopes for Robert and treated him well. Robert acknowledged that his father was around often, unlike many of his peers’ fathers, but Robert’s father actively encouraged Robert to engage in antisocial behavior and Robert was having a hard time pulling away from his father’s negative influence. He felt safer with his grandmother, whom he felt modeled a better way of living and he felt great remorse that she was not alive to meet Roberto. Robert was able to state how lost he had become once his grandmother passed away. He also felt guilty at times as he knew she would be disappointed in some of his recent behavior.

Interpretation and Treatment Planning

The WMCI and the Angels in the Nursery interviews highlighted some strengths and several areas of growth for both dyads. The information gathered from these assessments was incorporated into the treatment with Roberto and his parents. 3 Caregiver Perceptions of the Young Child: Assessment and Treatment Implications 101

After the initial assessment phase, the clinician met with Roberto’s mother to review the assessment and decide on a treatment plan. Overall, Sofia provided a coherent interview with significant detail that demonstrated her daily involvement in her son’s life. Sofia’s interview displayed some balance in being able to discuss Roberto’s positive and negative attributes at this time. However, it was evident from the interview that Sofia was projecting her fears onto Roberto that he would become violent like his father and Sofia overly interpreted Roberto’s emotions as intentionally hostile. Sofia also revealed that she felt unprepared to manage her son’s anger as his behavior was very triggering for her. This was seen in her misinterpreting some of her son’s behavior at times, for example Roberto holding onto his toy and not wanting to clean up, which is developmentally appropriate for his age, as fighting with her. In the dyadic sessions following the initial assessment phase, the clinician provided developmental guidance to Sophia, to help her understand the underlying meaning of her son’s behavior, as well as to help her understand that he was not purposefully fighting her or wanting to hurt her. Although Sofia had some strong negative associations towards Roberto, she also used some positive descriptors to describe both his personality and their relationship. Sofia conveyed her desire for help to be a better mother, and was committed to bringing Roberto to the services he needs. As the sessions progressed, the clinician also supported Sophia in reconnecting with her warm memories of her grandmother, and drawing on these to be able to provide the same warmth and comfort to her son. Robert showed many positive feelings about Roberto in his Working Model Interview. He also alluded to his own difficult past, but did not clearly mention the intimate partner violence that he exposed Roberto to. Becoming a parent was helping Robert reflect on his own childhood and what he would like to do differently with his son, though he was not fully owning up to his own behavior and the impact on his son. Like Sofia, Robert’s interview was coherent. Robert’s interview had much less details as Robert acknowledged that his time spent with his son was significantly less than Sofia’s, and Robert had been separated from Roberto due to incarceration. Roberto did not present negative attributes of his son and only spoke about Roberto positively, likely due to the guilt presented as not being there for his son. After his assessment, Robert joined the treatment. Given the on-again, off-again nature of Sofia and Robert’s relationship, early sessions were held separately with each parent and later sessions were held with both parents and Roberto. In Robert’s sessions he eventually acknowledged that he grew up in a home of intimate partner violence and he did not want that for Roberto. Robert began to process the impact this had on him as a child and how it contributed to his negative choices as a teenager and a young adult and his desire to live a different sort of life. Though Sofia had been the primary caregiver and was with Roberto more often, Robert proved to be more observant of their son and spoke with greater insight. Robert was able to eventually discuss the impact of the fear on Roberto even though Robert had never directly hurt his son. Robert was truly remorseful and wanted to develop a healthier relationship with Roberto, one in which his son felt safe with him. At the same time that Robert was in treatment with the infant clinician in regards to building a 102 A. Dickson and S. Bekman stronger relationship with Roberto, he was also receiving intimate partner violence counseling. Individual sessions with Robert after the dyadic sessions often addressed what Robert was learning in this group counseling and how it applied to his life with Roberto and his prior relationship with Sofia and what he had witnessed as a child with his parents’ relationship. Robert also used these sessions to recall the warm experiences of being parented by his grandmother and to explore what he would like to bring from that relationship into the relationship with his son. In sum, the WMCI and Angels Interview provided invaluable information about the unique relationships Roberto had with each of his parents. As described above, this information was used for postassessment feedback with the parents, as well as treatment planning.

Summary

Understanding the caregiver’s view of their child is critical to working with very young children. The caregiver may place unconscious projections onto their child with their hopes and fears which will impact how they parent this child. These projections are deeply influenced by cultural values, the caregiver’s own history of being parented, any caregiver traumas, and the caregiver’s ghosts and angels in their nursery. Interviews like the Working Model of the Child Interview, the Adult Attachment Interview, the Angels in the Nursery Interview, and the COSI help the clinician understand these complex factors that influence a caregiver’s perception of their child and set the stage for areas to be addressed in the treatment to improve the functioning of the dyad.

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Sherryl Scott Heller, Kate Wasserman, Anna Kelley, and Roseanne Clark

Background

It is widely acknowledged that the quality of interactions experienced with caregivers is crucial for early childhood development across the social, emotional, and cognitive domains (Schore, 2001; Sroufe, 1996, 2000; Westerlund & Lagerberg, 2007; Zeanah et al., 1997; Zeanah, Larrieu, Heller, & Valliere, 2000). Very young children use imitation to acquire the skills and conventions of their social, cultural, and familial groups. Caregiver sensitivity during early childhood can be observed in the following caregiving behaviors: reading and responding to infant/child cues, nurturing and valuing of desired activities, providing play and teaching activities that support both caregiver-led and child-led activities, as well as consistent and predictable responses to distress exhibited by the child and providing predictable structure and routine. Research has underscored the importance of the quality of caregiver– child interactions especially during emotionally arousing situations; it is during these interactions that children learn not only that the caregiver will be emotionally available but also strategies for modulating their emotional reactivity (Calkins & Hill, 2007; Robinson et al., 2009). The emotional attunement and strategies learned during these interactions over time, are expected to aid in the development of children’s emotional regulation. Caregiver warmth and responsiveness, as well as

S. S. Heller (*) · A. Kelley Department of Psychiatry and Behavioral Medicine, Tulane University Medical School, New Orleans, LA, USA e-mail: [email protected]; [email protected] K. Wasserman University of Maryland School of Social Work, Baltimore, MD, USA e-mail: [email protected] R. Clark School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA

© Springer Nature Switzerland AG 2019 107 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_4 108 S. S. Heller et al. negative control (i.e., parenting with threats or punitive behavior), are dimensions of caregiving that have been linked to children’s reactivity and regulatory behavior (Calkins & Hill, 2007). During emotionally arousing situations, warm and responsive caregivers are more likely to teach children appropriate strategies useful for the reduction of emotional arousal, even if they do not immediately change the child’s affect (Sroufe, 1996). In contrast, caregivers who utilize more controlling strategies are less likely to help the child implement new regulatory strategies. In these instances, a caregiver’s response can escalate the child’s emotional arousal (internally or externally) given the caregiver’s focus on immediate compliance to caregiver directives. These more controlling strategies typically increase children’s temperamental reactivity across different situations. The impact of the caregiver–infant interaction on a child’s emotional, social, cognitive, and language development is well recognized (Shonkoff, Phillips, & National Research Council (U.S.), 2000; Sroufe, 2000; Verhage et al., 2016). More recently, evidence from the field of neuroscience has demonstrated that most of the “wiring” in the human brain, that supports lifelong learning and behavior, is in place by the age of 6 (Schore, 2001). This finding highlights the importance of clinical assessment and intervention occurring in a child’s early years, when indicated. In the recently published diagnostic nosology DC:0-5, the importance of the contribution of the young child’s relationship with primary caregivers on the young child’s mental health is demonstrated through two different axes—Axis I (Relationship Specific Disorder of Early Childhood) and Axis II (Relational Context) (see Chap.8 ). Given the critical importance of the caregiver–child relationship, caregiver–infant/ young child assessments should be completed as part of any early childhood psychiatric assessment, along with clinical observations, clinical interviews, and collateral data. The range of social, psychological, and personal factors that can impact the capacity of a given caregiver to attend and respond to their infant’s needs and cues has also been well documented. These include the caregiver’s trauma history, personal experience with caregiving, their network of support, cultural beliefs, as well as their own cognitive and emotional capacities (see Chaps. 2 and 4). A significant factor within the caregiving role is the mental status of the caregiver. One example of how this can affect the child–caregiver relationship is a mother experiencing postpartum depression. Symptoms of postpartum depression and anxiety, for example feelings of worthlessness and guilt, negative feelings toward oneself and the baby, sleep difficulty, increased irritability, tension with family members, and a decreased ability to fulfill daily tasks may greatly impact caregiver self-efficacy, maternal responsiveness to infant cues, and the foundation for optimal maternal– infant attachment. It is important to consider caregiver stress and mental status as a significant factor impacting the dyad. Notably, one in every eight women suffers from postpartum depression during the postpartum period and the prevalence is higher for women living in poverty (Goodman & Gotlib, 2002; Grace, Evindar, & Stewart, 2003; Marcus, Flynn, Blow, & Barry, 2003). This high prevalence reflects the importance of destigmatization, education, prevention, and treatment in this realm. Although advancements have been made over the course of the past decade, 4 Observational Assessment of the Dyad 109 diagnosis and treatment of depression and anxiety in pregnancy and the postpartum period continues to be frequently overlooked. Assessing, discussing, and linking caregivers to their own mental health supports when indicated is in service to the dyad and ultimately in service to child outcomes. Assessment of the caregiver–child relationship should include components of both internal representation and interactive behavior. Whereas the prior chapter focused on the process of assessing the internal representations of the caregiver– child relationship, this chapter focuses on the interactive behaviors specific to the caregiver–child relationship. Assessing the interactive and relational qualities of the dyad includes attending to characteristics of the child (i.e., temperament and sensory reactivity, capacity for shared attention, intentional communication) and of the caregiver (i.e., responsivity and availability toward the infant, scaffolding for the infant/child, emotional style, and ability to co-regulate), and of the “space in between” (i.e., mutual engagement, interactional play). It is crucial to consider the child within the context of their environment, routine, culture and caregiver–child relationship(s). One important aspect of this process is selecting the appropriate measure(s) to administer to help with the assessment. In the following sections we outline key considerations or guidelines, functional domains to consider and a list of dyadic observation instruments commonly used for clinical application. These measures typically require extensive training to use, code, and incorporate into clinical plans with research or evidence-based fidelity; given this factor, clinicians typically integrate only one or two of these instruments into their regular practice with families. While the coding or scoring of these assessment instruments range in structure and application, there are many common elements (or functional domains) that are important for clinicians to consider when observing an infant or young child with their caregiver (see Table 4.1). Additionally, it is important for clinical teams to be reflective about global features such as: how the evaluative process may be impacting the comfort of the dyad, how the family’s culture may contribute to their caregiving behaviors and expectations, and how the clinician’s own culture, beliefs and values may be impacting their interpretations of the caregiver and child’s behaviors and interactions.

Guiding Principles of Assessment

A structured clinical assessment approach to assessing caregiver–child relationships and interactions is central to the identification of areas of strength and concern in the caregiver–child interaction and in the young child (Clark, Tluczek, Moore, & Evenson, 2004a, 2004b). Researchers (e.g., Ainsworth, Blehar, Waters, & Wall, 1978; Barnard, 1979; Clark, 1985, 1999; Emde, 1989; Feldman, Dollberg, & Nadam, 2011; Lyons-Ruth, Bronfman, & Parsons, 1999) have identified qualities of the caregiver, the infant or young child, and the caregiver–child dyadic interaction that should be the focus of an observational assessment. Ideally an assessment should also engage the caregivers in assessing their relationship with their infant/child. 110 S. S. Heller et al.

Table 4.1 Observable domains of functioning in the caregiver–child relationship Caregiver Infant/child behavioral and behavioral and affective domain affective domain Domain description and developmental purpose Emotional Emotion The degree to which a child is able to express and availability regulation manage a wide range of emotions is directly impacted by the caregiver’s capacity to share a range of emotional experiences with the child, label their own emotions for the child, and label the child’s inferred emotions. Nurturance, Security, trust, A caregiver who sensitively responds to the child’s empathic and self-esteem emotional experience, providing support and responsiveness encouragement to the child when needed, sends the message to the child to that their caregiver will be there when needed and respond predictably. This sensitivity and predictability support the child’s development of a healthy and positive sense of self. Protection Vigilance, In order for a child to comfortably explore their self-protection, environment they need to feel safe and free from danger. safety A child who fears for their own safety expends their mental energy on vigilance and inhibits their exploratory behavior. A child who feels confident that their caregiver will protect them from danger when needed is able to explore their world comfortably. It is noteworthy that in extreme instances a child may experience their caregiver as being both the protector and the source of danger. This paradoxical situation often leads to the development of pathological behaviors in the child. Comforting Comfort seeking Sensitive caregiving includes providing comfort for the child when the child needs it. When consistently provided, the child is able to seek comfort when distressed and to be soothed by their caregiver. Teaching Learning, A caregiver’s ability to support a child’s natural drive to curiosity, learn involves providing developmentally appropriate mastery challenges that do not overwhelm the child, scaffolding support to allow a child to master a task and encouraging the child’s efforts to acquire new knowledge. Play Play, Play is a pleasurable activity that not only supports a imagination child in learning about the world, but also allows a dyad to enjoy time together and strengthen their relationship. Ideally a caregiver is able to support the child’s fantasy play and follow the child’s lead. Discipline, limit Self-control, The degree to which a caregiver monitors, sets setting cooperation appropriate limits, clearly explains expectations and consequences, and implements these consequences are all important elements of discipline. Self-control involves the child’s ability for internal regulation and impulse control and allows a child to work cooperatively with others. (continued) 4 Observational Assessment of the Dyad 111

Table 4.1 (continued) Caregiver Infant/child behavioral and behavioral and affective domain affective domain Domain description and developmental purpose Instrumental care, Self-regulation, This entails the caregiver’s ability to meet the basic routines, structure predictability survival needs of the child (e.g., food, clothing, shelter, sleep) within a predictable routine and schedule. This consistency supports the child’s sense of security as well as supporting the development of independent regulatory functioning.

One method is to view the video recording of the parent child interactions recorded during the assessment with the parent and ask about the behaviors observed. In assessing the quality of the caregiver–child relationship using observational methods, key components include consideration of (adapted from Clark et al., 2004 and Clark et al., in press): 1. The quality of the caregiver’s mood, affect and behavior including observing the intensity, frequency, and duration of affect and behavior exchanged between caregiver and child. Also, it is important to listen for the caregiver’s attitude toward their child. These ways of “being with” may differentiate normative interactions from disturbed interactions and assist the clinician in determining the seriousness of a relationship problem. For example, the DC:0-5 Axis II uses this information to categorize level of quality of caregiver–child relationships as well-adapted, at-risk, compromised, and disordered relationships (Zero to Three: National Center for Clinical Infant Programs, 2016). 2. The context while assessing quality of interactions. For example, it is important to differentiate caregiving directives or conversation related to structured or teaching tasks from ways of “being with” in a play situation where the caregiver is following the child’s lead or engaging the child in mutually enjoyable play. 3. The quality and nature of the caregivers’ sensitivity and responsiveness relative to the child’s age and developmental level. Examples of a caregiver’s capacity to read the child’s cues and respond sensitively include a mother who adjusts the way she holds her infant after noticing the infant’s discomfort or the father who responds to his toddler tugging at his leg by bending down, talking with, picking up, or being playful with his child. 4. The caregiver’s responses to the infant/child. They should be contingently responsive (i.e. how rapid is the response to the child’s cues, requests, or needs) which helps the child feel that his or her actions are effective. 5. The presence (or absence) of a genuine attentiveness to the child, an empathic awareness of the child’s emotional state and emotional availability to the child. 6. The caregiver’s capacity to reflect the child’s affect and/or behavior through mirroring (the caregiver’s affective attunement to/imitation of the infant or young child’s emotional state and expression), gazing, behavior, approval, 112 S. S. Heller et al.

encouragement, and praise, as well as acknowledging and labeling of the child’s internal feeling states. 7. The caregiver’s capacity for “scaffolding” by looking at the amount and ways in which the caregiver gains and focuses the child’s attention to relevant aspects of the situation, recognizes their developmental capacities, and provides the child with opportunities for success through cognitive scaffolding and emotional availability. The caregiver’s scaffolding provides what Vygotsky (1978) described as the “zone of proximal development” and contributes to both language and cognitive functioning as well as emotional and behavioral regulation. Scaffolding with a younger infant may be seen in providing safe, protective caregiving. With an older child, this includes stating expectations clearly or teaching and setting limits with a sensitivity to the child’s cognitive abilities and emotional needs. 8. The caregiver’s consistency and predictability in their interactions with their child. It should be noted whether the caregiver follows their child’s lead or is controlling or intrusive in their interactions with their child. 9. The child’s perspective, “If I were this child, what is my experience/what do I see when I look up at my caregiver?” 10. The child’s affect, mood, emotional lability, temperament, activity level, attentional capacities, quality of play, social initiative and responsiveness, compliance, communicative competence, visual contact, and assertiveness or aggression in communicating their wishes/needs. 11. The dyad’s affective tone, organization, and regulation and the caregiver’s capacity to pace, as well as the dyad’s capacity for mutual enjoyment, joint attention, reciprocity, and the goodness of fit in affective expression, activity level and behavior. 12. The observation and wondering with the caregiver(s), how similar or different this interaction was from typical everyday interactions. If the caregiver indicates that it was different from their typical interactions ask what their typical interactions look like, also inquire about how it was different and what the caregiver attributes this difference to. For example, the caregiver may state that the child was much more cooperative than usual and attributes this to the uniqueness of having time alone together to play. This information can provide important information for the diagnostic process and contribute to the focus of the therapeutic work and recommendations.

Cultural Considerations

The integration of culturally sensitive and respectful approaches in the assessment of the caregiver–child relationship is critical to obtaining an accurate picture of the young child in the context of his or her family, community, and larger sociocultural environment (Clark et al., 2004a, 2004b; Sarche, Tsethlikai, Godoy, Emde, & Fleming, 2004). Caregiving is culturally determined. Each caregiver’s cultural views and style are influenced by a number of intersectional identities including, 4 Observational Assessment of the Dyad 113 gender, race/ethnicity, age, education, economic status, and religious beliefs as well as assimilation and acculturation (Lor, Crooks, & Tluczek, 2016; Sarche et al., 2004). Culture contributes substantially to the child’s identity and sense of self, which makes cultural awareness especially salient in clinical practice with infants and young children and their families (Tamminen, 2006). For example, mothers from different cultures may all be responsive to a baby’s cry, yet they might differ in how they choose to respond (i.e., touching the baby, feeding the baby, speaking to the baby), while there are similarities, differences are cultural (Tamis-LeMonda & Song, 2012). The meaning of the child and his or her behavior to the caregiver, as well as the caregiver’s response to the child, is shaped by the caregiver’s cultural lens. In addition, interactions may look different depending on a family’s community and cultural context. Some cultures value independence in the infant, while others value interdependence. Families in some cultures must focus on the survival of their infants, while others are able to focus on the achievements of their infants. Beliefs about successful infant/child adjustment, age of reaching various milestones in early childhood, and strategies of caring for the child, emerge from cultural beliefs and practices (Bornstein, 2012). For example, Japanese families tend to want their children to be emotionally mature, demonstrating self-control and good manners, while many American families prefer their children be independent, assertive, verbally competent, and self-actualized (Bornstein, 2012). When assessing caregiving approaches across cultures, culturally congruent clinical assessments and interventions require continuous examination and awareness of one’s own cultural beliefs and biases, a desire to learn about other cultures, cross-cultural engagement, knowledge of the family’s culture, and culturally sensitive and responsive interpersonal skills (Campinha-Bacote, 2002; Day & Parlakian, 2003; Dudas, 2012; Gaskins, 2006). Assessments should either be standardized within the populations they are used in or revised to become conceptually, semantically, and operationally equivalent (Fisher et al., 2002). Observational methods and consultation with cultural brokers (individuals knowledgeable about dominant culture as well as the under- represented culture) can provide clinicians with valuable insights and serve as liai- sons between the assessment team and the family (Day & Parlakian, 2003; Klotz & Canter, 2006). For observational parent–child relationship/interaction measures, it is especially important to consider the child’s caregiving network to determine who best to observe with the child. Wondering about infant/child development and caregiving beliefs with the caregiver will also inform the clinician and assist in their interpretations of their observations (Miron, Lewis, & Zeanah, 2009). The Diversity-Informed Infant Mental Health Tenets were developed by the Irving Harris Foundation (2012) Professional Development Network. These tenets include the importance of self-awareness regarding personal values and beliefs, a diversity-informed stance toward infants and families (i.e., acknowledgement of privilege and discrimination, recognition and respect for nondominant bodies of knowledge, and honoring of diverse family structures). The Diversity-Informed Tenets also suggest assessing and supporting families in their preferred language. Importantly, the Diversity Tenets promote the professional’s sensitive and respectful 114 S. S. Heller et al. consideration of their own and the client’s family values when conducting caregiver–child relationship assessments.

Domains to be Assessed

The observational measure(s) selected should allow the clinician to observe several key behavioral domains of functioning in the caregiver–child relationship (Emde, 1989; Zeanah et al., 1997). These domains are listed in Table 4.1 along with brief descriptions (see Larrieu and Bellow (2004) for full descriptions and case vignettes of each domain).

How to Choose Assessment Measures

One important aspect of assessing the caregiver–child interaction is selecting the appropriate measure(s) to administer. Factors that should be considered include whether the specific measure allows for continued assessment across developmental domains and the treatment process, whether the clinician is trained in administration and interpretation of the measure, the available resources, and time constraints. Developmental level. Caregiver and child behavior will vary by the child’s age and developmental level. For example, appropriate discipline or limit setting looks very different when caring for a 13-month-old versus a 35-month-old. Similarly, self-control and cooperation in a 12-month-old is expressed differently than in a 40-month-old. Thus, the child’s age and developmental level is an important consideration when selecting an observational measure as well as when observing caregiver and child interactional behavior. Some observational measures, such as the Still-face paradigm, will only be appropriate to use within a certain age range (Tronick, Als, Adamson, Wise, & Brazelton, 1978). Some measures may have procedural adjustments to allow administration across different age ranges, for example the Crowell procedure also has a Baby Crowell (Miron et al., 2009) procedure adapted for children under 12 months of age. Other measures are appropriate across a wide range of ages, for example the Parent–Child Early Relationship Assessment (Clark, 1985, 2010, 2015), with the manual providing age specific descriptions. The assessor should have a clear understanding of development and developmentally appropriate behavior across the age span. These measures will be discussed in more detail below. Purpose of evaluation. Another important element to take into consideration when choosing assessments is the purpose of the evaluation. Is the evaluation part of a full diagnostic evaluation or part of treatment planning? Is this a forensic evaluation or have the caregivers come in with a specific concern? For example, if there is concern around the child’s growth or the caregiver’s express concerns around the 4 Observational Assessment of the Dyad 115 child’s eating, then using a measure that allows for observation of the caregiver and child during an eating activity would be important, and the Nursing Child Assessment Satellite Training (NCAST) procedure would be an ideal choice. In a forensic evaluation, selecting measures that allow for observation with each caregiver separately across a wide variety of caregiving behaviors is essential. Evaluator training. To administer, score, and interpret an observational assessment to fidelity it is necessary that the evaluator have training and experience in the measure(s) selected. Whereas the administration, use and interpretation of many of these measures have been described in chapters and/or journal articles, in order to adequately incorporate these, an evaluator should be trained by a professional who has extensive experience in using a specific measure for evaluation purposes. Gaining the necessary expertise to administer, score and interpret these measures can occur in a variety of ways, such as through regularly scheduled workshops, in graduate and postgraduate training settings and through consultation. Available resources. The availability of resources impacts the measures the evaluator can select. Important resources to consider are video equipment material availability, and time or personnel constraints. For some of the observational measures it is necessary to video the interaction and use the recording to appropriately score the interaction. Video footage can also be helpful to use during the assessment and treatment process, as watching and discussing the interactions with the caregiver is a useful therapeutic tool. Other materials that may be needed while “low- tech” may still be burdensome. For some measures, specific and/or a variety of materials are necessary, for example the Crowell requires numerous developmentally appropriate toys.

Specific Assessment Instruments

This section describes the protocol and clinical interpretation of three commonly used dyadic assessment instruments: the Crowell Procedure, The Nursing Child Assessment Satellite Training (NCAST) Caregiver–Child Interaction (PCI) Scales, and Parent–Child Early Relational Assessment (PCERA). This is followed by a brief description of two dyadic assessments instruments that were originally developed as research tools but have been adapted in many clinic settings for dyadic assessments; the Strange Situation and the Still Face Procedure. At the end of this section a table has been included that lists several parent–child dyadic assessment instruments and the domains each assesses.

The Crowell Procedure

The Crowell Procedure (Crowell & Feldman, 1988), also known as the Parent– Child Interaction Procedure, is a semi-structured caregiver–child interaction assessment that allows the clinician to observe the caregiver and child across several 116 S. S. Heller et al. different situations. This procedure can be interpreted through a clinical lens (Larrieu & Bellow, 2004; Zeanah et al., 2000) as well as a research lens (Heller, Aoki, & Schoffner, 1998; Loop, Mouton, Brassart, & Roskam, 2016; Robinson et al., 2009; Sprang & Craig, 2015). Background. Crowell and colleagues adapted a laboratory procedure and coding system developed by Matas, Arend, and Sroufe (1978) for use in clinical settings (Crowell, Feldman & 1988; Crowell, Feldman & Ginsberg, 1988). This scoring system uses concepts from attachment theory, clinical experience, and the organization and structure of the Strange Situation Procedure rating protocol. The research coding system has been adapted on several occasions (for an example, see Osofsky, Bosquet, Kronenberg, & Hammer, 2003) and by Heller et al. (1998). Research using Heller and colleagues’ (1998) coding system found differences in Crowell scores between: maltreated and non-maltreated groups (Robinson et al., 2009), different levels of child psychopathology (Loop et al., 2016; Robinson et al., 2009), and scores on maternal adverse childhood experience (Crowell, Warner, Davis, Marraccini, & Dearing, 2010). It has also been used to demonstrate changes preclinical and postclinical intervention (Mouton, Loop, Stievenart, & Roskam, 2017). Use and training. Currently there is no official training protocol for administration or clinical interpretation of the Crowell procedure, although there are several articles that have been written on its use in clinical settings (Larrieu & Bellow, 2004; Miron et al., 2009; Zeanah et al., 2000) and trainings can be arranged through the Tulane University Institute of Infant and Early Childhood Mental Health. Crowell protocol. This clinic-based assessment typically requires 30–45 min to complete and is videotaped for later review. The Crowell has been used with children 12–48 months of age, and an adapted version called the Baby Crowell has been used with infant 9–12 months of age. The Crowell Procedure consists of 7–9 episodes which last for 2–5 min each: free play, cleanup, bubbles, 2–4 structured teaching tasks, a separation and a reunion. This combination of more and less structured activities with limited constraints on behavior allows for a relatively reliable means to assess the caregiver–child relationship. Furthermore, the information obtained is clinically useful for both assessment and intervention (Larrieu & Bellow, 2004; Zeanah et al., 2000). It is best if the observation room is minimally furnished. For example, limit furniture to two adult chairs, a toy task cabinet, and a very small table (do not put large tables in the room, as they tend to obscure the view of the child and caregiver). The free play-toys should be kept in a large bucket or bin and removed from the room after cleanup (otherwise it may distract the child and caregiver from the tasks, especially the difficult tasks). There is a telephone in the room which allows the clinician or researcher to call into the room and give instructions during the procedure. If a phone is not available, other means of communicating can be used such as cue cards, knocking, or brief verbal reminders. Typically, the caregiver is given basic instructions prior to the session and each task is demonstrated. The instructions are repeated between each transition by calling into the room on a telephone. 4 Observational Assessment of the Dyad 117

The free play episode lasts for 5–10 min. A longer amount of time is recommended to allow the dyad to become comfortable with the setting and being videotaped. This is a relatively unstructured activity which allows the clinician to see how the dyad interacts in a comfortable setting. The toys used in this episode should be selected to support imaginary play, such as dolls, play food and kitchen supplies, puppets, and a doctor kit. This episode allows the clinician to observe if the dyad tends to be task-oriented versus fun-oriented. Guiding clinical questions include the following: How familiar and comfortable is the dyad at playing together? Is there joint attention around the play? What is the level of warmth? Is there reciprocity in the interactions between the two? Following the free play episode, the dyad is asked to clean up. If the dyad is not finished within 5 min, a clinical team member can move in to help finish, quietly and without interacting with the child. The bin of toys should be removed from the room so as not to tempt the child when working on the teaching tasks portion of the Crowell. This episode allows the clinician to see how well the dyad can manage transitions and cooperate. Guiding clinical questions include: Does the caregiver work together with the child to clean up the room or does the caregiver do it all? Does the child comply with the caregivers’ requests, refuse or ignore the request? If the child refuses or ignores the request, how does the caregiver respond? Is the caregiver’s response developmentally appropriate? The third episode is bubbles. Here the caregiver is asked to blow bubbles for the child to pop. Typically, this activity pulls for spontaneity, enjoyment and enthusiasm. What the clinician is hoping to observe is shared positive affect. It is rare that one or neither member of the dyad exhibits positive affect, and it should be considered concerning if this occurs. In addition, the child may want to blow the bubbles themselves, and how the caregiver negotiates this request can also provide valuable information. The next 2–4 episodes consists of teaching tasks which increase in difficulty. Tasks 1 and 2 should be somewhat below the child’s developmental level; ideally the child should be able to do the task with little or no assistance from the caregiver. Tasks 3 and 4 should be slightly difficult for the child so that he or she needs the caregiver’s assistance to complete the task. As in the prior episodes, the clinician notes the emotional tone of the interaction. Guiding clinical questions include: Is there shared positive affect? How is affect regulated and shared by the dyad? How well does the dyad work together as the tasks become more demanding? Is the focus of the interaction on accomplishment or the experience of working together? How does the dyad manage transitions from one task to the next? The final two episodes involve a separation and reunion. In this sequence the clinician observes if and how the caregiver prepares their child for the separation. Guiding clinical questions include: How does the child manage distress? Does the episode need to be shortened because the child became overly distressed? Is the attachment system activated so that the child seeks comfort and proximity upon the caregivers return? (Note: with older children this may be done verbally). When the caregiver returns in the reunion episode, the clinician should focus on observing attachment behaviors (or the lack thereof). Does the dyad greet each other? How so? 118 S. S. Heller et al.

Does the child seek proximity? Does the child ignore or avoid the caregiver? Does the child seek the caregiver out but then is unable to be soothed by caregiver contact? Does the child’s response to the caregiver’s return match the distress level displayed during the separation? Can play be resumed before the end of the episode? And if so, at what level of enjoyment? Crowell instructions. Instructions given to the caregiver at the start of the session: I will call you between each task and remind you what to do; however, I will review everything with you now, so you will have an idea of what is going to happen. First, I want you to play with (child’s name) and the toys here (indicate free-play toys); then I will call you and ask you to have him/her clean up all of the toys. You can help (child’s name) if you think he/she needs it but see how much he/she can do on his/her own. I will then call and ask you to do each of the following tasks with (child’s name). Some of these tasks will be easy for him/her and some will be more difficult, you may help (child’s name) if you think he/she needs it (review the bubbles and four tasks). After the fourth task, I will call and ask you to leave the room. After leaving the room, you may come back into the monitoring room and watch (child’s name). After a few minutes, I will ask you to return to the room and the two of you will play for a few more minutes. If (child’s name) becomes too upset, we will end the separation early (Crowell & Feldman, 1988). Episode sequence and Instructions given at start of each episode:

Episode Duration Instructions Free play 10 min Play with (child’s name) as you would at home. Cleanupa Up to 5 min Have (child’s name) clean up, helping him/her if you feel the (child’s name) needs help. Bubbles 5 min I would like you to blow the bubbles and to have (child’s name) pop them. Tasks 1 & 2 2–4 min See specific tasks instructions. Tasks 3 & 4 3–5 min See specific tasks instructions. Separationb No more than Open the cabinet doors, so that (child’s name) can see the task 3 min toys and then leave the room as you would at home. Reunion 3 min Knock on the door, call (child’s name), and step all the way into the room. aThe cleanup episode ends when the room is clean or after 5 min, whichever comes first. bThe separation is ended early if the child is highly distressed for more than 20 s.

It is important to note that the length of time allowed for each task varies. In instances where the child finishes the task quickly, allow time for the task to be done one or two more times. However, if time is up and: (1) the dyad is close to completing the task, allow time for task completion and joy sharing, (2) the child is getting frustrated, then end the task, or (3) the task is far from complete, then end the task. Baby Crowell Instructions. Instructions given to the caregiver at the start of the session: Once you are in the room, please just make yourself and your baby comfortable. You can just spend time with your baby as you normally would. I will be leaving the two of you together to give you and your baby some play time to get used to the new room. 4 Observational Assessment of the Dyad 119

Episode sequence and instructions given at start of each episode:

Duration, Episode min Instructions Free play 2 See instructions in above paragraph. Stranger sequence 3 The instructions for each minute are below. Stranger sits Stranger sits quietly, pleasant expression on face. silently (1 min) Stranger talks with Stranger talks to caregiver. caregiver (1 min) Stranger plays Stranger interacts with baby. with baby (1 min) Cleanup 2 Stranger asks mother to pick up the toys, put them in the bucket and push them over to the door. Stranger then leaves the room. Bubbles 2 Please take out the bubbles and blow them for the baby. Task 1 3 See specific tasks instructions. Task 2 3 See specific tasks instructions. Separation 2 Please do whatever you feel is necessary to make your baby comfortable and then come out of the room. The baby will stay in the room for a few minutes. Reunion 3 Please knock on the door, call the child’s name, and then step all the way into the room. We would like you to spend some time with your child doing what comes naturally. You will have several minutes alone with your child.

Although lengthy to administer, the Crowell procedure allows the clinician to apply all the guiding principles of assessment and to assess all the functional domains listed in the prior section of this chapter. As with the other assessment tools discussed in this chapter the Crowell results can be shared with caregivers, offering an opportunity to reflect on the interactions, what strengths are demonstrated in the different domains, and where to focus clinical support for increased caregiving efficacy.

NCAST Caregiver–Child Interaction Scales (Feeding and Teaching Scales)

The Nursing Child Assessment Satellite Training (NCAST) Caregiver–Child Interaction (PCI) Scales collectively refers to two distinct assessment scales, each specifically focused on targeted caregiving practices: (1) feeding and (2) teaching. The PCI Teaching and Feeding Scales are used in both clinical and research protocols. The scales can be used together or individually with the same dyad, depending on the clinical concern. They contain a well-developed set of observable behaviors that describe the caregiver–child communication and interaction during either: a feeding situation, birth to 12 months of life; or a teaching situation, birth to 36 months of age (Barnard, Bee, & Hammond, 1984). Collectively, both PCI scales represent assessment measures that have been proven to be valid and reliable 120 S. S. Heller et al. assessments for measuring caregiver–child interaction with an extensive body of research across disciplines (Kelly & Barnard, 2000). For clinicians, the PCI scales offer reliable premeasures and postmeasures to document intervention effects with dyads. Due to the specificity of the items measured, the PCI scales offer identification of concrete areas to guide clinical supports and interventions and can often be useful to support providers with identifying the strengths and opportunities for growth in the caregiver–child relationship, especially when dyadic representation looks particularly concerning (Kelly, Buehlman, & Caldwell, 2000). For researchers, this tool has been used to support the legitimacy of clinical interventions. Background. Beginning in 1980, the University of Washington’s team, led by Barnard, Eyres, Lobo, and Snyder, developed a widely used observational system to support systematic observation of caregiver–infant interactions for children up to 3 years of age, based on an ecological model. This system, referred to initially as NCAST and more recently interchangeably as NCAST and PCI, was designed to be applied during feeding or teaching activities, and addresses interaction behaviors identified with responsiveness, clarity of communication, and socio-emotional and cognitive growth fostering. Central to this model is the concept of contingency or reciprocity; a consistent, predictable, and responsive pattern of contingency or reciprocity early in the relationship is the preference, as it is through this process, the infant/child learns to trust or mistrust the world (i.e., “When I have needs or feelings, my caregiver responds quickly and sensitively.”). Both scales were initially published in 1994 by a clinical team at the School of Nursing at the University of Washington (Sumner & Speitz, 1995a, 1995b), and have since been cited in hundreds of studies and scholarly journal articles. Use and training. To be an approved administrator of the scales, providers must participate in a 40-h training, provided by a national trainer certified by the NCAST team at University of Washington, on the protocol for each of the Feeding and Teaching Scales (80 h total) and reliably code a packaged series of five video-taped interactions of dyads. Scores on standardized videotaped interactions must be submitted into the University of Washington by an approved NCAST trainer and administration of the measures is allowed for clinical use if 75% reliability is reached and for research purposes if 85% reliability is reached. Within clinical practice settings, the instruments can be administered and scored to give a baseline score for the dyad as well as information about strengths and challenges with respect to the sub-scales. Administration can also serve as pre and post measures to anchor parent coaching around interaction and teaching practices offered by a clinical team. Because of the specificity of the variables scored, it is recommended to video tape interactions so that administrators can pause and rewind, rather than score during live observations. The existence of two scales gives the health care professional flexibility in choosing the setting that is most suitable to a given dyad. A guiding principle of the development of the NCAST Scales is that relatively brief observations of a caregiver–child interaction can provide a valid sample of the dyad’s ongoing experiences and expectations. Observations of teaching and feeding situations allow glimpses of somewhat different samples of interaction. The feeding situation is familiar and makes few new demands on the dyad. The teaching interaction assessed by the scale is quite brief but more novel and thus places some stress on the 4 Observational Assessment of the Dyad 121 caregiver–infant pair. This potential for stress allows for a measure of adaptive functioning outside of well-versed routines. Feeding & Teaching Scales—protocol and scoring. Collectively, both PCI Scales score 149 variables related to the caregiver–child interaction. The protocols for both measures mirror the same procedure: The observation tool assesses interactions during instrumental play or structured feeding and is based on the theory that both the infant and the caregiver share in the responsibility to facilitate an ongoing dialogue of reciprocity. Each of the elements tracked by the PCI variables must be present for an optimal interaction to occur. The PCI scales are administered to a caregiver–infant dyad when the infant is between birth and 36 months of age. The NCAST scales evaluate the adaptive patterns of both caregiver and infant at the infant’s zone of proximal development, where the infant cannot perform emergent skills independently, but requires the guidance and teaching on the part of the caregiver. For the feeding scale, caregivers are asked to feed the child in the typical manner (e.g. breast, bottle, or pureed or solid foods) and the interaction is observed, ideally video recorded. This allows the caregiver to review the procedure and reflect on the observed interaction and score together with the clinician. The clinician observes the interaction without intervening, and then scores the interaction for caregiver responsivity to cues, clarity of the infant’s cues, and sensitivity of the caregiver to setting up the child for success within the environment. For the teaching scale, there is a standardized list of activities delineated by age (e.g., shake a rattle, stack three blocks, or draw a square). The caregiver is asked to choose an item they think the child cannot yet do and are instructed to teach the task to the child. The provider again refrains from intervening and observes and scores the interaction, following the structure of the NCAST teaching loop, which is a structure to coach parents to support their children to engage in new activities by walking them through a four-step process of Alerting, Instruction, Performance, and Feedback. The Teaching Loop helps organize the interaction and makes learning a new task easy for children to understand. For clinicians, the NCAST PCI tools help to structure the observation of the dyad, carefully noting the structure of the environment, as scaffolded by the caregiver for the infant, how the task and task materials are introduced to the infant, the number of times the infant is asked to attempt or complete the task, and feedback given by the caregiver during the child’s attempts. The measure can be completed by direct observation or via video recording, which offers the opportunity to review with the caregiver. Through becoming familiar with the domains and scoring components of the scales, clinicians gain competence and confidence in their assessment of dyadic interactions and the drivers that facilitate or complicate such interactions. For each scale, scored items fall into two broad domains: Infants receive scores according to their ability to produce and share clear cues about their needs and regulatory state, as well as their ability to respond to caregiver during the interaction. Similarly, caregivers are scored based on their ability to respond to their infants cues, to alleviate and notice distress or frustration, as well as their ability to properly set up an environment and task that is supportive of their child’s success (proximity to task, how they prompt the child to start the task, how many times they ask the child to attend to the task, whether the child has access to reinforcement via the caregiver’s face, smile, eye contact, etc.) 122 S. S. Heller et al.

In both cases, the procedure consists of scoring the dyad’s behavior following a direct or videotaped observation, and the results are shared with caregivers, offering an opportunity to reflect on what they saw, what the scores illustrate, and where to focus clinical support for increased caregiving efficacy. The scales provide conceptually parallel views of the same caregiver/infant pair and allow for generality of observations across settings.

Parent–Child Early Relational Assessment (PCERA)

The PCERA (Clark, 1985, 2010, 2015) captures the infant/child’s experience of the parent, the parent’s experience of the child, the affective and behavioral characteristics that each bring to the interaction, and the quality or tone of the dyadic relationship. The PCERA ratings identify areas of strength, areas of some concern and areas of significant concern in the parent, the infant/child, and the dyad. The quality of the parent–child relationship is assessed from video observations of the infant/child interacting with the parent during four 5-min segments that include feeding, structured task, free play, and separation/reunion (Clark, 1985, 2010, 2015; Clark, 1999; Farran, Clark, & Ray, 1990). The PCERA can be been used as part of an initial diagnostic evaluation to develop a relational profile, formulate relationship issues and goals and to focus parent–child psychotherapeutic interventions and to monitor progress in therapy. Background. The PCERA parent, infant/child, and dyadic scales were initially developed in a NIMH-funded study of mothers with psychiatric disorders, their children birth to 5 years and the quality of the mother–child relationship (Clark, 1983). The rating scales were developed based on results of studies that determined associations between specific qualities of parenting and child developmental outcomes (e.g., Clarke-Stewart, 1973; Matas et al., 1978; Sander, 1964) as well as attachment (e.g., Ainsworth, 1969), psychodynamic (e.g., Stern, 1985, 2002; Winnicott, 1965, 1970), and cognitive-linguistic theories (Vygotsky, 1978). Additionally, election of scales was informed by clinical observations of parents experiencing difficulty parenting. The PCERA has been further developed for use with normative and other at-risk populations (Clark, 1999; Clark, Hyde, Essex, & Klein, 1997; Clark, Tluczek, & Brown, 2008). The PCERA has been found to differentiate mothers with depression and mothers with schizophrenic disorders from well-functioning mothers (Clark, 1983; Goodman & Brumley, 1990) and to differentiate positive and less sensitive mother–infant interactions with babies in the NICU due to premature births or medical conditions (Gerstein, Poehlmann-Tynan, & Clark, 2015; Korja et al., 2008; Poehlmann, Burnson, & Weymouth, 2014; Weber & Harrison, 2014). The PCERA has excellent internal consistency and predictive validity (Clark, 1999) as well as concurrent validity, for example with Working Model of the Child Interview (Korja et al., 2010) and with Security of Attachment at 12 months (Mothander, 1990; Teti, Nakagawa, Das, & Wirth, 1991). Evaluation of change following therapeutic intervention has been documented in numerous clinical intervention studies including in a psychiatric clinic to address sleep disturbances in toddlers (Minde, Faucon, & Falkner, 1994) in a clinical trial of a 4 Observational Assessment of the Dyad 123 mother–infant relationship intervention for major depression in the postpartum period (Clark et al., 2008) and in an intervention with caregivers in an orphanage in Russia (The St. Petersburg—USA Orphanage Research Team, 2008; see review, Clark, 1999). With clinician investigators choosing the PCERA for use in a variety of clinical programs and clinical research projects internationally studying high-risk and normative populations, the PCERA has become one of the most widely used clinical and clinical research measures for assessing the quality of parent–child relationships (Dallay & Guedeney, 2016). PCERA Use and Training. Ratings are made on five-point Likert scale for 29 domains of parental functioning, 30 domains of infant/child functioning, and 8 domains of dyadic functioning. Video recording of the parent–child interactions is recommended for rating purposes, the development of a Relational Profile, and for review with parents to elicit their perceptions and experience in their interactions with their child. Training is highly recommended and interrater reliability is determined following 40 h of training with a certified clinician/trainer. A Short Form of the PCERA and a training package is currently in development. PCERA Protocol. The PCERA takes about 25 min to provide instructions and video record the parent–child interactions in four situations. After the interaction procedure has been explained to parents, written consent is obtained for video recording. The clinician describes how the video recording is for the family’s benefit as the parent and clinician can look at the video together in a later session. The following introduction is provided to parents: We understand that this is a snapshot of one point in time. We’ll be interested in your sharing with us afterwards how the interaction is alike or different from how things usually go. The video recording procedure involves placing the camera at a 45° angle to the parent and infant/child, who are seated together, and using a medium shot to capture the facial expressions, behavior, and dyadic interactions of the parent and the child (Clark, 1985, 2010, 2015).

Time, Situation min Instructions Feeding 5 “We are interested in seeing [infant/child’s name] and you during a feeding or a snack time together. Please be with [child’s name] as you usually would.” Structured 5 The instructions for the Structured Task are determined by the age of the task infant/child. Parents of infants under 7 months are asked: Please change your baby’s diaper and try to get the her/him interested in shaking this rattle Parents of infants between 8–12 months are given two cups and a small animal figure toy and asked to Please hide the toy under one cup and alternately hide it under the second cup within your child’s sight and to have him/her try to find it. If time permits, you can read this book together. For children 13 months and older, parents are asked to Build a tower of three cubes and have (child’s name) do the same. With a child of 19 months and older, the instructions are: Please build a tower of 8(or more for older children) blocks, a bridge of five blocks, and to have the child make a design with the colored blocks that matches the increasingly challenging block design cards. This task is always a little too difficult for the child to complete on his or her own 124 S. S. Heller et al.

Time, Situation min Instructions Free play 5 The instructions for the Free Play are: This is a free play time for you and your baby/child. Please play with (baby/child’s name) as you normally would. For infants under 6 months, the instructions are: Here are some toys you may use if you choose. For infants over 6 months, instructions are: You or [child’s name] may chose the toy(s) that you would like to play with together Separation/ 2 At the end of the instructions for the Free Play, parents are also given reunion instructions for the Separation/Reunion episode. They are told, “We’d also like to see how things go for [child’s name] when you leave the room. After 5 min of play I’ll knock on the door but won’t come in. Let [infant/ child’s name] know that you’re going to be leaving the room briefly to talk with the assessor. Then please come stand outside the room for a few minutes with me.” To ensure the child’s safety, this episode is only conducted when there is a one-way mirror, video camera, or another adult is in the room with the child

The Feeding Situation allows for an assessment of the parent’s capacity for nurturance and social interaction as well as sensitivity to the child’s cues and need for regulation. The child’s readability, affect regulation, social initiative, and responsivity during feeding may also be assessed. The comfort, tension, and regulation of the dyad in this situation are observed. The Structured Task Situation allows for an assessment of the parents’ capacity to take the role of the adult, to provide structure and scaffolding of the environment with an awareness of the child’s individual developmental capacities and emotional needs. The tasks tap the child’s emerging abilities and require both parental emotional availability and quality of assistance and cognitive scaffolding for the child to complete the task successfully. The child’s interest, attention, persistence and willingness to comply with their parent’s expectations in a structured situation are observed. The dyad’s capacity for joint attention, reciprocity, and mutual enjoyment may also be observed. The Free Play Situation allows for an assessment of the parents’ capacity for playfulness and enjoyment with their infant/child, their sensitive responsiveness to their infant’s cues and needs and to follow their child’s lead in play. The child’s capacity for exploratory and representational play and the parent–child dyad’s capacity for social interaction, mutuality, and reciprocity may also be assessed. The PCERA Free Play Toy List is standardized and includes rattles, plastic keys, a busy box, two toy telephones, a ball, two puppets, a baby doll, bottle, blanket, small cars/trucks, bristle blocks, crayons and paper, and plastic animal and human family figures. TheSeparation/ Reunion situation allows for an assessment of the parent’s capacity and comfort in the preparation of their child for a brief separation. The child’s ability to self- regulate and their mood and engagement in exploratory play during the parents’ absence and the nature of the dyad’s affect and engagement at reunion may also be assessed. Eight subscales have been determined through factor analysis and include: Parental Positive Affective Involvement and Verbalization; Parental Negative Affect and Behavior; Parental Intrusiveness, Insensitivity, and Inconsistency; Infant Positive Affect, Communicative and Social Skills; Infant Quality of Play, Interest, 4 Observational Assessment of the Dyad 125 and Attentional Skills; Infant Dysregulation and Irritability; Dyadic Mutuality and Reciprocity and Dyadic Disorganization and Tension. Objective assessments alone often do not allow for an understanding of the parents’ experience of and with their infant/child, thus a Video Replay Interview, in which brief segments of the video-recorded interactions are reviewed with the parents, is an essential part of the PCERA assessment process. In this semi-structured interview, the parent is engaged in assessing their relationship with their child and goals for therapeutic intervention can be collaboratively developed. In “wondering along” with the parent(s) about their perceptions, feelings about their infant/child and their attitudes and goals in the interaction, the clinician can gain insight regarding the parents’ experience of the relationship that may contribute to their interactions with their infant/child. The meaning of the infant/child to the parent is assessed with questions such as: “I wonder who [child’s name] looks like or reminds you of [physical features, temperament, behavior]?” The parent’s capacity for mentalizing or reflective functioning may be listened for, that is, their ability to reflect upon the internal emotional experience of their child and themselves (Fonagy & Target, 1998; Slade, 1999). The clinician engages the parent in wondering, how they were feeling during that interaction… “What do you imagine was going on for your child?” “What do you imagine your child may have been feeling then?” This process helps the clinician to assess the parents’ capacity to see the child as a separate individual and their ability to read their child’s cues and respond, or if they misinterpret their child’s cues or attribute negative intentionality to their child’s behavior, making it difficult to respond empathically.

The Still-Face Paradigm

The Still-Face Paradigm (SFP, Tronick et al., 1978) can be used to assess dyadic interactions, including mutual regulatory capacities, in infants aged 3–6 months and their caregivers. There are different variations of the SFP, however, the procedure usually consists of three phases, which are each 2 min in duration. Throughout the procedure, the infant and caregiver are positioned so they are facing each other, and there are separate cameras filming the caregiver’s face and the infant’s face. During the first phase, the caregiver is instructed to engage naturally with the infant. During the second phase, the caregiver is instructed to “still” their face and not show any affect or engage with the infant in any way. During the third phase, also known as the “reunion,” the caregiver is instructed to resume normal interaction with the infant. While the SFP is primarily used as a research tool, it has valuable clinical applications. For example, the SFP can provide information in regard to the dyad’s mutual interactions and communication process across the three different phases of the procedure, including whether the infant and caregivers interactions are matched or mismatched, how fluid or smooth the interactions are, how the infant and the caregiver resolve distress and repair any ruptures (i.e., Can the infant eventually return to positive affect after the rupture experienced in the second phase?), how 126 S. S. Heller et al. flexible the caregiver is with the infant (i.e., Can they change their strategy of engaging or soothing the infant if necessary?), the caregiver’s ability to comfort the infant, and the infant’s ability to seek comfort from the caregiver. Interestingly, mothers’ internal representations of their infants have been found to be linked with infant behaviors during the SFP (Rosenblum, McDonough, Muzik, Miller, & Sameroff, 2002). In addition, caregiver sensitivity during the SFP has been found to be connected to the infants’ behavior throughout the procedure and to predict later attachment patterns (Braungart-Rieker et al., 2014). The SFP can be used to inform treatment as necessary, as well as to measure pretreatment and posttreatment outcomes.

The Strange Situation Procedure

We mention the Strange Situation Procedure (SSP, Ainsworth et al., 1978) here, as it is a well-known procedure designed to assess the young child’s attachment style with their caregiver. The SSP is a standardized procedure developed by Ainsworth and colleagues in 1978 (Ainsworth et al., 1978) and is used with children from 12 to 20 months. The SSP is most frequently used in research settings but can also be included in clinical settings. Modified versions of separation/reunion episodes are included in several of the assessments noted above. The SSP consists of eight episodes in total, designed to activate the infant’s attachment system: The caregiver and infant settling into the assessment room (episodes 1 and 2), the introduction of a stranger (episode 3), two separation episodes during which the caregiver leaves the infant in the room (episode 4) and during which the stranger remains in the room with the child (episode 6), and two reunion episodes (episodes 5 and 8). In addition, during episode 7, the stranger returns to the room where the child is waiting and interacts with the child as necessary before the caregiver reenters. The infant’s behavior during the reunion episodes (when the caregiver returns) is especially important in classifying the specific attachment style. Four attachment categories have been identified: Secure (“B”), Insecure— Avoidant (“A”), Insecure—Resistant/Ambivalent (“C”), and Disorganized, (“D”). The SSP is recorded on video and is coded after the procedure is concluded. For a full description of the directions for the procedure and classifications, we refer to Ainsworth et al. (1978). Administration and subsequent classification of the child’s attachment style requires extensive training and the procedure should not be used without in-depth knowledge of the attachment classifications.

Overview/Table

Below (Table 4.2) we have included an overview of several dyadic observation measures with the corresponding domains of the caregiver–child relationship assessed in the various measures. It is important to note that Table 4.2 is not an exhaustive list of dyadic observation measures but rather includes measures and scoring systems 4 Observational Assessment of the Dyad 127

Table 4.2 Overview of selected dyadic observation measures Domains as described by Domains that can be Instrument Age the authors clinically observed Crowell Procedure 12–48 months, Parent: – Emotional also known as adapted version – Emotional availability availability/emotion Clinical Problem- (“Baby – Nurturance/empathic regulation Solving Procedure Crowell”) has responsiveness – Nurturance, empathic (Crowell & Feldman, been used with – Protection responsiveness/ 1988) infant – Comforting/response security, trust, and 9–12 months of to distress self-esteem age – Teaching – Protection/vigilance, – Play self-protection, safety – Discipline/limit – Comforting/comfort setting seeking – Instrumental care/ – Teaching/learning, structure/routines curiosity, mastery Child: – Play/play, imagination – Emotion regulation – Discipline, limit – Security/trust/ setting/self-control, self-esteem cooperation – Vigilance/self- – Instrumental care, protection/safety routines, structure/ – Comfort seeking Self-regulation, – Learning/curiosity/ predictability mastery – Play/imagination – Self-control/ cooperation – Self-regulation/ predictability Emotional Infancy/early Parent: – Emotional Availability Scales childhood – Sensitivity availability/emotion (Biringen, 2000, version: birth – Structuring regulation Pipp-Seigel & to 5 years – Nonintrusiveness – Nurturance, empathic Biringen, 1998; – Nonhostility responsiveness/ Biringen, 2005; Child: security, trust, and Biringen et al., 1998) – Responsiveness to the self-esteem parent – Play/play, imagination – Involvement of the – Discipline, limit- parent setting/self-control, cooperation – Protection (continued) 128 S. S. Heller et al.

Table 4.2 (continued) Domains as described by Domains that can be Instrument Age the authors clinically observed Marschak Interaction Infant, toddler, Caregiver: – Emotional Method (MIM), preschool/ – Structure availability/emotion (Jernberg & Booth, scholl age, and – Engagement regulation 1999) adolescent – Nurture – Nurturance, empathic – Challenge responsiveness/ Infant/Child: security, trust, and – Ability to respond to self-esteem caregiver’s efforts – Protection/vigilance, self-protection, safety – Comforting/comfort seeking – Teaching/learning, curiosity, mastery – Play/play, imagination – Discipline, limit- setting/self-control, cooperation – Instrumental care, routines, structure/ Self-regulation, predictability Nursing Child Teaching Caregiver: – Emotional Assessment Satellite Scale: infancy – Sensitivity to the availability/emotion Training (NCAST): to 3 years; child’s cues regulation NCAST Parent– Feeding Scale: – Response to the – nurturance, empathic Child Interaction birth to child’s distress responsiveness/ Feeding and 12 months – Fostering social- security, trust, and Teaching Scales emotional growth self-esteem (NCAST-PCI) – Fostering cognitive – Discipline, limit- (Feeding Scale— growth setting/self-control, NCAFS) (Teaching Infant/Child: cooperation Scale—NCATS) – Clarity of cues – Instrumental care, (Barnard, 1979; – Responsiveness to routines, structure/ Sumner & Speitz, caregiver self-regulation, 1995a, 1995b) predictability – Teaching/learning, curiosity, mastery (continued) 4 Observational Assessment of the Dyad 129

Table 4.2 (continued) Domains as described by Domains that can be Instrument Age the authors clinically observed Parent–Child Early Birth to 5 years Caregiver: – Emotional Relational – Positive affective availability/emotion Assessment involvement and regulation (PCERA) (Clark, verbalization – Nurturance, empathic 1985, 2010, 2015) – Negative affect and responsiveness/ behavior security, trust, and – Intrusiveness, self-esteem insensitivity, and – Protection/vigilance, inconsistency self-protection, safety Infant/Child: – Comforting/comfort – Positive affect, seeking communicative and – Teaching/learning, social skills curiosity, mastery – Quality of play, – Play/play, imagination interest, and – Discipline, limit attentional skills setting/self-control, – Dysregulation and cooperation irritability – Instrumental care, Caregiver–Child Dyadic routines, structure/ Factors: Self-regulation, – Mutuality and predictability reciprocity – Disorganization and tension Video Reply and Interview: – Meaning of child and child’s behavior – Parent’s perception of self in parenting role – Parent’s history of being parented Parenting 10–47 months Caregiver: – Emotional availability Interactions with – Affection – Nurturance, empathic Children: Checklist – Responsiveness responsiveness of Observations – Encouragement – Encouragement Linked to Outcomes – Teaching – Teaching (PICCOLO) *Especially helpful for (Roggman et al., home visiting 2013) (continued) 130 S. S. Heller et al.

Table 4.2 (continued) Domains as described by Domains that can be Instrument Age the authors clinically observed Still-Face Paradigm 3–6 months Several different coding – Emotional (SFP) (Tronick et al., systems have been availability/ emotion 1978) developed, including the regulation MACY Infant–Parent – Nurturance, empathic Coding System (Earls, responsiveness/ Muzik, & Beeghly security, trust, and 2009), which includes self-esteem behavioral (for both – Comforting/comfort caregiver and child), seeking affective and dyadic rating domains Strange Situation 12–20 months Infant: – Emotional Procedure (SSP) – Proximity- and availability/emotion (Ainsworth et al., contact-seeking regulation 1978) behavior – Nurturance, empathic – Contact-maintaining responsiveness/ behavior security, trust, and – Resistant behavior self-esteem – Avoidant behavior – Protection/vigilance, self-protection, safety – Comforting/comfort seeking

which have been found to have useful clinical applications, as opposed to being used solely for research purposes. Many of these measures require training to use the applicable coding systems as well as to interpret the measures correctly. As noted above, due to the extensive nature of the training, clinicians frequently limit themselves to the use of one or two procedures.

Clinical Case Vignette

Identifying Information

Roberto is an 18-month-old, Hispanic male. He is tall for his age and presented as shy and rather quiet, standing in the waiting room behind his mother. He presented to a community mental health clinic with his biological mother, Sofia, due to “aggressive” behavior at childcare. In addition, Roberto’s mother is concerned that he is a “bully” and would like help managing his behavior. Roberto’s pediatrician recommended that they contact the community mental health clinic after Roberto’s mother reported her concerns to her. Roberto’s mother is fluent in Spanish and English, identifying herself as bilingual, having been raised in the USA since 4 Observational Assessment of the Dyad 131 infancy. She speaks both English and Spanish with Roberto at home. Roberto’s mother is Catholic and reported that her religion is a source of comfort for her.

History of Presenting Concerns and Prior Intervention

Sofia reported that Roberto had always been a difficult child, and was hard to soothe, ever since he was a newborn. She also stated that he hits her and hits and pushes other children at childcare. Additionally, she reported that he throws toys and gets “very angry, very quickly.” Roberto’s mother further reported that Roberto cries in his sleep, and she believes he is having bad dreams. Additional symptoms include sensitivity to loud noises, startle response and appearing “on edge.” Roberto has not received any prior intervention in regard to these concerns.

Social and Family History

Sofia initially denied that Roberto had been exposed to any traumatic events. However, overtime as she began to trust the clinician and develop more rapport with her, Sofia acknowledged ongoing intimate partner violence between herself and Roberto’s father, which had ended several months prior when Roberto’s father was incarcerated. When asked further, Sofia disclosed that Roberto’s father hit her repeatedly in front of Roberto, and on one occasion choked her. As per her report, Roberto would cry and appear to freeze during these episodes of violence, and would then be very clingy toward her for several hours afterward. Currently, Roberto lives alone with his mother. His father was recently released from jail and has weekly supervised visits with Roberto. Sofia also reported that her own mother is a support to her and Roberto. Grandmother often cares for Roberto, and Sofia described their relationship as close and loving. Sofia’s mother immigrated to the USA from Honduras several weeks after having given birth to Sofia. Sofia’s father was already in the USA and had taken Sofia’s older brother with him, as well as his parents (Sofia’s paternal grandparents) to begin to look for a job and find housing. Sofia’s parents are still part of a tight-knit Honduran community in the USA. Sofia reported feeling conflicted about this, as she struggled to “fit in” as a teenager with her peers who were not a part of their community. She reported being drawn to Roberto’s father Robert because he was “much more American.” Roberto’s father is of Mexican heritage. His grandparents immigrated to the USA as young adults, and Robert identifies as American. While Robert speaks Spanish, he prefers to speak English and speaks primarily in English with Roberto. Given the cultural and linguistic considerations, Sofia was asked which language she would prefer her therapy to be conducted in. Sofia stated that while she speaks Spanish at home on occasion, she would prefer for the therapy to be conducted in English. A bilingual therapist was able to conduct the treatment in case there were specific themes that would be more helpful to address in Spanish, while respecting mother’s wishes to conduct the majority of the treatment in English. 132 S. S. Heller et al.

Medical and Developmental History

When asked about any mental health diagnoses in the family, Sofia reported that she was not aware of any. However, she reported that she has had periods of feeling depressed, and experienced anxiety during her pregnancy and for a few months following Roberto’s birth. Sofia added that she still has occasional feelings of anxiety, but overall feels better than she did when Roberto was an infant. She has never received treatment for her anxiety or depression. She also reported that Roberto’s father has “anger issues.” There are no known medical concerns in the family. During the intake, mother reported that Roberto was born full-term, and there were no medical complications during the pregnancy or the delivery. Mother notes no substance use or medications during pregnancy. However, Sofia did report that she felt very stressed and received minimal support during the pregnancy. When asked to expand on her feelings of stress during the pregnancy, Sofia noted that there was tension with Roberto’s father, and she also had financial concerns and was not sure how she would be able to take care of the baby while continuing her job. She reported feeling anxious at times throughout the pregnancy, which continued for a few months after the birth. Roberto does not have any known medical conditions. Roberto was Sofia’s first and only pregnancy. His pediatrician insists that Roberto is healthy and there is not a medical cause for his behavior. He is developmentally on target in all domains with the exception of communication. During his last visit to the pediatrician, Roberto was referred for a Speech and Language evaluation, and determined to have a 4 month delay. He is currently receiving speech therapy in the home. An Ages and Stages Questionnaire (ASQ-3) was administered to screen for any developmental concerns. Roberto performed in the average range in all domains, with the exception of communication, as was expected based on the report from the pediatrician and his past screening results. In the domain of communication, he scored below the cutoff. As he was already receiving speech therapy, no further referrals were made at this time. As Roberto and his mother had not received intervention for his presenting symptoms previously, there were no available records from past therapies. However, the clinician obtained consent to speak with Roberto’s teachers as well as his speech therapist to gather additional information for the purposes of coordination of care. His speech therapist stated that Roberto is making some progress in their intervention, however, he is slow to warm up and was very shy initially. Robert’s teacher reported that she enjoys having him in her class. She noted that he has recently started to push other children, and occasionally stares off into space. She also reported that while he did not use to struggle separating from his mother when she drops him off in the morning, he has started to whine and protest the separation. She did note, however, that when his grandmother drops him off he seems to be able to separate with more ease. During the week, Roberto is in childcare throughout the day and spends the mornings and evenings with his mother. His grandmother, Sofia’s mother, helps her daughter take care of Roberto and is an important primary caregiver for Roberto. 4 Observational Assessment of the Dyad 133

Until recently, Roberto was reported to do well at childcare and had no behavioral problems or issues with separation. A comprehensive young child assessment was performed, including a developmental assessment/screening, an observation in the child care setting, as well as interviews with other caregivers, such as his teachers. For the purposes of this Chapter, only the parent–child assessments are described in more detail, while Chapter 3 describes the parent perception of the child interviews for the same case study. Ideally, both types of assesment should be conducted to assess the parent–child relationship.

Dyadic Assessment

To gather a better understanding of Roberto’s needs and the relationship with his parents, as well as to inform treatment, an assessment of the parent–child relationship was conducted with Roberto and each of his parents. In addition to the relationship assessment, a comprehensive assessment with a young child should also include a developmental assessment/screening, an observation in the child care setting, as well as interviews with other caregivers, such as his teachers.

Parent Child Interaction Assessment with Roberto and His Mother: Crowell Procedure

During the free play portion of the Crowell procedure, Sofia sat on the floor with Roberto. She pulled out several toys and attempted to engage him in playing with them. She held them very close in front of his face and when he did not respond right away, she pulled out other toys and again attempted to engage him. Roberto looked somewhat overwhelmed, and eventually picked up a toy. Rather than following his lead, his mother picked out a new toy, again holding it close to his face. When he moved away from her, Sofia stated, “Why won’t you play with mommy?” When it was time to clean up, Roberto held on tightly to the toy he was playing with, and began to whimper as his mother tried to pry it from his hands. Sofia pleaded with him not to cry, asking him to show her a “big smile, for mommy.” When he continued to whimper and pull away from her, Sofia told him to “stop being a bad boy and fighting mommy.” During the bubble task, the dyad shared several moments of joy and positive affect. Following the bubble task, Sofia and Roberto engaged in four structured tasks together. Here, Roberto’s mother was able to set the tasks up well, explaining them to Roberto in an age-appropriate manner and modeling them for him. She praised him when he engaged in the tasks, and was adept at following his lead and allowing him to attempt the tasks. It was clear that Roberto’s mother was more comfortable engaging with Roberto when there was structure. She was also less intrusive during these tasks, and Roberto engaged more readily during this portion of the assessment. 134 S. S. Heller et al.

When it was time for her to leave the room for the separation episode, Sofia prepared Roberto by telling him she would be right back. Roberto immediately began to follow her to the door, whimpering. After his mother left, Roberto threw himself on the ground and began to cry. When his mother came back into the room, he remained on the floor, crying. Sofia went over to the toys, and brought some over to him, attempting to distract him. She told him, “It’s okay, you’re a big boy. Don’t cry. No tears for mommy, you’re a big boy,” and continued to attempt to engage him with the toys. Eventually he looked at the toys she was showing him, but continued to whimper and did not appear to have resolved his distress by the end of the assessment.

Parent–Child Interaction Assessment with Roberto and His Father

Roberto was brought to the assessment by his maternal grandmother. He was calm and in a positive mood. Robert had arrived earlier to complete additional background interviews and was already in the evaluation room as the clinician had just explained the procedure to him. The clinician went and retrieved Roberto to bring him to his father. Roberto was familiar with the clinician at this point, having worked with her and his mother for several months in the clinic. When the clinician handed Roberto to his father, Roberto looked at Robert in a wide-eyed, startled manner. As soon as the clinician left the room and closed the door, Roberto began to loudly cry. Robert remained calm and tried to show Roberto various toys from the free play bucket. Roberto would stop crying at times and look at the toy and then look at his father and resume his wailing. Robert tried many strategies to soothe his son, but Roberto continued to wail in true distress. Given Roberto’s distress, the clinician ended the procedure prematurely. When she entered the room, Roberto gladly reached for her and stopped crying the minute she held him, though he continued to breathe heavily and make a slight whimper. Roberto gripped the clinician’s shirt tightly as she explained to Robert that this procedure did not seem to be working today and she would take Roberto back to his grandmother and then would come back to talk. Roberto clung to the clinician and relaxed fully when handed to his grandmother who left the clinic with him. When the clinician returned to meet with Robert, Robert acknowledged that this behavior happens at all visits with Roberto.

Interpretation and Treatment Planning

The Crowell procedure with Roberto and his mother, and the attempted Crowell procedure with Roberto and his father, highlighted some strengths and several areas of growth for both dyads. The information gathered from these assessments was incorporated into the treatment with Roberto and his parents. After the initial assessment phase, the clinician met with Roberto’s mother to review the assessment and decide on a treatment plan. During the feedback, the 4 Observational Assessment of the Dyad 135 clinician spent a lot of time highlighting Sophia’s strengths, using video review to show her some of the positive moments she had shared with Roberto. The clinician also reviewed some of the difficult moments from the interaction procedure, in a warm, nonjudgmental manner, wondering how these moments might have felt for both Sophia and Roberto. Engaging in a dialogue about this, the clinician discussed how treatment can help with these difficulties. Overall, it was evident from the assessment that Roberto’s mother was misinterpreting some of his behavior at times, for example holding onto his toy and not wanting to clean up, which is developmentally appropriate for his age, as well as fighting with her (Note: Her perception of him, which clearly contributed to this interpretation, was gathered through the parent perception of the child interview, described in Chapter 3. In the dyadic sessions following the initial assessment phase, the clinician provided developmental guidance to Sophia, to help her understand the underlying meaning of her son’s behavior, as well as to help her understand that he is not purposefully fighting her or wanting to hurt her.) Sophia also appeared to be uncomfortable with Roberto’s feelings of distress or sadness, and struggled to comfort him when he was upset. Rather, it was evident that she wanted him to act older than he is, and be less dependent on her. For example, when he was crying and clearly upset in the Crowell procedure, she attempted to distract him with the toys, rather than comfort him. This may be due to experiences in her own history, which were explored and addressed in individual sessions with Sophia. In addition, it was clear that Roberto needed help in organizing his feelings, especially when he is distressed. He had started to learn that his feelings were too uncomfortable for his mother, and that he needed to manage his own feelings—which he is not yet able to do at his age. Treatment goals included helping Roberto feel safer and more secure in using his mother as a source of comfort and security, which contributed to a reduction of some of his symptoms including the frequent crying, nightmares, aggression and general feeling of being “on edge.” In addition, Sophia was intrusive at times during the free play portion of the assessment, and struggled to follow Roberto’s lead. This led Roberto to become overwhelmed, and he attempted to manage the overstimulation by withdrawing, which his mother then interpreted as a rejection. Helping her follow his lead and read his cues was another area of intervention for the mother–son dyad. Despite some of these challenges, Roberto and his mother also had positive moments in their interaction procedure. For example, there were moments of shared joy during the bubbles episode, and the dyad clearly benefited from tasks that had more structure. In addition, Roberto’s mother clearly wants help and wants to be a better mother, and is committed to bringing him to the services he needs. As the sessions progressed, the clinician also supported Sophia in reconnecting with her warm memories of her grandmother (Note: as assessed in the “Angels in the Nursery” Interview, see Chap. 3), and drawing on these to be able to provide the same warmth and comfort to her son. In regard to Roberto’s interaction with his father, it was clear that he was so distressed that the interaction had to be ended early. Roberto’s reaction to his father gave the clinician cause to think that Roberto may be afraid of his father, and 136 S. S. Heller et al. certainly was not able to use him as a secure base from which to explore. (When children show significant distress, as Roberto did, it is important to end the procedure, even if it has not been completed. Clinical judgment is imperative when this occurs). Following the assessment, the clinician spent several sessions meeting individually with Robert, to process the reaction his son had had. Here, Robert was eventually able to acknowledge that he grew up in a home of intimate partner violence and he did not want that for Roberto. Robert began to process the impact this had on him as a child and how it contributed to his negative choices as a teenager and a young adult and his desire to live a different sort of life. By connecting with his own experience of fear as a child, Robert was eventually able to accept the connection between Roberto’s distress in the Crowell procedure to having seen Robert hurt Sofia. He could also discuss the impact of the fear on Roberto even though Robert had never directly hurt his son. Robert was truly remorseful and wanted to develop a healthier relationship with Roberto, one in which his son felt safe with him. During this time, Roberto was also referred to a domestic violence group for men, and attended the weekly group sessions. Once Roberto was able to make progress in understanding the impact of the intimate partner violence on his son, the clinician began conducting dyadic treatment sessions to support the dyad in establishing a safe and trusting relationship. In sum, the Crowell provided invaluable information about the unique relationships Roberto has with each of his parents. As described above, this information was used for postassessment feedback with the parents, as well treatment planning. Ideally, a parent perception of the child interview would also be conducted, and the information from both these procedures would be combined to gain a comprehensive picture of the dyad’s functioning.

Summary/Discussion

Caregiving relationships in early childhood have permanent effects on physical, cognitive, language, social, emotional, and brain development. A multimodal structured clinical assessment approach to assessing caregiver–child relationships is central to formulating an accurate diagnosis and corresponding treatment plan. When considering behavioral and mental health supports and interventions for young children, it is essential to consider the child within the context of environment, routine, culture and caregiver–child relationship(s); ensure a culturally informed understanding of findings and corresponding recommendations between evaluator, family, and other potential service providers; and, to identify areas of strength as well as areas of concern. The assessment process should allow for the clinical team to be reflective about global features such as: how the evaluative process could be impacting the comfort of the dyad, how the family’s culture impacts their caregiving behaviors and expectations, and how the clinician’s own culture, beliefs, and values impact their interpretations of the caregiver and child’s behavior. While the assessment instruments 4 Observational Assessment of the Dyad 137 vary in administration structure and clinical interpretation, there are several domains of functioning (see Table 4.1) and guiding principles that are important for clinicians to hold in mind when observing an infant or young child with their caregivers. It should be noted that these assessment instruments require extensive training to use, code, and incorporate into clinical plans properly; given this factor clinicians typically integrate only one or two of these measures into their regular practice with families. When used by skilled practitioners, the information gained from a dyadic observational assessment is invaluable for diagnosis and treatment formulation with young children and their caregivers.

References

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Diane Misch, Giovanni Billings, Ji Su Hong, and Joyce Harrison

Introduction and Background

Infants and young children are being brought to clinical attention in increasing numbers. For the past 25 years, the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI) has developed a series of documents called “practice parameters” intended to inform clinical practice in child and adolescent psychiatry. Historically, the gold standard of psychiatric clinical assessment of the young child has been the AACAP Practice Parameters for the Assessment of Infants and Toddlers (Thomas, 1997). Over the next few years the practice parameters will be phased out and replaced by Clinical Updates and Clinical Practice Guidelines. The AACAP Workgroup on Infant and Preschool Psychiatry is in the process of defining the Clinical Practice Guidelines for infant and young child assessment.

D. Misch Department of Psychiatry, Institute for Juvenile Reseach, University of Illinois at Chicago, Chicago, IL, USA e-mail: [email protected] G. Billings Vanderbilt University Medical Center, Nashville, TN, USA e-mail: [email protected] J. S. Hong Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] J. Harrison (*) Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 143 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_5 144 D. Misch et al.

The current practice parameters embrace the guiding principle described in previous chapters that an infant or young child must be evaluated for concerns about emotional, behavioral, relational, or developmental difficulties within the context of caregiving relationships. As outlined in the introductory chapter and previous chapters of this book, a number of additional factors including developmental and cultural factors must also be considered. More recent guides to young child assessment (Gleason & Zeanah, 2016; Navsaria & Luby, 2016) also stress the importance of an approach that is different from older children in that a developmental perspective of multiple contexts, particularly family, social, and cultural, must be central to assessment. The rationale for this approach is comprehensively described by Gleason and Zeanah (2016) with its evidence base as follows: • The child’s important caregiving relationships are more predictive of future outcomes than the child’s individual characteristics. • Infants and young children learn to interact and understand the social world and develop a sense of competence through caregiving relationships. • Environmental risks exert their effect primarily through the caregiving relationship. • Intrinsic risk factors can be moderated by the caregiving relationship. • Clinically significant problems may have their origins within the child, within the caregiver or from the interaction between the two. Evaluation of the very young child in the clinic setting is a process which requires flexibility and the ability to pull from a range of skills, the most important of which is observation. The previous chapter focused on relationship-based assessments and the one that follows will focus on understanding and interpreting how children express their inner world through behavior, emotion, and interactions. This chapter will focus on combining observational skills and a structured context of the child alone for completing a comprehensive assessment. Although no child can be adequately assessed in a vacuum, approaches more specifically geared to assessing the individual child will be described here. The chapter will begin with practical sug- gestions about structuring the evaluation and organizing the physical space. A discussion of the roles of the clinician with guidance about engagement, play, and monitoring one’s own responses follows. Tools for assessment including types of toys and their uses, parent report questionnaires, and the Infant and Toddler Mental Status Exam (ITMSE) are then described. Although not typically used for a general assessment, the chapter will end with a discussion of several semi-structured tools such as the Autism Diagnostic Observation Schedule (ADOS) and the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS), which can be useful for clarifying specific diagnoses. It is important to note that although interactions between the child and the caregiver are crucial to assessment, when possible, it is helpful to attempt to separate toddlers or preschoolers from their caregivers briefly for evaluation purposes. This provides an opportunity to interact and observe behavior that may be absent or different in the presence of the caregiver. 5 Observational Assessment of the Young Child 145

Structuring the Evaluation

Current AACAP practice parameters recommend that an evaluation be completed over several visits, given the need for multiple sources of information which may include additional caregivers, medical providers, teachers, or involved agencies. Because some very young children are unable to separate from caregivers or may have disruptive behavior during the visit, it is critical to schedule a specific meeting with the caregiver alone. As discussed in depth in the second chapter “Gathering a History in Context,” this provides an opportunity to discuss topics like parental psychiatric illness or substance abuse, trauma exposure or even the child’s challenging behavior without exposing the child to this content. Young children’s behavior can be affected by factors like fatigue and hunger, so seeing a child at different times of the day on different days is optimal. At the time of intake, a questionnaire can be sent to the family which may be completed before the first visit is scheduled. The questionnaire covers medical history and primary care provider, previous and current services, family history, social history, educational history, birth history and developmental milestones, chief concerns and reason for assessment as well as referral source. This allows the clinician more time to focus on pertinent history and face to face assessment. The parent should be informed beforehand about the length and structure of the visit. This will allow the parent to prepare with things like food, activities or even an additional adult. This visit without the child is also an opportunity to inform caregivers about specific aspects of the evaluation, particularly those that might create discomfort for a family. For example, some caregivers may be reluctant to have a female child who is able to separate be alone with a male clinician, particularly where there is a history of trauma. Explaining the reasons or rationale for elements of the exam may allow the clinician to complete rather than omit elements. For example, some caregivers may object to having their male children engage in dollhouse play because of cultural values. Explaining the use of observational play may allow caregivers to feel more comfortable. The clinician must inquire about and be sensitive to these family concerns, always being respectful of the family’s values. A final visit to discuss formulation and treatment recommendations as well as informed consent in the case of medication initiation should also be scheduled without the child. If sufficient time for extended observation is not feasible because, for example, a family arrives late, or the child cannot tolerate the length of the visit, then obtaining parent video recordings of the child can enhance understanding of the child’s behavior. Asking the parent to do an activity with the child, joining the child–parent dyad in an activity, then asking the parent to disengage, and continuing the activity with the child provides helpful information in a short amount of time. 146 D. Misch et al.

Ending the Session

At some point during the assessment, it is important to determine whether the child will participate in cleaning up the toys or not. In general, it is useful to give the child a 5 min warning, before cleanup to help with a smooth transition out of the playroom, and to provide an opportunity to observe the caregiver manage the situation if the child is oppositional. A clinician may forgo cleanup in the event that the clinician is running late, or the child is volatile or dysregulated and the clinician does not want to escalate the situation. If the decision is to not include the child in cleanup, then a 5 min warning is needed, such as, “In 5 min our time will be over, and it will be time to leave this playroom. The toys will need to stay in the room and you will be able to visit them next time. What would you like to play with before we stop?” At 1 min, it is often helpful to set a timer and explain, “In 1 min the timer will go off and it will be time to leave this playroom. Would you like to hug the stuffed bear you are playing with? or “Would you like to put the doll family in their beds?” When the timer goes off, “All right. Our time is up. You can earn a sticker if you are able to leave this room with your mother.”

The Physical Setting

While most experts agree assessment of the young child in both her natural environment and in a clinical setting is important, there is little information about how to set up an office conducive for a mental health assessment of the very young child. Room setup and toys can be extrapolated from play therapy data (Kottman, 2011; Landreth, 2002; O’Connor, 2000). The ideal set up would include office space to accommodate families in the child room, the presence of windows, a one-way mirror, two wide-angle cameras located diagonally from each other, a dimmer switch for lighting control, thermostat con- trols, and ability to video record and simultaneously record the child and parent independently of each other. The location of the rooms would be in a quiet area with little outside noise and distraction, which would also minimize the noise problem for nearby offices or people passing by. A waiting area with comfortable chairs would be outside of the offices. The child room environment would be set up to easily control sensory input (light, temperature, noise, vision) while facilitating assessment of the regulatory state and inner control of the child. Blinds/shades on the windows are important to regulate light and outside distractions. The walls of the child room would be a soothing pastel color of washable enamel paint with a few child friendly washable decals (i.e., fish, seahorses, starfish) or small murals of nature. The ceiling should be made up of acoustical tile to reduce noise, but none on the walls as it is easy for children to damage or destroy it. The child room would include an adult size round table and a child table with enough appropriate sized chairs at each to accommodate all family and staff members. 5 Observational Assessment of the Young Child 147

The furniture should be constructed of wood or molded plastic for durability and easy cleaning. There should be enough shelves for toys and labeled bins so they are not crowded, and preferably no taller than 38 in. for the smallest children to reach the top shelf. A cabinet with a lock would contain special toys, paint, bubble soap, fidgets, extra paper, and drawing materials. It would be available to secure any toys in the environment that are overstimulating to the child. Particular toys planned for the session would be taken out of the cabinet prior to the session and placed strategi- cally in the room. A dollhouse with furniture and sets of culturally diverse family dolls, a container of large interconnecting blocks, and crayons and paper are commonly used and may be permanently left out in specified locations. Open shelves filled with toys are not recommended as it may be overstimulating for children with certain disorders such as ADHD, developmental delay, or anxiety. A small sink might be available with cold running water but not hot water due to potential for injury. If possible, having some countertop space is helpful for providing a place for artwork, but the adult and child tables could also fill this purpose. Having a small bathroom attached to the main room would minimize delays and interruptions commonly associated with the assessment of young children who may need frequent toileting breaks. Weighted blanket or vest, or a small backpack with 3–5 pounds of weight should be available for children unable to manage their disruptive behavior. An emergency system to obtain help in the clinical setting is important to have in place for children who escape the room or who are displaying severe aggressive behavior. The parent interview room would contain comfortable chairs and a sofa, end tables, soft lights, and neutral colors. The parent room would be appropriate to interview parents alone or with infants, but not appropriate for older siblings who may accompany the family. In that case, it is best to keep all children in the child room, and address any particular topics the parent needs to discuss privately at another time, or recruit more staff to supervise the other children while talking to the parent. Kleenex should be available in both rooms. After the assessment, toys, table, and any other frequently contacted, dirty, or contaminated surface should be cleaned with disinfectant. Although a one-way mirror and an observation room are ideal, many clinics and/ or private offices are not equipped in this way and need a more “bare bones” approach. Other approaches might include having the clinician sit unobtrusively in the corner of the room observing, or the use of tablets with video-conferencing applications (e.g., Zoom or FaceTime) over a secure WiFi network. Many young children, especially those who have experienced trauma, are unable to separate from caregivers, requiring creativity in situating the caregiver in such a way as to be least intrusive or distracting. When a single caregiver brings such a child for evaluation, the clinician may need to be flexible and work with both the caregiver and child in the room. The ideal minimalist office set up is a sturdy play table that easily accommodates the child, the caregiver, and the clinician. “grown up” chairs and a desk and chair for the clinician may be used during portions of the parent interview while the child is occupied at the play table. 148 D. Misch et al.

There is no prohibition of doing a young child assessment when the office space changes frequently or the space does not fit this description. The most important factor in establishing a place to do an assessment is the clinician’s own comfort. If the clinician feels safe and at ease in the space, it will help the child and family feel comfortable.

The Clinician’s Roles

Engaging with an infant or young child in play is one of the mental health clinician’s primary methods for observing the behaviors that provide information about the child’s thoughts, feelings, and development. For many clinicians, playing with an infant or young child may be an activity that comes naturally. However, when play serves as the medium for a clinician’s assessment, it is critical to keep in mind how one plays with the child. This section offers considerations for how the clinician may conduct him/herself while playing with an infant or young child so useful assessment information can be elicited during the observation.

Play Technique and Establishing Rapport

As with older children, adolescents, and adults, a necessary first ingredient for conducting a meaningful assessment with an infant or young child is establishing rapport, particularly since assessments often serve as the starting point for therapy (Lieberman & Van Horn, 2008; Zelenko, 2004). Many of the nonverbal techniques a clinician might use with older children to do this (e.g., a warm tone of voice or eye contact) could also apply for young children. Because interactions with this young age group are not as verbally mediated, the clinician’s demeanor and behavior in the session is very important for developing that sense of trust. One of the simplest and most helpful ways to do this is for the clinician to physically lower themselves to the child’s level during the session, such as squatting to be at eye level when introducing oneself to the child and sitting on the floor or at a child-size table when playing. While in play, young children often show great exuberance and look to adults for feedback about their discoveries and work (Lieberman, 2017). In response, the clinician might consider using more exaggerated facial expressions or tones of voice to reflect back emotions such as joy, curiosity, or frustration that arise for the child in play. For infants, this could involve speaking to them in “baby talk” or parentese (for more information about parentese, see Chap. 2). Like empathic statements to an older child, these nonverbal forms of communication help the young child feel recognized and validated, which in turn enables him/her to share more with the clinician. When adults (clinicians or otherwise) play with young children, it is not uncommon for them to try and direct the play by selecting the activity, creating many rules, 5 Observational Assessment of the Young Child 149 or asking the child questions about the play. However, these approaches can inhibit, frustrate, or otherwise discourage young children from expressing themselves, limiting the range of behaviors the clinician is able to observe. At the start of the assessment, it is important to explain—even to young children—the purpose of the playtime (i.e., “I want to play with you to get to know you better”) and state basic rules around safety (i.e., “we must play gentle” and/or “no hurting people or stuff”). However, beyond that, facilitating a relatively unstructured, child-led play session allows the clinician to obtain observations of the child’s feelings and thoughts as manifested through behaviors that occur spontaneously. This approach can be especially valuable early in the assessment process in order to foster the child’s comfort in the setting as well as to gather a baseline of behaviors (Tuters & Doulis, 2000). Over the span of the assessment, it might become necessary to transition to more structured play-based procedures, as described elsewhere in this chapter (i.e., the ADOS-2 or DB-DOS). However, initially allow the child to explore the environment where the assessment is taking place and select the toys with which he/she wants to play. While observing the child, offer non-leading verbal communication by using concrete descriptions of his/her actions (e.g., “you are driving the car to the house”) and parroting back what the child says to you. The P.R.I.D.E. skills (i.e., praise, reflection, imitation, description, and enthusiasm), as outlined within parent–child interaction therapy (PCIT), are helpful techniques for conducting an interactive play-based session with a young child (Eyberg & Funderberk, 2011). By using these strategies in play to establish rapport and facilitate the child’s engagement in the assessment, the clinician aims to create the conditions that will elicit the range of the infant or young child’s behaviors and developmental abilities under observation.

The Clinician–Child Relationship

As the clinician observes an infant or young child in play, it is important to notice and reflect upon one’s own experience in relation to the child (Gleason, 2009). Behaviors the child exhibits in interactions with the clinician and the responses they evoke from the clinician can serve as sources of data about the child’s mode of being in the world and the potential meanings of his/her behaviors (Tuters & Doulis, 2000). For example, it is valuable assessment information to know the clinician’s experience of reciprocity from the child in play, such as whether the child interacts with the clinician or plays independently. When a clinician experiences a child as withdrawn, this may lead to several clinical hypotheses: the clinician may consider if the child has a slow-to-warm temperament, is avoidant with others because of a history of trauma and/or attachment disruptions, or has social deficits related to an Autism Spectrum Disorder diagnosis. Thus, observations of how the clinician does or does not feel incorporated into the play can be an important source of information about the child’s functioning, to be considered in conjunction with other assessment data when developing a case conceptualization. 150 D. Misch et al.

From an interpersonal perspective, the reactions a clinician has to the young child during play provide assessment information about the experience others (e.g., caregivers or childcare providers) may also have being in relationship with the child. For example, is the child’s level of activity in the play exhausting or does the clinician find him/herself having to frequently set limits or boundaries with the child? Although the clinician might be engaging in unstructured playtime to observe the young child, if that child’s behavior begins to pose a safety concern (e.g., climbing on furniture or throwing toys at people) the clinician should set a limit with him/ her. When the caregiver is present in session during the observation, it is helpful to first allow him/her to try and set the limit. If he/she is unable to effectively set a limit and the child’s behavior continues to pose a safety concern, the clinician should intervene and assist the caregiver in responding to the behavior. Asking the caregiver’s “permission” to help or take charge can communicate respect for the caregiver’s authority and promote a better therapeutic alliance than reflexively jumping in. How the child responds to limits and what type of direction is effective are valuable assessment observations about the child’s behavioral regulation and patterns of relating to adults. Such experiences can provide the clinician first-hand experience of the challenging behaviors facing adults responsible for the young child’s care, which can enhance the clinician’s empathy as well as provide insight into possible helpful therapeutic interventions. The clinician should also attend to and reflect upon thoughts and emotions he/she experiences in response to the content of the young child’s play. Since play is a primary mode for young children to communicate their thoughts and feelings, it is critical for the clinician to observe what themes the child is expressing in the play (Lieberman & Van Horn, 2008). It is also important that the clinician recognize his/ her own reactions as sources of information about the play’s meaning for the child (Tuters & Doulis, 2000). A 3-year-old with symbolic play skills who has been exposed to trauma might engage in play with themes of violence, shame, or loss. In response, the clinician may find him/herself experiencing states of worry or sadness, which may parallel the emotional difficulties the child might be experiencing. For example, a young child exposed to interpersonal violence might repeatedly play out loud fighting scenes, throw toys, or pretend him/herself to be an aggressive character. In turn, the clinician might feel worried that the play could escalate and cause harm (e.g., breaking a toy or disrupting the clinic), which might mirror thoughts and feelings the child had about the interpersonal violence or continues to have when remembering it. By observing one’s own responses to the play, the clinician is able to empathically attune to the child’s communication and gain a window into his/her internal experience. In conclusion, because relationships are essential to the growth and well-being of infants and very young children, assessments should include not only observation of the child on an individual level but also observation of what arises in the relationship between the child and clinician. 5 Observational Assessment of the Young Child 151

Interacting with Caregivers

Young children are typically accompanied to assessment appointments by their caregivers and it can be necessary to have the caregiver present in the child’s session, even when the clinician is focusing on observations of the child’s individual functioning and not parent–child interactions. That is, sometimes even when the clinician’s session goal is to observe just the child’s behavior, the caregiver may still need to be present (e.g., because of the child’s developmental stage, a separation from caregiver for the session is not appropriate). One valuable aspect of having a caregiver present is being able to ask him/her, at the end of session, if the play and behaviors displayed during that time were typical for the child and what the caregiver’s understanding is of any notable behaviors that might have been exhibited in the session (Tuters & Doulis, 2000; Zelenko, 2004). At the same time, a parent’s presence can sometimes pose obstacles to observing the child. It is not uncommon for caregivers to report on their child’s behaviors when the child is present, and balancing the gathering of this information while trying to attend to observing the child’s behavior and play can be challenging. It is important to note whether the caregiver disproportionately demands the clinician’s attention, undermining the focus on the child, as well as how the child reacts to the caregiver’s discussion of him/her. At times, it might be necessary for the clinician to set a limit or boundary on a caregiver’s sharing, if it detracts from the clinician’s ability to observe the young child. The caregiver can be gently guided away from discussion of their own issues by empathic statements like “That sounds like it was rough for you” or “I’m sorry you had to go through that, but in the interest of time, I’m going to shift our focus to hear a bit more about…”. Another strategy for managing this scenario could be the caregiver sitting in an adult chair in one part of the room while the clinician plays on the floor with the child; in effect creating a slight separation, but still allowing the young child proximity to his/her caregiver. Optimally, a clinician would want to spend some time with the child individually away from his/her caregiver, particularly if the child is an older toddler or preschooler. This allows the clinician to observe how the child’s behaviors differ when interacting and playing with the caregiver versus another adult. Such an assessment scenario can also be especially useful in observing how the young child emotionally responds to separation from his/her caregiver (Tuters & Doulis, 2000). Observations of the level of anxiety, or lack thereof, at the separation as well as the child’s response to his/her caregiver upon reuniting can provide helpful information about the child’s relationship with the caregiver and ability to cope with stress. For young children who have experienced trauma and/or attachment disruptions, observation of separations and reunions with caregivers can offer very helpful assessment information about the child’s sense of safety and trust with his/her caregiver (Miron, Lewis, & Zeahah Jr., 2009). Some things to observe during a separation include the following: Does the child look to his/her caregiver for explanation, permission, and/ or comfort prior to the separation? How does the young child express his/her 152 D. Misch et al. distress about the separation? How does the child cope with that distress? How does the child respond to the clinician during the separation (e.g., the clinician is able to distract the child from his/her distress through engagement in play)? It should be noted, the meaning of young children’s behaviors during a separation from caregivers will vary significantly depending on their developmental stage. For example, emotional distress a 10-month-old shows at separation would be developmentally typical, whereas the same level of distress in a 4-year-old may have different clinical significance (for more information about parent–child relationship assessment, see Chap. 4).

Documenting Observations

The clinician’s sustained and focused attention during behavioral observations is critical—especially for young children, given that they convey so much more information nonverbally than through verbal dialogue with the clinician. However, young children’s behavior and play is often very active, so it can be challenging to simultaneously track the child’s behaviors, document them, and maintain engagement with the child in session. Therefore, it can be helpful to develop strategies for note- taking during the session. Using a handout that has structured categories of behaviors that are to be observed (play activity/exploration, verbalizations, compliance with directions, etc.) can help organize the clinician’s thinking and streamline note- taking. It can also be helpful to develop a system of symbols that correspond to particular behaviors that can be written quickly by the clinician, as shorthand, during the observation. Another aid for gathering information that is commonly used in infant mental health work is video recording sessions. The first step to utilizing recording is to consider the relevant ethical issues, such as obtaining consent from the guardian to record the child and proper storage of recorded material that ensures confidentiality. Once those things are addressed, recording sessions can be used to allow clinicians to go back and review moment-to-moment interactions and capture minor details that might be easily overlooked (Cohen, Stern, & Balaban, 1997; Zelenko, 2004). This can be particularly helpful in ascertaining the sequence of behaviors; that is, if a particular concerning behavior is exhibited by the child, the clinician can go back and review what interactions or situations served as antecedents to it. Collectively, video recording and note- taking tools can be used to ensure that the clinician is capturing all the relevant behaviors during a session, so that when he/she later attends to conceptualizing and formally documenting the assessment of the child, the maximum amount of data is available for review. 5 Observational Assessment of the Young Child 153

Assessment Tools

Toys and Materials

Toys in the office may be used for assessment as well as to keep the child occupied during history taking. Toys that can be used to occupy the child include blocks or large Legos, coloring pages with washable markers, puzzles, a doctor kit, toy food and dishes, and a dollhouse or other structure conducive to imaginary play like a castle or pirate ship. Toys should include diverse representations and even languages. Toys should be sturdy and easily cleaned after each use. There are a few rules to keep in mind when arranging toys and the room environment (i.e., furniture). Placement needs to be predictable and consistent. Play materials should go back to approximately the same place after every session. Furniture should remain in the same location. In this way young children know that things are predictable, consistent, and have an organization easily remembered. To facilitate return of toys to their usual spots, arrange them according to specific categories. For example, squishy dinosaurs go on one shelf, baby dolls on another, and transportation toys on a third. Or farm animals go in the blue bin, and dollhouse families go in the red bin. If the assessment room is transitory, consistent and predictable arrangement of toys can still be maintained by placing the toys in a certain order on the floor or table in whatever space is used. Landreth (2002) suggests that toys and play materials used for play in a clinical setting should: • Facilitate a wide range of emotional and creative expression by children. • Engage the interest of children in some way. • Encourage verbal and nonverbal investigation and expression by children. • Provide mastery experiences in which children can experience success without having to follow certain rules about how to use them. • Be sturdy and safe for children to use in play. Different ethnic and cultural factors should be taken into account when selecting toys, including baby dolls and doll families with a variety of racial identities. Five distinct categories of toys should be available in the young child assessment. It is often unclear what issue will be on the child’s mind despite an intake or referral description of the current problem. The variety of toys will allow for emergence of a more comprehensive understanding of the issues at hand. Categories might include family/nurturing toys, scary toys, aggressive toys, expressive toys, and pretend/fantasy toys (Kottman, 2003). Family/nurturing toys: These provide an opportunity for children to build rapport with the clinician, provide insight into family dynamics and relationships, and represent situations that happen in the child’s life. Such toys could include a dollhouse, furniture, families of dolls that are bendable with removable clothes, baby dolls, a cradle, animal families, a soft blanket, people puppets, baby clothes, baby bottles, stuffed toys, and dollhouse pots, pans, dishes, silverware, food, a child 154 D. Misch et al. potty, crib, and high chair. Some particularly popular items include Velcro wooden fruit and vegetables with cutting board and wooden knife, Velcro wooden birthday cake with removable candles, and spatula, plastic ice-cream scoops, cones, and scooper. Play with the dollhouse may occur with the caregiver and child, clinician and child, or child alone. It is optimal to give the child an opportunity to play alone or with the clinician. The play in the dollhouse can often be a clue to the home life of the child. For example, the placement of many people in one bedroom, child in bed with parents, chaotic play, or avoidance of certain rooms in the house may be indicative of the child’s family life. Children may play out traumatic events such as home invasions, fires, or assaults. The baby doll and the play food are a good way to assess whether a child can respond to others with empathy. By 18 months of age, a child should be able to engage in pretend play by feeding a doll. The clinician pretends the baby is crying and asks the child what is wrong with the baby. If the child is too young or unable to respond, the clinician can say “The baby is hungry” and offer the bottle or food to see if the child will feed the baby. The clinician can watch to see if the child holds and comforts the baby while pretend feeding with the bottle, places the bottle in the baby’s mouth at a distance, or tries to drink the bottle himself. Some parents are uncomfortable having their male child play with dolls, in which case this should be respected and omitted. Puppets are very useful for shy or inhibited children who may not be able to respond to direct questions. A turtle or snail who retreats into its shell can normalize shyness for that child. Puppets also provide an opportunity, like the dollhouse, for the child to play out themes or conflicts. Scary toys: These toys provide opportunities for children to deal with their fears. They often include rubber snakes, lizards, rats, insects, alligators, plastic monsters, dinosaurs, dragons, alligators, and some predator animal puppets like a wolf, a bear, or an alligator. A favorite is often a plastic model 12-in Godzilla. The mouth has an opening to swallow small animals or dolls. The tail can be pulled off to release the objects swallowed. Aggressive toys: These provide opportunities for children to express anger and aggression, to protect themselves from fears, and to explore control issues. These toys could include knights with play weapons such as swords and catapults, Star Wars™ figures with laser swords, shields, tanks, and aircrafts. Some children will use toy police cars and other emergency vehicles. Expressive toys: These provide opportunities for children to express feelings, enhance mastery, problem-solve, and be creative. These materials include crayons, water-based markers, paper, Play-Doh, child crimping scissors, tape, and pipe cleaners. Expressive toys also allow for assessment of the young child’s fine motor skills, ability to copy, and to write their name, the alphabet, and numbers. For infants or young toddlers, rattles or simple musical instruments can be used as expressive toys and offer observations of motor development. Pretend/fantasy toys:These provide opportunities to express feelings, explore roles, and act out situations and relationships from their life. These toys can include 5 Observational Assessment of the Young Child 155 capes, crowns, magic wands, hats, doctor kits, telephones, blocks, interconnecting building blocks, cars and trucks, blanket to make a table tent, farm and zoo animals, puppets, wooden train with magnetic interlocking cars and wooden track, and plastic molded veterinary hospital with doors, locks, and a set of keys. Sensory toys: A sixth category of sensory toys can be an added benefit to the assessment as they facilitate observation of the young child’s sensory needs and can assist in self-soothing. Examples include squishy animals composed of soft rubber exterior and rice filling, sensory cardboard books that display different textures, wooden hammer and peg board, thinking putty, sticky animals, and for suspected auditory processing disorder/autism spectrum disorder a rain tree. Bubbles can be used alone with a child or as an activity for a parent and child to engage in. Lack of enjoyment in the bubble play can signal a depressive disorder in either the child or the caregiver, or both. It can also reflect a relationship problem if the parent is unable to engage or enjoy the activity.

Miscellaneous Toys for Developmental Assessment

Behavioral disorders are highly comorbid with developmental disorders. When behavioral problems are the presenting concern of parents of preschool-age children, 35–70% have undetected developmental disorders that require intervention (Yimgang, 2017). The importance of assessing for possible developmental delays or concerns cannot be overemphasized because of the impact of early intervention and should be considered part of any diagnostic assessment of young children (ZERO TO THREE, 2016; see Chap. 8 for further detail). Assessment of speech/language, cognitive, and motor skills is part of the Infant and Toddler Mental Status Exam described below (Table 5.1). The tables below are useful for reference. Some of the toys which can be used to help assess developmental level include the following: A garage with cars and keys: There are several commercial plastic garages of this type which require matching the key by color and shape to open the garage door. This is an extremely useful tool in that it allows the examiner to assess the child’s problem-solving ability (matching the color and shape) as well as whether the child can name or match colors (Chud & Fahlman, 1985). Language can be tested by giving a simple instruction like “Can you open/lock the door now?” It can also be used measure frustration tolerance when/if they are unable to open or lock the garage door. A child may engage in imaginative play, having the cars converse, or narrate the action. Attention can be measured by how long the child is engaged with play as well as whether the child can sustain attention to problem-solve. Repetitive behaviors like mechanically opening and locking the doors or pushing the lever that lifts the garage floor for the cars to exit can signal developmental differences. Unusual behavior such as trying to insert the key places other than the keyhole, placing the garage in an upright or upside down position may suggest developmental delays or disorders like autism spectrum disorder. The examiner Table 5.1 Developmental milestone table Developmental red Language Social/emotional flags Age Motor milestones milestones milestones If not achieving … 2 months Social smile 4 months Steady head To and fro, reciprocal Steady head control while alternating control sitting vocalizations Roll over, front to back 5 months Roll over, back to front 6 months Sit up Babbling Stranger anxiety Turn to sound or momentarily voice propped with Smiling or other hands joyful expressions Grasp with one hand 8 months Engages in gaze monitoring: when adult looks away, child follows adult glance Shakes head for no 9 months Crawl “Mama,” Orients to name well Babble consonant Immature pincer “Dada” Follows a point, when sounds grasp nonspecific a parent point things Reciprocal (back out and forth sharing of) vocalizations, smiles, or other facial expressions Sit up 10 months Sit up well Enjoys Peek-A-Boo Waves bye-bye 11 months First word other than “Mama,” “Dada” 12 months Stand alone “Mama,” Shows objects to Proto-imperative briefly “Dada” with parent to share interest pointing for Walk with one meaning Proto-imperative desired objects hand held pointing to get desired Reciprocal Mature pincer object gestures (showing, grasp reaching, waving) Respond to name when called 14 months Proto-declarative pointing to indicate and share interest 15 months Walk without 3–5 words Shows empathy Proto-declarative holding on pointing to express Imitate scribble interest or other Stack two blocks showing gesture Use three words (continued) 5 Observational Assessment of the Young Child 157

Table 5.1 (continued) Developmental red Language Social/emotional flags Age Motor milestones milestones milestones If not achieving … 18 months Walk upstairs 10–25 words Passes M-CHAT Say “mama,” with one hand Early symbolic play “dada,” or other held names Scribble Follow one-step spontaneously directions Stack 3 blocks simple pretend play Spoken language/ gesture combination Walk independently 22 months Use a fork and Point 5–6 body spoon without parts spilling 24 months Run well >50 words Parallel play Point to pictures Stairs up/down I, You, Me or body parts alone Two-word when they are Imitate stroke phrase named Stack seven Refers to self Two-word blocks by name meaningful 50% of speech phrases (without understood by imitating or strangers repeating) 30 months Differentiate Imitates adult Two-word unique horizontal and activities phrases, including vertical stroke Complex symbolic noun-verb play combinations Verbally respond or nod/shake head to questions 3 years Ride tricycle Three-word Starts to share with/ Three-word Stack nine blocks sentence without prompt sentence Copy circle 75% of speech Child can use words Follow two-step understood by to think about what directions strangers someone else is Have echolalia to thinking (Dad thought questions I was at home) 4 years Button clothing Name four Passes Sally and Anne Copy cross colors test Copy square 100% speech Child can be understandable concerned about being deceived or tricked by others Has a preferred friend 6 years Tie shoes Has best friend of same sex Gerber, Wilks, and Erdie-Lalena (2010, 2011), Schum (2007) 158 D. Misch et al. should observe and note the child’s ability to seek help. Whether the child looks to the caregiver or the examiner may signify a lack of the child’s trust that the caregiver can meet their needs. The child’s inability to engage either the caregiver or the clinician in the play, the clinician’s inability to engage the child, and the caregiver’s ability to read the child’s needs and respond may signal problems with relatedness. A shape sorter geared to younger children may also provide some of the above information. Puzzles: Sturdy age-appropriate puzzles with the alphabet, animals, or numbers can be used as a task for the child and caregiver to complete together. This provides an opportunity for the clinician to observe their interactions in a goal oriented activity. It can also provide information about the child’s cognitive level, ability to communicate frustration to the caregiver. Paper and washable thick markers: Age-appropriate tasks from the Ages and Stages Questionnaire [1] can be used to assess both fine motor and cognitive ability. By 18 months of age, a child should be able to hold the marker and attempt to draw on paper. For example, a 3-year-old should be able to copy a circle. Balls: Various shaped and size balls can be used to look at gross motor skills, for example whether a child can throw overhand, or catch a large ball. Playing catch can be used to measure frustration tolerance if the examiner holds the ball for too long or stops the play before the child is ready. An additional finding is that when the clinician holds the ball for too long, children in the autism spectrum may look at the ball instead of the clinician, seeing the object rather than the person as the agent of action. Some clinicians may choose to omit balls because of the risk of damage by overly aggressive children. Books. Board books, particularly those with few words can be used to assess language, and a child’s ability to weave a narrative. An impulsive or rough approach to handling a book could indicate attention or hyperactivity concerns, or could be due to lack of familiarity or exposure to books. Books can also be a way to measure joint attention (i.e., the child points out things of interest to the caregiver or the clinician).

Structured and Semi-structured Assessment Tools

Careful psychiatric interview and mental status examination should be adequate to develop a working diagnostic formulation for most cases. The Infant and Toddler Mental Status Exam is a framework with elements that can be completed for all assessments as it asses general functioning. If there is significant uncertainty about the child’s particular symptoms and diagnosis, other observational assessments may be considered for further clarification. The tools mentioned below (ADOS-2, DB-DOS) typically are not part of a general assessment, but they merit discussion as additional ways to get more specific information to clarify particular diagnoses. 5 Observational Assessment of the Young Child 159

Infant and Toddler Mental Status Exam (ITMSE)

The mental status exam outlined below is an adaptation of the mental status exam described in the American Academy of Child and Adolescent Psychiatry’s Practice Parameters for the Assessment of Infants and Toddlers (1997). It was designed for use with children 0–36 months of age but can be extrapolated up to 60 months of age. A template with prompts expedites this process, which is mostly observational. It highlights the theme of caregiver context, as portions of it cannot be completed with the child alone. It can be used with preverbal and nonverbal children. The majority of the items can be addressed within 10–20 min, which may be the upper limit of the amount of time a young child can sustain attention, complete tasks, or be separated from their caregiver. The general approach to the infant and toddler mental status exam should be a description of behaviors observed rather than an interpretation of what the behaviors might mean (e.g., “the child hid under the chair when I approached” vs. “the child was fearful of the evaluator”). Describing the child so that he might be picked out of a waiting room full of children, is a helpful way to practice attention to detail with observational skills. The following are the domains that are rated during the observations: Appearance. Attention should be paid to the child’s body type, for example whether a child is thin or overweight, or appears malnourished. Whether a child appears age appropriate, younger, or older than their stated age should be noted. Adults may have developmentally inappropriate expectations of a child who appears large and older or petite and hence younger than their chronological age. Dysmorphic features such as eye and ear placement, epicanthal folds, or head shape should be noted as they may indicate a genetic or medical condition that should be further explored. Clothing can be indicative of care and hygiene or lack of resources; for example, a child is inadequately dressed for weather. Dark circles, or a tired or ill- appearing child, should also be noted. Reaction to situation. The structure of the evaluation should be described—for example, when during the session caregivers were present and/or whether it was possible to see with child without the caregivers for any portion of the visit. The child’s initial reaction to the situation and to the clinician should be noted. A child who is overly willing to go with a stranger could indicate attachment problems or a lack of developmentally appropriate fear of strangers. A child who is overly distressed or too fearful at 5 years to separate from caregivers could indicate anxiety or trauma. The child’s adaptation to the waiting room or the clinician’s office could indicate strengths or vulnerabilities. Reactions to transitions also provide helpful information about the child’s rigidity or flexibility. It is not unusual to see tantrums at the end of a visit or during transitions away from play or desired activity. The caregiver should be allowed to manage the tantrum, except in the event that ineffective management jeopardizes the safety of the child or others. Self-regulation. Regulation of sensory input should be noted. For example, vigilance to noises outside of the office or the building such as police sirens or loud voices could be a sign of trauma. Seeking sensory input with spinning, inappropriate 160 D. Misch et al. smelling, or mouthing could signal developmental delay or autism spectrum disorder. Responses to stimuli may include fear, aggression, tantrum, or avoidance (hands over ears). Activity level is often challenging for the clinician to rate as most toddlers may be viewed as hyperactive. Research on typical activity levels is available and can assist with distinguishing typical from atypical activity and attention (Gleason & Humphreys, 2016). A description of how long a child was able to engage in play or a certain task, as well as describing the child’s activity (i.e., running around the room, sitting calmly at the play table) can be more helpful than describing a child as “overactive.” Descriptions of how a child sits at the play table or on the floor, for example V-sitting or bouncing on their knees, are also useful. Frustration tolerance, and the response to being frustrated, as well as the ability to seek adult help when frustrated, should be noted. Attention span, with awareness that young children may have short attention spans, should be noted. Describing the length of time attention was maintained, and to which activity or task, is more useful than saying “short attention span.” Distractibility should also be described, for example “he was distracted by the sound of the clock.” Aggression should be described and if possible, with antecedents, mode of aggression (i.e., biting, hitting, kicking, throwing things, pushing over furniture), where the aggression was directed, and responses of the caregivers. Motor. Overall muscle tone, coordination, child’s sense of himself in space, gait, and unusual movement (e.g., tics or stereotypies) should be noted here. Handedness, which usually declares by about age 3, but even as late as age 5, should also be noted here. Gross motor skills can be examined by having the child run, walk, or catch a ball. Fine motor skills can be assessed with use of a marker, completing a puzzle, or stacking small blocks. Manipulating keys or small objects can also reveal fine motor deficits. Speech and language. Children should have 2–3 words by age 1, 50–200 words by age 2 and should be able to speak in two-word sentences. By age 3, a child’s vocabulary has increased to about 500 words and by age 4 sentence length should increase to 4–5 words, with a vocabulary of about 1000 words. In addition to vocabulary, attention should be paid to phonologic, expressive, receptive, and pragmatic language. Phonologic speech refers to the motor ability to say words. By 18 months of age, 25% of what a child says is understandable. By age 2 this increases to 50–75%; by age 3 75–100% should be understood by family and caregivers. By the age of 4–5 most of a child’s speech should be understood by most listeners in all situations (ASHA, 2018). When assessing a child the clinician should note how much of the child’s speech is intelligible as well as asking the caregivers, “How much of his/her speech do you understand?” Receptive language refers to the input of language or the ability to make sense of questions and sentences. Receptive skills precede expressive language skills. Expressive language refers to the output of language into phrases and sentences as well as the appropriate use of gestures and facial expression. Receptive language can be examined by giving simple commands without gestures “put the book on the 5 Observational Assessment of the Young Child 161 table.” Unusual expressive language such as echolalia, jargon, pronoun reversal, or bizarre responses could be indicative of a communication disorder or an autism spectrum disorder. Pragmatic language problems, the social use of language which includes understanding turn taking, and being able to understand nonverbal cues in communication, can also be picked up with good attention to language. The communication domain of the Ages and Stages Questionnaire (ASQ) (Squires, Twombly, Bricker, & Potter, 2009) (described below) is a useful brief assessment tool for all aspects of language. It should be noted whether the child is a native English speaker, is in a home where more than one language is spoken, as milestone expectations may be different. Thought. Thought disorders almost never appear in very young children, and thought processes may be difficult to discern in children with language limitations or those who have experienced severe trauma. It is important to remember that young children have active imaginations and may “see” or “hear” imaginary play- mates, which is developmentally appropriate. Non-organic hallucinations at this age are extremely rare. Asking a child about dreams and nightmares may elicit some thought content. Specific fears can be addressed. Alternately asking a child to tell you about a favorite TV show may provide themes, in addition to language ability and appropriateness of TV choices. Imaginative play is also a good way to elicit thought content and will be described in more detail below. Affect and mood. Young children are usually joyful, so noting an absence of reciprocal smiling or expression of happiness can signal issues like depression and anxiety, trauma or autism spectrum disorder. Young children may not have the language to describe their mood, which makes careful observation even more critical. Noting how a child expresses feelings—facial expression, body language, and voice tone—is helpful. Tools such as a feelings chart which depicts various facial expressions with drawings or photos, stuffed animals or puppets can be helpful for young children. The clinician should note the range and intensity of affect, as well as the situation that elicits it. Play. Play can be used to obtain a great deal of information in most of the other domains of the ITMSE, and is the “gold standard” for a good assessment with infants and young children (see Chap. 6). Children play, and engaging in play in the office, either with the examiner or their caregivers provides information about their language, thoughts, relatedness, cognition, and affect. A detailed table of developmental stages of play can be found in the Chap. 6. Sensorimotor play occurs before the age of 1 and involves exploring objects. Mouthing toys after age 1 suggests atypical development or sensory needs. By 12–18 months of age, children should be engaging in functional play, for example putting the toy telephone to their ear. How they speak on the phone, their animation, whom they choose to speak to, the content of the conversation, and whether they engage the examiner or their caregivers can be noted in a very brief toy phone conversation. Children with atypical development may choose to spin the dial in a repetitive manner. 162 D. Misch et al.

After 18 months of age, early symbolic play emerges and by 30 months of age, a child should be able to engage in complex symbolic play, where he/she acts out scenes with dialogues. The choice of toys, which is described above as well as themes that emerge in the play, may provide information about family life, possible traumatic events or fears. Cognition. Information obtained from all the above areas, particularly language and play, can help determine whether a child might have cognitive delays or precoc- ity. Items from the problem-solving and the personal–social domain of the ASQ-3 can also be used as very broad screen for developmental concerns. The “draw a person” or task, as described below, is a useful tool. Asking a child to draw a self- portrait can provide information about self-concept in addition to cognitive ability. The Goodenough–Harris draw-a-person test has been controversially used as a tool to measure intelligence; however, it can be useful to elicit young children’s experiences, thoughts, and feelings. Simply asking a child to draw themselves or a person can be used to assess developmental level. Between the ages of 2 and 3, children begin to learn to make shapes, with most children able to draw a circle by age 3. A typical 3-year-old’s drawing of a person is a circle with arms and legs coming off the circle. By the age of 5 there is a discernible body, clothes and details like eye- lashes and shoes (Harris, 1963). Watching the process of the child drawing can provide information about attention, frustration, perfectionism, as well as fine motor skills. Relatedness. There is detailed attention to observation of dyads in previous chapters (see Chap. 4 in particular). Within the context of the infant and toddler mental status exam, there are multiple opportunities, both structured and informal, to assess the child’s relatedness, both with caregivers and with the clinician. It is very useful to observe the child and caregiver’s interactions in the waiting area before they are aware of being observed. Caregivers may be harsh, distant, or inattentive to the child while in the waiting room. It is useful to attempt to simply describe the behaviors and affect observed without judgment or interpretation. While they are in the office together, activities like play and puzzles provide an opportunity to observe the caregiver’s ability to allow the child to lead the play, to manage the child’s negative affect, to respond to the child’s positive affect or shared attention, and to set limits. The child’s interest in the clinician, and the ability to engage as well as to be engaged are important aspects of relatedness.

Other Tools to Be Incorporated

The following checklists and parent reporting tools can be useful adjuncts to the observations and interactions described above. The reader is referred to Chap. 7, which provides a more detailed discussion of rating tools. 5 Observational Assessment of the Young Child 163

The Ages and Stages Questionnaires

The Ages and Stages Questionnaire-III is a widely used parent-report developmental screening questionnaire for children aged 1–66 months which has been standardized in over 2000 children across the USA (Squires et al., 2009). It is designed to be completed by a primary caregiver with the aim of identifying children who may have developmental delays. Parents rate whether the child demonstrates specific developmental milestones (“yes,” “sometimes,” or “no”) in the domains of communication, gross motor, fine motor, problem-solving, and personal social. There are different forms based on the chronological age of the child. Items from each of the domains can be used as screening items to be incorporated into the mental status exam. The Ages and Stages-Social Emotional Questionnaire compliments the ASQ-3 by focusing on social-emotional development and behaviors. It is a highly validated parent report screening tool which takes 10–15 min to complete and has eight questionnaires from 6 to 60 months of age. (Squires, 2002). It covers domains of self- regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people.

Autism Diagnostic Observation Schedule-2

The Autism Diagnostic Observation Schedule-2 (ADOS-2) is a semi-structured, standardized assessment of communication, reciprocal social interaction, play/imagination, restricted and repetitive behaviors, and other abnormal behaviors to assist in the diagnostic evaluation of autism spectrum disorder. It is often regarded as a gold standard assessment in the evaluation of autism spectrum disorder. Administration of ADOS-2 for clinical use requires training. ADOS-2 clinical training can be done through WPS workshop, WPS DVD training package, or third-party independent trainers. (https://www.wpspublish.com/app/home/TrainingandWorkshops). If a clinician wants to use ADOS-2 for research purposes, he or she needs additional ADOS-2 research training which is provided by the Center for Autism and the Developing Brain (CADB) or third party independent trainers (https://psychiatry. weill.cornell.edu/education-training/autism). The ADOS-2 has five different modules, based on a child’s expressive language level and age. The toddler module and module 1 are for child with preverbal and single words (toddler module: 12–30 months, module 1: 31 months and older). If a child is nonverbal or uses single words, the Toddler module and module 1 are used based on age. Module 2 is for young children who use phrases well but are not yet fluent. In ADOS-2, phrase speech is defined as flexible use of non-echoed, three- word utterances that sometimes involve a verb, that are spontaneous, meaningful combinations. Modules 3 and 4 are for verbally fluent children whose expressive language level is of a typically developing 4-year-old or above. In the ADOS-2, fluent speech is defined as a range of flexible sentence types and grammatical forms, 164 D. Misch et al. which provide information about events out of immediate context and some logical connections within sentences (e.g., using but, though). Some grammatical error may be allowed. Module 3 is for children and younger adolescents (usually under 16 years old). Module 4 is for the older adolescent and adults (16 years and older). In the toddler module, module 1, and module 2, a caregiver is present during the testing and child’s interaction with a caregiver is coded as a part of the evaluation. In Module 3, the testing is administered without a caregiver. Most infant or preschool assessments would use the toddler module, module 1, or module 2. If a child is 2 years old with fluent speech, module 2 is used. A very verbal 3-year-old child would need module 3. A series of activities in ADOS-2 is designed to elicit language use, nonverbal communication, social/emotional reciprocity, rapport with the clinician (and a caregiver), restricted and repetitive behaviors, and other abnormal behaviors (Table 5.2). Each activity has a specific protocol for a clinician to conduct while observing a child’s behaviors. For example, during the Response to Name activity in module 1, a clinician conducts this activity while a child is involved in a toy or other activity of interest. The clinician positions himself or herself at a distance of 3–5 f from the child so that the child should turn his or her head or look up to see the clinician’s face. The series follows: 1. The clinician calls the child’s name. If the child looks at the clinician or makes eye contact with the clinician, the activity is completed. If the child does not respond, the clinician repeats calling child’s name up to three more times (total four attempts). If the child responds, the activity is completed. If the child does not respond during the four attempts, the clinician proceeds to the next step. 2. The clinician asks the parent to call the child’s name to get the child’s attention without physical contact. The parent makes up to two attempts. If the child responds, the activity is completed. If the child does not respond during the two attempts, the clinician proceeds to the next step. 3. The clinician asks the parent “Is there any other vocalization or noise you can use, without touching him (or her), to get him (or her) to look at you?” The parent uses vocalization up to two attempts. If the child responds, the activity is completed. If the child does not respond during the two attempts, the clinician proceeds to the next step. 4. The clinician asks the parent to do whatever he or she would do at home to get the child’s attention, including touching or tickling the child. During the Response to Name activity, the clinician should observe how the child responds to his or her name; eye contact, looking at the clinician’s face or general direction, looking at the parent’s face or general directions, or vocalization. Immediately following the ADOS-2 administration, the clinician rates each coding items based on the child’s behaviors throughout the ADOS-2 administration (Table 5.3). The general guide for coding is as follows: Code 0: no evidence of abnormalities as specified. Code 1: mild abnormal or slightly unusual but not necessarily grossly abnormal or not as clear as the type specified. Table 5.2 ADOS-2 administration Expressive Preverbal/single words: no speech, up to Phrase speech, up to Fluent speech language and including, simple phrases fluent speech Age 12–30 months 31 months and Any age Child/younger adolescent; older later preschool years up through 15 years Module Toddler module Module 1 Module 2 Module 3 Participant Child, caregiver, Child, caregiver, Child, caregiver, Child, clinician clinician clinician clinician Activities Free play Free play Free play Free play—ball Response to name Response to name Response to name Response to joint Response to joint Response to joint attention attention attention Bubble play Bubble play Bubble play Bubble play— teasing toy play Anticipation of a Anticipation of a Anticipation of routine with objects routine with aroutine with objects Anticipation of a objects routine with objects—unable toy play Responsive social Responsive social smile smile Anticipation of a Anticipation of a social routine social routine Functional and Functional and symbolic imitation symbolic imitation Snack Snack Snack Birthday party Birthday party Blocking toy play

Bath time Bath time—ignore Construction task Construction task Make-believe play Make-believe play Joint interactive play Joint interactive play Conversation Conversation and reporting Demonstration task Demonstration task Description of a Description of a picture picture Telling a story from Telling a story from a book a book Cartoons Emotions Social difficulties, annoyance Break Friends, relationships, marriage Loneliness Creating a story Lord et al. (2012) 166 D. Misch et al. MODULE 3 adolescent with Child/younger later preschool fluent speech; 15 years up through years A. LANGUAGE AND A. LANGUAGE COMMUNICATION A1. Overall level of non- level A1. Overall language echoed spoken A2. Speech abnormalities associated with autism(intonation, volume, rate) rhythm, A3. Immediate echolalia A4. Stereotyped/idiosyncratic A4. Stereotyped/idiosyncratic or phrases use of words MODULE 2 up speech with phrase Any age to fluent speech A. LANGUAGE AND A. LANGUAGE COMMUNICATION A1. Overall level of non- level A1. Overall language echoed spoken A2. Speech abnormalities associated with autism(intonation, volume, rate) rhythm, A3. Immediate echolalia A4. Stereotyped/ or idiosyncratic use of words phrases 31 months and older with some than more words; (d) five words A. LANGUAGE AND A. LANGUAGE MODULE 1 Preverbal/single words: No speech up to No speech words: Preverbal/single and including simple phrases 31 months and to older with few less no words; (c) than five words COMMUNICATION A1. Overall level of non-echoed spoken of non-echoed spoken level A1. Overall language A2. Frequency of spontaneous A2. Frequency to others (c, d) directed vocalization A3. Intonation of vocalization or A3. Intonation of vocalization (c) verbalizations A4. Immediate echolalia A5. Stereotyped/idiosyncratic use of A5. Stereotyped/idiosyncratic or phrases (d) words 21-30 months with five some words; (b) or more words ADOS-2 coding

MODULE T Preverbal/single words: No speech up to No speech words: Preverbal/single and including simple phrases 12–20 months, 21–30 months with less to no words; few (a) than five words AND COMMUNICATION A. LANGUAGE A1. Overall level of non-echoed spoken of non-echoed spoken level A1. Overall language of babbling A1a. Frequency A2. Frequency of spontaneous A2. Frequency to others (a) directed vocalization A3. Intonation of vocalization or A3. Intonation of vocalization (a) verbalizations A4. Immediate echolalia A5. Stereotyped/idiosyncratic use of words A5. Stereotyped/idiosyncratic use of words or phrases Table 5.3 Table 5 Observational Assessment of the Young Child 167 (continued) A5. Offer information A5. Offer Ask for information A6. A7. Reporting events A8. Conversation A9. Descriptive, A9. Descriptive, instrumental, conventional, gestures or informational B. RECIPROCAL SOCIAL B. RECIPROCAL INTERACTION B1. Unusual eye contact B1. Unusual eye B2. Facial expressions expressions B2. Facial to Examiner directed B3. Language production and nonverbal linked communication B4. Shared enjoyment in B4. Shared interaction A5. Conversation A6. Pointing A7. Descriptive, instrumental, conventional, gestures or informational B. RECIPROCAL SOCIAL B. RECIPROCAL INTERACTION B1. Unusual eye contact B1. Unusual eye B2. Facial expressions expressions B2. Facial to others directed B3. Shared enjoyment in B3. Shared interaction B. RECIPROCAL SOCIAL B. RECIPROCAL A6. Use of another’s body A6. Use of another’s A7. Pointing (d) A7. Pointing A8. Gestures (c, d) A8. Gestures INTERACTION B1. Unusual eye contact (c, d) B1. Unusual eye B2. Responsive social smile B2. Responsive to directed expressions B3. Facial others (c, d) B4. Integration of gaze and other (c, d) during social overtures behaviors B5. Shared enjoyment in interaction B5. Shared (c, d) A6. Use of another’s body A6. Use of another’s A7. Pointing (b) A7. Pointing A8. Gestures (a) A8. Gestures A9. Frequency of undirected vocalization A9. Frequency SOCIAL INTERACTION B. RECIPROCAL B1. Unusual eye contact (a, b) B1. Unusual eye B2. Teasing toy play toy Teasing B2. play B3. Unable toy to others directed expressions B4. Facial (a, b) B5. Integration of gaze and other (a, b) during social overtures behaviors B6. Shared enjoyment in interaction (a) B6. Shared 168 D. Misch et al. B5. Comments on others’ emotions/empathy B6. Insight into typical social situations and relationships B7. Quality of social overtures B8. Amount of social B8. of overtures/maintenance attention B9. Quality of social response B10. Amount of reciprocal Amount of reciprocal B10. social communication B11. Overall quality of B11. Overall rapport C. IMAGINATION B4. Response to name B5. Showing B6. Spontaneous initiation of joint attention B7. Response to joint attention B8. Quality of social overtures B9a. Amount of social B9a. of overtures/maintenance attention: Examiner B9b. Amount of social B9b. of overtures/maintenance attention: Parent/Caregiver B10. Quality of social response B11. Amount of reciprocal Amount of reciprocal B11. social communication B12. Overall quality of B12. Overall rapport C. PLAY C. PLAY C. PLAY C. PLAY B6. Response to name B7. Requesting B8. Giving (c, d) B9. Showing B10. Spontaneous initiation of joint attention (c, d) B11. Response to joint attention (c) B12. Quality of social overtures (c, d) B12. Quality of social overtures B13a. Amount of social overtures/ B13a. maintenance of attention: Examiner B13b. Amount of social overtures/ B13b. maintenance of attention: Parent/ Caregiver B14. Quality of social response B15. Level of engagement B15. Level B16. Overall quality of rapport B16. Overall (a, b)

C. PLAY (continued)

B7. Response to name (b) B8. Ignore (b) B8. Ignore B9. Requesting (b) Amount of requesting B10. B11. Giving (a) B12. Showing B13. Spontaneous initiation of joint attention (a, b) B14. Response to joint attention (a) B15. Quality of social overtures B16a. Amount of social overtures/ B16a. maintenance of attention: Examiner B16b. Amount of social overtures/ B16b. maintenance of attention: Parent/ (b) Caregiver B17. Level of engagement B17. Level B18. Overall quality of rapport (b) B18. Overall Table 5.3 Table 5 Observational Assessment of the Young Child 169 (continued) C1. Imagination/creativity D. STREOTYPED D. STREOTYPED AND BEHAVIORS RESTRICTED INTEREST D1. Unusual sensory interest D1. Unusual sensory interest in paly material/person D2. Hand and finger other complex mannerism D3. Self-injurious behaviors D4. Excessive interest in or interest D4. Excessive to unusual or references highly specific topics or objects or repetitive behaviors D5. Compulsions or rituals E. OTHER ABNORMAL E. OTHER BEHAVIORS E1. Overactivity/Agitation C1. Functional play with objects C2. Imagination/creativity D. STREOTYPED D. STREOTYPED AND BEHAVIORS RESTRICTED INTEREST D1. Unusual sensory interest D1. Unusual sensory interest in paly material/person D2. Hand and finger other complex mannerism D3. Self-injurious behaviors D4. Unusually repetitive D4. Unusually repetitive or stereotyped interests behaviors E. OTHER ABNORMAL E. OTHER BEHAVIORS E1. Overactivity C1. Functional play with objects C2. Imagination/creativity D. STREOTYPED BEHAVIORS AND BEHAVIORS D. STREOTYPED RESTRICTED INTEREST D1. Unusual sensory interest in paly D1. Unusual sensory interest material/person (c, d) D2. Hand and finger other complex mannerism (c, d) D3. Self-injurious behaviors D4. Unusually repetitive interests or interests D4. Unusually repetitive (c, d) behaviors stereotyped E. OTHER ABNORMAL BEHAVIORS E. OTHER E1. Overactivity (a, b)

C1. Functional play with objects C2. Imagination/creativity C3. Functional and symbolic imitation AND BEHAVIORS D. STREOTYPED RESTRICTED INTEREST D1. Unusual sensory interest in paly D1. Unusual sensory interest material/person D2. Hand and finger movements/ posturing (a, b) D3. Other complex mannerisms D3. Other complex D4. Self-injurious behaviors D5. Unusually repetitive interests or interests D5. Unusually repetitive (a, b) behaviors stereotyped E. OTHER ABNORMAL BEHAVIORS E. OTHER E1. Overactivity 170 D. Misch et al. E2. Tantrums, aggression, E2. Tantrums, behavior or disruptive negative E3. Anxiety E2. Tantrums, aggression, E2. Tantrums, behavior or disruptive negative E3. Anxiety 0. → 2 Rating 0 → E2. Tantrums, aggression, negative or aggression, negative Tantrums, E2. behavior disruptive E3. Anxiety Algorithm score of 0 → Algorithm score of 2 ) → Algorithm score of 1 → 2012 (continued)

E2. Fussiness/Irritability E3. Aggression and disruptive behavior Aggression and disruptive E3. E4. Anxiety Table 5.3 Table CODING of abnormalities as specified Code 0: no evidence not necessarily grossly abnormal or as clear the type specified Code 1: mild abnormal or slightly unusual but way specified Code 2: definitely abnormal in the is so limited that judgments about quality are impossible that interferes with the assessment or when behavior abnormal in a way Code 3: markedly ADOS-2 approximations during the entire or word T and 1; no spontaneous use of words A1 of Module Code 4: only in Item of a type that is not encompassed by the other ratings Code 7: abnormal behavior in question did not occur and/or the rating is applicable Code 8: when the behavior an error) makes Code 9: when an item cannot be rated for some reason other than that listed a code of 8 (e.g., examiner Bold coding item are used for algorithm score ALGORITHM Rating of 0, 7, 8, 9 Rating of 1 Rating of 2, 3 contact. Rating 1,2, 3 module, Item B1. Unusual eye Toddler Exception: Lord et al. ( 5 Observational Assessment of the Young Child 171

Code 2: definitely abnormal in the way specified. Code 3: markedly abnormal in a way that interferes with the assessment or when the behavior is so limited that judgments about quality are impossible. Code 4: only in Item A1 of Module T and 1; no spontaneous use of words or word approximations during the entire ADOS-2. Code 7: abnormal behavior of a type that is not encompassed by the other ratings. Code 8: when the behavior in question did not occur and/or the rating is not applicable. Code 9: when an item cannot be rated for some reason other than that listed for a code of 8 (e.g., an examiner makes an error). Each coding item has specific guides for rating. For example in B6, the Response to Name in Module 1, code 0 is given if the child looks toward the clinician and makes eye contact immediately on at least one of the first two presses by the clinician. Code 3 is given if the child does not look toward either the clinician or the parent after any verbal or vocal attempt to get attention. Once rating is completed, item codes are converted to algorithm scores. It is important to note that not all items are converted to algorithm. In Module 1, 2, and 3, each module has a specific cutoff for ADOS-2 classification, and overall total score is used to determine the classification: autism, autism spectrum, or non-spectrum. Overall total score is also used to produce comparison score, and comparison score indicates level of autism spectrum-related symptoms: minimal-to-no evidence, low, moderate, or high. In Toddler Module, overall total score indicates ADOS-2 range of concern: little-to-no concern, mild-to-moderate concern, or moderate-to-severe concern. It is important to note that ADOS-2 is a classification system to assist clinical diagnosis and does not determine the clinical diagnosis of autism spectrum disorder. The clinical diagnosis should be established based on diagnostic criteria of DSM-5, ICD-10, or DC: 0–5, and it requires comprehensive evaluation including clinical interview of a child and caregivers, behavioral observation of a child, and collateral information from school and daycare just as required in all comprehensive infant and early childhood evaluations. ADOS-2 and other scales may be used to assist diagnostic process. ADOS-2 manual clearly indicates “The ADOS-2 classification should never be used in isolation to determine an individual’s clinical diagnosis or eligibility for services.” Gotham, Risi, Pickles, and Lord (2007), Gotham et al. (2008) and Luyster et al. (2009) explored sensitivity and specificity of each module. Sensitivity ranged 72–98% and specificity ranged 76–94%.

Disruptive Behavior Diagnostic Observation Schedule

The Disruptive Behavior Diagnostic Observation Schedule (DB-DOS) is a semi- structured, standardized, and observational assessment tool used to evaluate disruptive behaviors, such as noncompliance, aggression, negative affect, and/or lying, in young children 3–5 years old (Wakschlag et al., 2005). Because some disruptive 172 D. Misch et al. behavior is developmentally normative in preschoolers, the DB-DOS aims to systematically measures the child’s behavior and delineate concerning disruptive behaviors from typical, age-related ones. It is modeled after the ADOS (described above) in terms of using “presses” to elicit the behaviors under evaluation, providing guidelines for examiner behavior during the procedure, being relatively brief to administer (about 1 h), and classifying behaviors along a scale from normative to atypical (Wakschlag et al., 2005). The DB-DOS has shown good reliability and validity in research studies, but the developers encourage it be used in conjunction with other measures of early childhood disruptive behaviors, such as parent interview and paper–pencil questionnaires (Wakschlag et al., 2005; Wakschlag, Hill, et al., 2008; Wakschlag, Briggs-Gowan, et al., 2008). Up to this point in time, the DB-DOS has primarily been used in research settings and a clinical application of the tool is still being created. However, a review of the developers’ published scholarly work, as described below, can provide an understanding of how the tool is used to observe disruptive behaviors. As described by Wakschlag et al. (2005), the DB-DOS involves completing three different interactive scenarios between the young child and an adult, with the clinician observing for examples of disruptive behavior. The scenarios are referred to as “modules” and include a playtime between the child and clinician during which the clinician is highly engaged (Module 1—Examiner Engaged), one where the clinician is busy and minimally engaged (Module 2—Examiner Busy), and a playtime with the child and his/her caregiver (Module 3—Parent). The modules are intended to be as naturalistic an encounter as possible; therefore, play- or game-based activities that are either pleasurable or challenging (e.g., a sorting game, bubbles, and/or a puzzle) are used as the tasks for each module. Each task is conducted for 5 min, with Modules 1 and 2 having three tasks and Module 3 having four tasks. Although the clinician has flexibility to use his/her clinical judgment during the DB-DOS, he/she is provided some guidelines for how to interact with the young child during Modules 1 and 2. In Module 1 the clinician shows responsiveness to the child during play by sitting beside him/her, watching the play, smiling, and com- menting. However, in Module 2 the clinician withdraws his/her attention and gives the child tasks to do while the clinician is busy, responding only minimally to the child when he/she initiates an interaction. Across the two modules, the clinician also gives the young child commands that are positively stated (“Do…”) in Module 1 or negatively stated (“Don’t…”) in Module 2, and observes if he/she complies. When a child exhibits disruptive behavior during the module (e.g., refuses to follow a direction) the clinician can deliver a prompt, such as restating the direction or using a firm tone of voice. If the child’s behavior escalates quickly, such as him/her becoming aggressive, the clinician can employ his/her clinical judgment about using a higher level of prompt or intervention to deescalate the child and maintain safety. In contrast to Modules 1 and 2, changes to the nature of the interaction between the child and his/her caregiver during Module 3 are accomplished just by altering task demands within the module; it does not include the element of the caregiver withdrawing attention. The caregiver completes four tasks with the child, with one 5 Observational Assessment of the Young Child 173 involving a press for compliance using a positively stated command and another using a negatively stated command. The young child and caregiver also complete a puzzle together and engage in a time of free play. After administration of the procedure is finished, the clinician scores the behaviors he/she observed, as presented in Wakschlag et al. (2005). There are three domains that the DB-DOS developers conceptualize as core areas of functioning to consider when evaluating for disruptive behavior disorders, and these represent the broadest categories of measurement within the DB-DOS system. The domains are disruptive behavior, modulation of negative affect, and competence. They encompass the DSM nosology for some disruptive behavior disorders, but are not tied exclusively to diagnostic criteria for any particular disorder. Within each of the domains, there are subdomains as follows: • Disruptive behavior: Oppositional Behavior, Aggressive Behavior, Deceptive Behavior. • Modulation of negative affect: Emotional Tone, Escalation of Negative Affect. • Competence: Social Competence, Coping and Mastery. Within each subdomain, there are several items that are scored based upon behaviors the young child exhibited during the DB-DOS modules. Examples of items include “Passive Noncompliance” (under Oppositional Behavior subdomain), “Aggression to Objects” (Aggressive Behavior subdomain), and “Easy to Elicit” (Escalation of Negative Affect subdomain). Scoring the DB-DOS involves rating each item on a scale that ranges from a normative to atypical level of the behavior. The scale goes from zero to three, with a score of 0 indicating no evidence of a problem, 1 indicating a mild form of the behavior, and 2 and 3 meaning a clearly problematic level of the behavior. For each item, a description of what the behavior might look like and/or an example of it is provided beneath the numeric score. Items are not scored just on frequency; rather, the clinician makes a global, integrated judgment about where to rate the child’s behavior on an item based on his/her overall conduct during all modules of the DB-DOS. For example, a behavior that occurs only once during the administration, but is notably serious (e.g., hitting an adult), might elevate the child’s score on the relevant item to a two or three because of its severity.

Case Illustration

A clinical case is now provided to illustrate how a framework for observation of the child can provide information crucial to assessment. The following evaluation took place over multiple visits. It incorporates the basic elements of the Infant and Toddler Mental Status Exam (ITMSE) into the individual, dyadic, and family information to guide diagnosis and treatment planning. 174 D. Misch et al.

Identifying Information and Description of Presenting Concerns

Maria was a 42-month-old bilingual Mexican American girl referred for diagnosis and treatment by her maternal grandmother’s psychiatrist. Maria presented to the young child outpatient clinic with her mother, Ms. L, and maternal grandmother, Mrs. J, due to concerns about disruptive behavior, including aggression toward family members and school peers (hitting, biting, kicking, and pushing), temper tantrums with self-injurious behavior (head banging and scratching self), high level of motoric activity, and inability to attend. Secondary concerns included regression of potty training, somatic complaints of stomachaches, and fears of the dark and of separation from mother and grandmother in the home but not at preschool. A three- session evaluation was completed to obtain the following information.

History of Presenting Concerns

Mrs. J, Maria’s grandmother reported that Maria would “behave better if Ms. L, Maria’s mother, would control her emotions.” Grandmother reported that mother often yells and displays hostility toward Maria’s neediness and demands for attention. Mother talks disparagingly about Maria’s father in front of Maria and acts out her frustration with other family members by slamming doors, name calling, and swearing. She has low tolerance for Maria’s tantrums and aggression. Grandmother described herself as an experienced mother. She admitted to often being the victim of verbal abuse from both of her daughters and her husband in the presence of Maria. Grandmother is tolerant of Maria’s aggression, demands, and neediness and believes whatever is wrong can be handled with love. She provides few consequences, but structures Maria for short periods of time. She allows Maria to sleep with her at night.

Social and Family History

Maria lived with her 21-year-old mother, 24-month-old brother, her maternal grandmother, her maternal grandfather, and her 14-year-old aunt in a large house where everyone has a separate bedroom. The entire family is bilingual, but grandparents often speak Spanish to each other on serious matters. There were frequent heated arguments between family members. Maria’s mother complained that maternal grandparents undermined her parenting. Mother further felt that her parents did a poor job with their youngest daughter (mother’s sister) who was allowed to display rage and aggression in the home. Ms. L is a stay-at- home mother. Mrs. J, also a full-time mother, is parenting both her daughters as well 5 Observational Assessment of the Young Child 175 as her grandchildren. Maria’s grandfather works nights full-time and indulged his granddaughter and youngest daughter, but is not a primary caregiver. Maria’s 24-year-old father, a Mexican immigrant, is primarily Spanish speaking and had a significant history of perpetrating interpersonal violence against Maria’s mother. She currently had an order of protection against him and he did not live in the home. Maria was a witness to many attacks of physical aggression toward her mother. Maria had unsupervised visitation with her father at 24 months of age and would often return from visits extremely tired and quiet. Maria’s mother and grandmother suspected that he had given her some sort of sedative, but denied suspicion of physical or sexual abuse. Secondary to these concerns custody rights needed to be revisited. Maternal family history was significant for global developmental delay in Maria’s younger brother, bipolar disorder and ADHD in the 14-year-old aunt living with them, depression in mother and grandmother, and juvenile systemic lupus erythematosus (SLE) in mother which caused intermittent cognitive impairment as well as physical disability. Paternal family history was significant for learning disorders, probable ADHD, and bipolar disorder by mother’s report. Mother was currently without psychiatric treatment and having an untreated SLE flare due to insurance problems. Grandmother was seeing a psychiatrist for medications and therapy weekly. Maria’s school was contacted for collateral information. The primary teacher reported that Maria displayed difficulty initiating social interaction and negotiating her needs in a group more than the average peer. Maria had made great progress in her speech and social skills since joining the school at 24 months of age when she barely spoke and was almost unintelligible. She received speech therapy and social skills training upon advancing to preschool at 36 months of age. She has been above grade level academically. She has a baseline restlessness, and periodically arrives at school hyperactive, but will generally calm down as the day progresses. She looks forward to going to school, has no difficulties separating, and is emotionally regulated until the transition for dismissal. At that point, she becomes visibly distressed, cries, dawdles, and either finds an activity to occupy her time or clings to the teacher. She willingly joins her grandmother when picked up by her, however Maria yells and displays a temper tantrum when her mother appears.

Child Medical and Developmental History

Maria was an unplanned, unwanted pregnancy. Maria’s mother was 19 years old with this first pregnancy. She had been in a tumultuous relationship with Maria’s father for 2 years leading up to the pregnancy where she was the repeated victim of interpersonal violence. She was not receiving adequate treatment for her SLE. She had discovered that she was pregnant when 4 weeks along, but had hidden the pregnancy until she was at 20 weeks because of her family’s extreme disapproval of the relationship. She suffered from depression before and during the pregnancy, and 176 D. Misch et al. had no support from Maria’s father or her family. She reported having a lot of joint pain and headaches. She denied any injury from domestic violence or exacerbation of her lupus during the pregnancy. There was no intrauterine exposure to toxins. The pregnancy was high risk and adequate prenatal care was provided after 20 weeks gestation. No medical care for lupus or psychiatric care for depression and stress was sought out. Maria’s birth was a spontaneous vaginal delivery at 37 weeks. She weighed 6 pounds, 2 ounces. Her height was 16.3 in. She needed bilirubin light treatment for jaundice that cleared within 36 h. Mother and baby were discharged from the hospital in 48 h. During the first year of life, Maria had colic and dysregulation of feeding and sleeping. Maria met physical developmental milestones on time, but did not say her first word until 24 months of age. She spoke two words at 30 months of age. She was never referred for early intervention. She was completely toilet-trained at 34 months of age. Maria had started a full-day preschool at 24 months of age. Caregivers reported “She was a whole new person at school.” She looked forward to school. She was able to regulate herself, participate in routines, and bonded well with the teachers. She had, on occasion, bit or hit peers. Mother noted that Maria seemed angry when leaving preschool each day. Maria had no history of major medical illnesses. Although she currently was low in weight for the past year, Maria had become a picky eater and refused to drink Pediasure. Her BMI was in the 37th percentile.

Behavioral observations

The observations were conducted by a faculty clinician and a trainee clinician since it took place in a training clinic. One of the clinicians stayed with Maria and began the Infant and Toddler Mental Status Exam (ITMSE), while the other clinician interviewed the adults. Observations were also conducted in subsequent dyadic and individual sessions. Below is the information from the Infant and Toddler Mental Status Exam (ITMSE). Appearance: Maria was a short, thin, frail-looking girl who looked younger than stated age. There were no dysmorphic features. Her eyes were large and widely spaced. Her dark hair was neatly combed. She was well groomed and dressed in a matching outfit from hair bow to shoes for each visit. She carried a dirty worn-out stuffed rabbit with her and sucked her thumb periodically in the waiting area. She made brief eye contact, then averted her gaze when introductions were made. She did not talk and partially buried her face in her grandmother’s leg. Clinician interpretation—Maria was a healthy but frail appearing child who was well cared for physically. Reaction to situation: Upon entering the interview room, she immediately broke away from her grandmother, and ran about the perimeter a few times. She 5 Observational Assessment of the Young Child 177 then moved from one set of toys to another. She ran to the dollhouse and threw all of the adult dolls across the room. She locked the baby in a closet of the dollhouse. She put a girl doll on a sofa by a TV. She then ran over to a container of giant blocks and emptied it on the floor. She attempted to step into the container, caught her foot, and fell down. She ran to her grandmother for comfort, but squirmed away from a hug after a few seconds. Mother sometimes yelled out commands to Maria who loudly banged and clattered toys. Grandmother calmly redirected Maria at the same time. Maria ignored her mother and grandmother. Both adults resumed talking with the interviewer and ignored Maria. Clinician interpretation—Maria appeared disorganized by the new situation and did not have age appropriate exploration skills. Caregiver differences in parenting were apparent. Motor skills: Maria picked up a fat brown crayon and scribbled across the paper and onto the table when asked to draw her family. Eventually she hastily drew a simple stick figure of herself with the family dog whose teeth were exaggerated, a large grandmother stick figure near her, a tiny oval in the corner for her brother, and a frowning small stick figure for her mother in the background. No details were noted on the figures other than a frown on the mother and teeth on the dog.Clinician interpretation—Maria’s fine motor skills appeared age appropriate; she also appeared to have the capacity to express emotions symbolically. Speech: When asked to explain the picture, less than 50% of Maria’s words were understandable. Maria was then distracted by a set of squishy dinosaurs and went over to manipulate them. She calmed down as she pulled and squeezed them. She put her finger in the mouth of a tyrannosaurus rex and yelled out, “ouch.” Clinician interpretation—child’s speech remains delayed. Play: She then gathered up the adult dolls off the floor and, along with the dinosaurs, brought them to the dollhouse. She put all of the dolls in the house. A grandfather doll slept while mother and grandmother dolls fought off a dinosaur trying to enter the house. The girl and baby dolls watched, sometimes threw furniture at the scene, and sometimes fought each other. Maria loudly enacted the part of adults, dinosaur, and children though it was difficult to understand. Some of her words were name calling and threats. When asked what could be done to keep the dinosaurs away, Maria built a wall with large building blocks rather than utilize a police car or telephone which were present. Eventually she seated all the dinosaurs and dolls in the kitchen for class, and had a female doll be the teacher. Clinician interpretation—while the narrative depicted in play was somewhat disorganized, Maria demonstrated capacity to process events and feelings through play. Self-regulation: Maria was given a graduated warning that soon the session would end. She ignored the verbalized expectations to clean up. She took out the toys that were put away. She eventually lay on the floor, screaming and crying. She demanded to carry a dinosaur to the waiting room. She was able to regulate herself when allowed to arrange the dolls and dinosaurs in the house and waved good-bye until visiting them again. She was given a princess sticker for her effort. Clinician interpretation—Maria’s self-regulation capacities are below age level and compromised. She requires structure and support to self-regulate. 178 D. Misch et al.

Relatedness (to Mother): This capacity was assessed during a separate mother– child session using several dyadic tasks and a separation. During one of the tasks, a clinician knocked, then entered the room, and explained that it was time to read. Maria became highly excited and ran to the table to look. Ms. L commanded in a stern voice for Maria to clean up. Maria did not respond. Her mother repeated the statement, then without following through, sat at the table with Maria and began reading to her. She held the book at Maria’s eye level, and named animals and colors that she observed. Maria repeated the words of her mother. Her mother responded in a hostile voice, “Can you let me read?” and Maria stared at her mother and yelled, “No!” Maria heard a man’s voice in the hallway, jumped up, showing distress on her face. She made fists and paced, as she listened silently near the door. She complained her stomach hurt and crossed her legs. When Maria returned to her side, Ms. L allowed her to hold a seek-and-slide book and manipulate the slides and doors. Maria was able to focus for 2–3 min when given control of the book and the freedom to manipulate it. When her mother took the book back and resumed naming colors and animals, Maria stood up, took another book from the pile, sat down at the child’s table across the room, and explored the pages. Maria then attempted to leave the room, opening the door and stepping out into the hallway. Her mother remained seated, yelling for Maria to come back. Maria was quickly stopped by the clinicians and brought back into the observation room. Maria made no eye contact with or movement toward her mother. Clinician interpretation—the relationship between Maria and mother is clearly disturbed with anxious, hostile, and dysregulated tendencies. It would be an appropriate target for intervention. Relatedness (to grandmother): Mrs. J entered the room and Maria immediately ran to her. They hugged each other, then Maria sat down on her grandmother’s lap. Each took a puppet and grandmother talked through the puppet asking Maria’s puppet to play. Play consisted of chasing each other, hugging, and dancing. The puppets told each other that they were friends. Maria’s puppet said that it was afraid and pretended to run away. Mrs. J’s puppet provided comfort. The puppets picked up crayons and wrote their names in their favorite colors. There was much shared enjoyment, eye contact, and physical closeness during the interaction. Mrs. J’s tempo was slow, her voice warm, and demeanor calm. Maria matched her grandmother’s presentation, though she exhibited fidgeting and difficulties articulating her thoughts. When the knock on the door came after 15 min of play, Mrs. J hugged Maria, made eye contact, and said she “had to use the washroom, but would come back soon.” Maria protested and clung to her. Mrs. J gently removed Maria from her lap and said to play with the puppets until she comes back. Maria insisted that she stay, then asked to go to the washroom with her. Mrs. J was unable to leave Maria as the child became more distraught, tearful, and demanding. She attempted to hit Mrs. J, who blocked her hand. No separation occurred. As she left, Maria made multiple demands of the staff for stickers, “candles,” and animal crackers. She then became distracted by the activity in the waiting area. Clinician interpretation—the relationship between Maria and grandmother is warm and reciprocal. Grandmother is lenient and does not set strong limits but appears to be able to get Maria to comply. 5 Observational Assessment of the Young Child 179

Mood/affect: Maria showed a full range of affect. Maria and Ms. L were told that Maria could play with any puzzle she wished, but if she put together the jigsaw puzzle before the clinicians returned, she would win a prize. Ms. L immediately took out the jigsaw pieces and asked Maria to help her. Maria ignored the request and played with a magnetic fishing puzzle while her mother put together the jigsaw puzzle. Maria struggled to hold the small fishing pole and allow the magnetic hook to capture the fish. She said, “Look I caught a shark!” Ms. L responded with, “You got the shark—good job” without looking up from her work or displaying any enthusiasm. Maria smiled, then began to help her mother put together the jigsaw puzzle. When the clinician walked into the room, Maria asked for the prize and showed the clinician the completed jigsaw puzzle. She was presented with a gift- wrapped package. Upon finding a broken but colorful pencil inside, Maria said, “They are candles!” She displayed joy and said that she would take the candles home for cake. Ms. L was shocked and distraught with the prize. When asked to compare Maria’s behavior during the session with her usual behavior at home, Ms. L stated that Maria would not play with her at home, but the oppositional behavior was the same. Maria showed the full range of appropriate affect. She did not describe her subjective reported mood.

Rating Scale Information

CBCL was clinically significant for syndrome scales of withdrawn behavior, attention problems, and aggressive behavior; clinical for externalizing summary scale and DSM ADHD; borderline for syndrome scales of emotionally reactive, anxious/ depressed, and somatic complaints; and borderline for internalizing summary scale, and DSM affective problems, and anxiety problems. The Minnesota Parent Rating Scale indicated Maria’s mother parenting style was primarily passive but also had an elevated score for authoritarian. Parent Stress Index was significant for domestic abuse, physical illness, loss of income, and legal problems.

Formulation and Plan

The information obtained from the history, rating scales, and opportunity to observe Maria with and without her caregivers led to the clinical formulation. The observations coded with the Infant and Toddler Mental Status Examination (ITMSE) provided invaluable information about Maria’s strengths and challenges as well as those of her two caregivers. Diagnostic disorders considered for Maria included (1) trauma related conditions like PTSD or Acute Stress Disorder; (2) difficulties in early regulatory conditions of sleep, feeding, and aggression; and (3) developmental issues such as ADHD, developmental delay, and/or language disorder. 180 D. Misch et al.

These diagnostic possibilities were informed by the observations which showed that Maria demonstrated significant trauma issues. Maria displayed acute distress when she heard a strange man’s voice in the hallway. She was hypervigilant, paced, and showed bodily tension and displayed bodily complaints of a stomachache. The response was an overreaction to a minor distraction outside of the room. Trauma issues were also displayed through Maria’s play with dinosaurs, dolls, and a dollhouse. She identified the tyrannosaurus rex as something that can hurt her. She reenacted the family situation where T-rex tried to enter the house and the grandmother doll fought it off while the grandfather doll slept and mother doll was non existent. The child dolls watched, attempted to defend the grandmother doll, and then fought among themselves as they were overactivated from the traumatic scene. Walls were built to protect the family from dinosaur attacks. Regulatory issues were noted through self-soothing as squishy dinosaurs were pulled and squeezed upon immediately entering an unfamiliar clinical room. She tended to have a short attention span when reading. She needed to be physically occupied in order to maintain engagement. She impulsively ran out of the room without concern for her safety. Unless given control of the situation, she displayed bodily and emotional collapse as she lay on the floor screaming and crying when warned the session would end, and as she threw her body across the table when her mother refused her access to a puzzle. There was also clear evidence of dysregulated behavior and affect throughout all of the observations. Maria frequently cried, screamed, ran out of the room, and tantrumed. She had a very high level of inattention and distractibility and was difficult to soothe. These behaviors appear best understood through a trauma lens, though further evaluation may be warranted. Finally, observations of both Maria and her caregivers (not detailed here extensively) indicate significant difficulties in the relationship. The modes and ineffec- tiveness of family communication and problem-solving were clearly seen in Maria’s behavior and style of relating. She looked to her grandmother as the primary caregiver. She listened to her and complied best with Mrs. J. Maria displayed affection and looked to her grandmother for security and physical comfort. She missed her grandmother during separation and happily reunited with her. Their interactions were mutually joyful with expressions of affection verbally and physically. Mrs. J did not set limits with Maria and was uncomfortable when she became upset. This was best demonstrated when Mrs. J was unable to separate from her. Maria did not learn how to handle her distress, but did learn that high intensity protests will be rewarded. Displays of negative attention seeking, as in making demands for stickers, animal crackers from staff, and need to be carried by grandmother when refus- ing to clean up at the end of a session, indicated the need for more structure and consistency. Maria interacted with her mother, Ms. L, as a non-primary caregiver rather than as her mother. Maria modeled her grandmother’s criticisms of Ms. L. She was less likely to comply with her requests. At times she attempted to make meaningful connection, but was met with resistance, out-of-sync responses, hostility, and criticism. Maria worked hard to keep her depressed and traumatized mother happy and engaged. She did not react much to her mother’s absence and reunited with minimal 5 Observational Assessment of the Young Child 181 response. She did not appear to trust that Ms. L would provide security and comfort when triggered by a man’s voice in the hall. In the presence of her mother, Maria chose more independent activity and impulsively left the room to seek out other stimuli. Language between them was often harsh and authoritative. Ms. L’s requests and directives were ignored as a result of relational difficulties. Generational and individual differences in acculturation should be taken into account as they present conflicting roles and values to Maria by caregiving adults. While the family displayed traditional Mexican values of multiple generations living together, there was a disconnect in provision of emotional support and practical guidance to each other. Maria’s grandparents took on traditional gender-specific roles where the grandfather was the breadwinner and the grandmother cared for the household and children. Play reenactment demonstrated Maria’s understanding of her mother as a victim of her father’s anger and physical abuse, and as a childlike figure who was seen arguing with family members and being parented particularly by Maria’s grandmother. 1. Plan for ongoing treatment is informed by the observational assessment of this child and family. Not only does the child need trauma-focused therapy, but the mother needs individual treatment recommendations for depression, trauma, and access to medical care. 2. Parent management therapy must include multiple generations so roles are better delineated and boundaries set in the context of differing family values. Circle of Security therapy may be useful in initially helping Maria’s mother engage in treatment. Establishment of a crisis plan for handling violence and threats from Maria’s father can provide security to Maria and all family members. 3. Recommendations for speech/language assessment and services both in school and in the community would determine Maria’s dominant language and support further development. 4. Parent–child interaction therapy can deepen the relationship between Maria and her mother, and help grandmother tolerate her grandchild’s distress while supporting her ability to problem-solve and gain better self-control. 5. Further assessment of ADHD is warranted while other interventions are implemented. Legal resources to assist with order of protection from Maria’s father should be considered. 6. Other members of the household should be invited into the treatment with mother’s permission to strengthen family unity and structure.

Summary

This chapter has focused on the tools and observational skills as well as reflective skills required to complete an assessment of a toddler or preschooler. One of the most important take-home points from this chapter is that the assessment of the very young child is a complex process, which requires a skilled clinician and multiple 182 D. Misch et al. visits. The clinician must be able to observe multiple facets of the visit including the child’s behavior and interactions as well as engage in direct interaction with the child, in structured and unstructured ways, and with a good developmental and cultural understanding. The chapter provides guidance for the physical space, toys and tools, both self report and observational, from which the clinician can select to build a framework for a practical but comprehensive assessment. The case illustrates one of the guiding principles described at the beginning of this chapter, that clinically significant problems may have their origins within the child, the caregiver(s), their interactions, and/or the environment. Given the variability of a young child’s language skill, developmental level, and relationship with the caregivers, the need for flexibility of and attention to multiple aspects of the visit and the child individually is crucial.

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Theodore J. Gaensbauer, Sarah Gray, and Virginia I. Hatch

Introduction and Background

Whereas previous chapters have described evaluations of the caregiver–child relationship and the gathering of information from caregivers about the child’s functioning, this chapter focuses on helping children “speak for themselves.” Based on their lived experiences, very young children will develop their own internal representations and expectations about the world around them. They will also bring patterns of behavior based on these representations into their interactions with others. The more insight the clinician has into the child’s internal representations and the “relational scripts” associated with them, the more effective interventions can be. This chapter describes ways in which an evaluator can gain access to a young child’s inner world through direct interactions with the child. Historically, relatively little attention was given to including young children’s voices in the psychiatric assessment process because it was assumed they were unable to understand what was going on around them or remember what they experienced. Several factors contributed to these assumptions, a major one being young children’s inability to express their memories verbally. Additionally, since most adults do not have memories of events that occurred prior to 3 or 4 years of age, a phenomenon described as “infantile amnesia” (Freud, 1953), it was assumed that children under the age of 3 or 4 would not remember even the most traumatic of events. In addition, the dramatic developmental changes occurring over the first 5 years of life posed challenges in the development of standardized methods of assessment for this age group.

T. J. Gaensbauer (*) Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected] S. Gray · V. I. Hatch Department of Psychology, Tulane University, New Orleans, LA, USA e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2019 185 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_6 186 T. J. Gaensbauer et al.

Developmental and clinical research over the last several decades has brought about dramatic advances in the understanding of young children’s developmental capacities and their inner worlds, advances that have had important implications for psychiatric assessment (Courage & Cowan, 2009; Fivush & Nelson, 2004; Gaensbauer, 2004a; Hayne, 2004; Madsen & Kim, 2016). Using novel paradigms that rely less on language, this research has shown that very young children remember much more than has been previously imagined. Additionally, it has demonstrated that young children are able to communicate about these memories, particularly if they are provided opportunities to express their memories in nonverbal forms—for example through play (Gaensbauer, 2002; Simcock & Hayne, 2002). Based on these enduring memories, young children’s behavior and responses to their environment and to specific caregivers will be shaped by expectations that have grown out of prior learned experiences. In turn, given that caregiver–infant interactions are a two way dialogue, young children’s patterns of behavior and emotional reactions will have a strong influence on the responses of those around them (Bell, 1968; Crouter & Booth, 2003; Davidov, Vaish, Knafo-Noam, & Hastings, 2016; Gaensbauer & Sands, 1979; Mischel, 1973; Patterson, 1982, 2002). Children under the age of 5, then, are very capable of providing information that enhances the clinician’s conceptualization of the presenting problems and the formulation of interventions to address them. Eliciting this information from young children, however, will not be as straightforward as it is for older children or adults. Successfully bringing young children’s perspectives into the assessment process requires first that the clinician create a facilitative therapeutic environment that provides opportunity for and scaffolds on developmentally expectable communication, and second, that the clinician carefully observe children’s verbal and nonverbal communication. Indeed, careful observation is an irreplaceable tool in assessing young children’s inner worlds, as elegantly expressed in the adage attributed to the pediatrician Sally Provence, one of the pioneers in infant studies: “Don’t just do something; stand there and pay attention. [The] child is trying to tell you something” (Slade et al., 2017). In describing the kinds of approaches that have allowed researchers and clinicians to gain access to young children’s inner worlds, this chapter first discusses general therapeutic practices that help children under 5 feel comfortable in a clinical setting and that optimize opportunities for eliciting meaningful communications. The chapter then moves to a discussion of more specific approaches to assessment. Given that different approaches and different modes of communicating will be necessary at each new developmental level because of the rapid and qualitative shifts in young children’s biological, psychological, and social development, the chapter focuses on two separate time frames: the period from birth to 2 years, and the period from 2 to 5 years of age. Recognizing that any age grouping is arbitrary and that there are significant individual differences as to when children will reach developmental milestones, the chapter will highlight the major qualitative changes in development that occur within each of these time frames and describe the implications that these qualitative changes have for assessment. Areas of focus for each age range will include: the 6 Assessing the Inner World of the Young Child 187 child’s overall cognitive functioning and the types of memories or internal representations of experienced events associated with the period; the ways that memories are likely to be expressed; specific approaches likely to elicit meaningful communications from the child; the types of toys and props that are useful in facilitating such communication; and the developmental and clinical research that has served as the basis for the points being made. Clinical examples are provided that illustrate how, by using the approaches described, children at different ages can communicate useful clinical information. A table summarizing the major points made about each developmental stage and a detailed case vignette are also provided at the end of the chapter.

General Principles Applicable to the Evaluation of the Young Child

In establishing a framework for approaching assessment with the young child, it is strongly suggested that the clinician meet with the caregivers alone. Some clinicians, including the authors of this chapter, prefer to have the caregiver-only session as the initial meeting, while other clinicians or settings schedule this meeting later in the evaluation process. In either case, the adult only session allows the clinician to freely obtain detailed information from the caregivers, in the child’s absence, about the specific problems that have brought the child for evaluation and what was going on in the child’s and family’s life during the period of onset or intensification. For example, if the child is having temper tantrums or anxious symptoms, the clinician will want to know in what forms the symptoms are expressed, their intensity and duration, under what circumstances the symptoms are triggered what interventions have been tried, and how the child responded to the interventions. Obtaining information about the child’s prenatal, developmental, and medical history, the family history and structure, the cultural background of the family, and the caregivers’ own childhood experiences and family background is also very important (see Chaps. 2 and 3 for further detail on history gathering). To gain understanding of the child and family’s social/cultural background and expectations regarding assessment and treatment, cultural issues should also be discussed at this time—including specific toys that are relevant for play-based assessment and what types of games, toys, and play activities the child enjoys and is familiar with. The mindful clinician brings into the clinical encounter self-reflection about his or her own cultural values as well as an awareness and openness to differences that may surface between his/ her perspective and the values of the family presenting for treatment. The purpose of this detailed psychosocial and developmental data gathering is to enable the clinician to enter the child interview with specific hypotheses about possible contributors to the child’s symptoms and ideas about how to explore them. Such data gathering also will help the clinician to recognize when the child is expressing something of clinical significance through his or her play, behavior, or 188 T. J. Gaensbauer et al. emotional reactions, as well as provide clues about how to obtain further information from the child about his or her experiences in a culturally appropriate way. A further reason for careful psychosocial history-taking and emphasis on the child’s experience is that even if there are biological or temperamental factors contributing to their symptoms, in very young children the manifestations of any affective or behavioral disturbance are likely to have strong environmental and cultural components and to vary across situational contexts (see Chap. 2 regarding history-taking). The more specifically the environmental factors contributing to a child’s symptomatology can be identified, the more likely it is that the problematic conditions can be altered through intervention. Unless there are obvious reasons for why it might be contraindicated, such as abuse perpetrated by the caregiver or a caregiver who might be “triggered” mal- adaptively by the child’s experiences, it is recommended that the initial session with young children be done with a caregiver present. Very young children are not only more comfortable in a new situation with an unfamiliar adult if a trusted adult is present, but caregivers can also be extremely helpful in identifying meaningful behavior or play on the part of the child and in providing background information as to its significance. Infants and toddlers do not generally engage in extended play scenarios, so there can be an easy shifting back and forth between engagement with the child and conversations with the caregivers while leaving the child free to pursue what interests him or her next. If the child is communicating about something stressful, the clinician has an opportunity to observe how the caregiver–child dyad negotiates stressful content. It is not uncommon, when given the opportunity, for very young children to express memories or feelings that their caregivers were not aware of. In these situations, by being present, the caregivers may obtain a clearer understanding of the sources of the child’s difficulties, ideally leading in turn to discussion about how the child’s distress may be alleviated. The caregivers’ reactions to such play disclosures also provide information on the caregivers’ insightfulness into the child’s inner world (Gray, Forbes, Briggs-Gowan, & Carter, 2015; Oppenheim & Koren-Karie, 2013). Having caregivers present from the beginning also establishes a structure of working with caregivers and their child together and underlines the importance of the caregivers’ role that will likely be applicable in ongoing therapeutic work. While the caregiver’s presence is generally recommended, as children become increasingly able to express themselves independently, typically around age 4 but perhaps even younger, decisions about whether caregivers should be present during subsequent sessions can become more a matter of the circumstances of the particular case. Important qualities of the clinician that will help put young children at ease and facilitate young children’s play and expressive communication include patience, nonjudgmental acceptance, giving positive feedback, a willingness to enter the child’s world and follow the child’s lead, and paying attention to the details of the child’s play. Ideally, to avoid having to put restrictions on the child’s exploration, the clinician should have access to a playroom that is completely child-centered. If this is not possible, it is recommended that a particular area of the room is set up exclusively for children with toys and testing materials where the child has enough 6 Assessing the Inner World of the Young Child 189 space to play without overlapping with the adult area. Toys should be available in the playroom that are appropriate to the age of the child and that will facilitate the children’s self-expression (see chart at the end of the chapter for a listing of suggested toys). In general, recommended toys are those that will both engage the child and facilitate substantive expression, as opposed to those that have limited expressive potential, such as puzzles or games with well-defined rules. In carrying out a complete evaluation at least two sessions with the child are typically necessary. The goal of the first session is to help the child become comfortable with the new situation and to allow him or her to become engaged in play activities. As the child is exploring, the clinician can observe the child’s spontaneous behavior and choice of play materials and identify opportunities for reciprocal engagement (See Chap. 5 for more on child observation). In the second session and/or at whatever point the child has become comfortable and engaged, the clinician can begin to more actively explore not only presenting problems but also the child’s perception of the issues that have brought him or her for evaluation. For younger children or until the child is able to move about independently, he or she will likely either be held by or be close to the caregiver and it will be the clinician who takes the initiative in engaging directly with the child. As children become more mobile and advance cognitively, the balance will shift, and the child can begin to initiate engagement both with others and with their environment. By letting the child take the lead, either by responding to the immobile infant in an open-ended fashion or by allowing the locomoting child to explore and play freely, the clinician facilitates the child’s spontaneous expression of his or her interests, wishes, capacities, and memories. The clinician can observe the child’s capacity for engagement with the environment around them, the child’s use of play materials, and the types of play themes that emerge spontaneously. The Infant and Toddler Mental Status Exam (ITMSE; Benham, 2000) reviewed in Chap. 5 of this text, provides an organizational structure for evaluating overall aspects of the child’s development within the context of the child’s free play. Play has many purposes. It serves as a vehicle for exploration of the world, a means of self-expression and communication, a stimulus for creativity, a forum for problem-solving and trial and error in the learning process, a channel for gaining mastery over difficult situations, an opportunity for abreaction, an outlet for the expression of emotions, wishes, beliefs, and experiences, a support for developing capacities in storytelling and meaningful narratives, and a medium to facilitate reciprocity and social relationships (Benham & Slotnick, 2006). In these many ways, play is a developmental competence that serves a wide range of affective, cognitive, and social purposes for very young children. The ability to play in an age-appropriate, organized, and coherent manner is a meaningful psychological resource for all young children, but can be especially important for very young children struggling with emotional or behavioral problems or with general life stressors. The clinician should look for play that can be directly or symbolically linked to the presenting problems that brought the child to treatment, paying particular attention to play content, recurring themes, affective tone, enacted representations of self and others including family members, and distortions in the child’s under- 190 T. J. Gaensbauer et al. standing of experienced events. In addition to content, the clinician is also reminded to observe the child’s play process, keeping in mind that the child’s play skills are an important adaptive resource both developmentally and therapeuti- cally. Whether spontaneous or facilitated by the clinician, the role of play as a vehicle for gaining access to very young children’s inner worlds, even as their verbal skills grow, cannot be overemphasized and is a primary focus at every age group discussed below.

Ages Birth to 24 Months

Developmental Background

When one considers the differences between a newborn and a 2-year-old child, it is clear that the first 2 years are a time of rapid and dramatic change (Ramey & Ramey, 1998). However, it is also a time when enduring patterns of social relatedness are being laid down. From birth forward, infants are developing capacities for social engagement and memory that help them understand and adaptively respond to their environment and that facilitate the development of attachment relationships. As their cognitive and social capacities progress into the second year of life, typically developing children begin to develop rudimentary symbolic play, or the ability to replicate their experiences through play (Belsky & Most, 1981). Additionally, throughout this period children become increasingly sensitive to others’ emotions and their significance (Roth-Hanania, Davidov, & Zahn-Waxler, 2011). Most notably for caregivers and others, toward the end of the second year children make dramatic strides in their verbal expression and their ability to make sense of their experiences. In short, developmental advances from birth to 2 years lay the foundations for children’s interactions within caregiving relationships and for their internal representations of their world. One can think of the first year as a time when infants are absorbing what is happening in the world around them and modifying their behavior and emotional responses based on their experiences, especially their experiences with caregivers (Cassidy & Berlin, 1994). Developmental and clinical research has documented infants’ awareness of their surroundings and responsiveness to their caregiving environment from birth. For example, using the Brazelton Neonatal Assessment Scale (BNAS), a number of abilities relating to social engagement can be assessed in newborns, including eye contact, gaze following, and responsiveness to voice (Brazelton, 1973; Brazelton & Nugent, 1995). Newborns also are capable of imitation of facial expressions of an adult (Meltzoff & Moore, 1977) and both instrumental and operant conditioning (Blass, Ganchrow, & Steiner, 1984; DeCasper & Fifer, 1980; Little, Lipsitt, & Rovee-Collier, 1984). By 10 days of age, infants’ eating and sleeping patterns can be significantly affected by changes in caregivers or feeding schedules (Burns, Sander, Stechler, & Julia, 1972; Sander, Stechler, Burns, & Julia, 1970). 6 Assessing the Inner World of the Young Child 191

Infants from the first days of life begin to develop what have been called “relational scripts” (Gaensbauer, 2016; Trevarthen, 1993), or expectations about how interactions with particular caregivers are likely to go (Stern, 1985; Waters & Waters, 2006). These relational scripts increasingly shape the quality of young children’s interactions with others based on their previous caregiving experiences (Bretherton & Munholland, 2008). In considering these processes, the cultural context of the child and family needs to be considered. Caregivers provide care for, respond to, and develop expectations for their very young children through the lens of the norms of their culture and begin to enculturate children even from the youngest ages into culture-specific expectations for how to think, feel, and behave (Rogoff, 2003). While evidence of relational scripts is cross-cultural and play is universal (Vaughn et al., 2007), very young children’s expectations about social interactions with their caregivers and others will from birth forward reflect culture-specific socialization processes (Bornstein, 2013; Chen & French, 2008). Overall, developmental progress in the first 2–3 months may be measured primarily by increasing physiological regulation and sensory-motor based patterning such as the establishment of predictable feeding and sleep–wakefulness cycles and the recognition and responsiveness to external stimuli such as turning the head toward sounds. Unless there are dramatic problems in these areas, such as failure to thrive, extreme fussiness, unexplained injuries, or lack of responsiveness to external stimuli, infants of this age are unlikely to be brought for psychological evaluation. If an assessment is indicated in this age group, it is most likely to focus on the overall growth and development of the child, the events that precipitated the referral, the parents’ cognitive and affective experience of the transition to parenthood or to a newly expanded family, and, most importantly, the quality of the caregiver–child relationship including the infant’s soothability, caregivers’ infant- directed speech, and parenting behaviors such as attendance to the infant’s emotional and physical needs. Between 2 and 3 months, typically developing infants make a dramatic shift in their social engagement with their caregivers. At this time, caregivers often begin to describe their child as recognizing them and responding to them personally. In response to caregiver engagement, infants will start to focus their attention to caregiver’s faces and voices, accompanied by smiling and bodily animation (Haith, Wentworth, & Canfield, 1993; Polak, Emde, & Spitz, 1964). Also, infants begin to express negative emotions in response to caregiver emotional unavailability, such as that seen when mothers maintain a “still face” toward their infant (Tronick, Als, Adamson, Wise, & Brazelton, 1978). These negative responses to a caregiver’s “still face” demonstrate the development of the infants’ social expectations of caregiver responsiveness as well as the crucial role of familiar caregivers in modulating and regulating infant affective arousal. Infants continue to establish a preference for primary caregivers and differentiate responses to familiar caregivers vs. unfamiliar adults over the first year. Between approximately 4 and 8 months, infants do not initially differentiate familiar from unfamiliar adults with negative affect, but will typically carefully examine the unfamiliar person, a scrutiny that has been described as “custom’s 192 T. J. Gaensbauer et al. inspection” (Mahler, 1972). Also, during this period infants’ temperaments begin to stabilize in ways that can be reliably observed by adults, as infants manifest individual differences in their responsiveness to environmental stimuli, as well as in their soothability and negative affect. These individual differences also draw different responses from caregivers, and the “goodness of fit” between an infant’s temperament and caregivers’ disposition becomes increasingly relevant to consider (Seifer et al., 2014). It is around 8–9 months that a clear preference for and attachment to primary caregivers emerges. This clear preference is frequently characterized by an initial negative reaction on first encounters with an unfamiliar adult who tries to approach or engage the infant, a phenomenon termed as “stranger anxiety” (Emde, Gaensbauer, & Harmon, 1976; Gaensbauer, Emde, & Campos, 1976). Stranger anxiety may be seen most commonly in infants raised in homes with a small number of primary caregivers. In cultures where children are cared for by multiple caregivers, a negative reaction to an unfamiliar adult may be less likely and a positive response to a stranger in the presence of caregivers can be a sign of good caregiving and healthy socialization (Mesman, van IJzendoorn, & Sagi-Schwartz, 2016). A child’s attachment to his or her primary caregivers continues to consolidate into the end of the first year of life, as does the child’s distress when being left with unfamiliar adults. This has been most dramatically demonstrated by the work of Mary Ainsworth and her colleagues through the use of a standardized, structured research paradigm termed the “Strange Situation” (Ainsworth, Blehar, Waters, & Wall, 1978, 2015). As described in Chap. 4, the infant’s responses to brief separations and reunions with the caregiver provide important information about the quality of the infant’s attachment to the caregiver. However, again one would expect much less in the way of distress for children raised in cultures where multiple caregivers are the norm (Mesman et al., 2016). Attachment quality can also vary by caregiver and is significantly impacted by the stability of the caregiving environment (Main & Weston, 1981; Waters, Hamilton, & Weinfield, 2000). From a cognitive and memory standpoint, even without language, young infants are developing increasingly sophisticated assimilations of the world around them. By 3 months of age, infants are able to remember over several days how to carry out an action that results in a pleasurable event, such as kicking a leg to make a mobile move, thereby demonstrating explicit, nonverbal memory functioning (Rovee- Collier, Hartshorn, & DiRubbo, 1999). The duration and complexity of memory capacities increase significantly over the next year. By 9 months, infants are able to show what has been termed “deferred imitation,” the ability to carry out simple actions demonstrated to them on one occasion 24 h earlier (Meltzoff, 1988). At 13 months, infants exposed to multistep event sequences will be able to replicate them 8 months later (Bauer, Hertsgaard, & Dow, 1994). By the end of the first year, infants also begin to imitate the actions of the people around them and to use various objects in their imitations. Into the second year, children are able to use either real objects or toys that represent real objects, such as baby bottles, toy cribs, dolls, din- nerware and other food utensils, to replicate actions that they have experienced or witnessed (Bretherton & Oppenheim, 2003). 6 Assessing the Inner World of the Young Child 193

By sheer coincidence, the 18-month-old daughter of one of the authors (SG) provided an example of early imitation during the writing of this chapter. While making breakfast one morning, her mother knew she was moving some of her kitchen toys into the nearby bathroom to play, but did not know what she was doing. Several hours later, her mother happened to walk into the bathroom where her daughter had been playing and discovered that on the floor, she had created a breakfast table setting. This included a baby doll sitting on her potty chair facing three plastic cereal sized bowls with spoons in them, two empty bowls, and a small pretend baby food jar with a baby spoon inside it, all neatly laid out in front of the baby doll. Finally, as noted earlier, during the second year, typically developing infants become increasingly aware of the emotions of those around them and the significance of these emotions, adjusting their own behavior accordingly (Roth-Hanania et al., 2011). They move from demonstrating empathic distress [such as crying when another infant cries] to empathic concern [characterized by tangible concern at the distress of another person]. For example, studies of empathy have shown that infants as young as 14 months can bring a tissue over to a person who is demonstrating sadness (Roth-Hanania et al., 2011). As one might expect, empathic caregivers influence infants’ ability to respond to others’ distress (Zahn-Waxler, Radke-Yarrow, & King, 1979). In summary, children’s emergent memory, cognitive, and social-emotional capacities during the first 2 years will be associated with a growing capacity to participate actively in the assessment process. By 3 months, infants’ cognitive capacity supports developing behavioral repertoires and expectations associated with their caregivers, and this differentiation will continue to grow in specificity and complexity over this 2-year period. Infants’ behaviors with their caregiver(s) and with the clinician in the treatment room will likely reflect increasingly established behavioral, affective, and cognitive schemas. Additionally, growing memory capacities have significant implications for children who experience traumatic events. Infants in the first months of life will show stress reactions when exposed to stimuli associated with a traumatic event (Gaensbauer, 2002) and this sensitivity to traumatic reminders will only increase as infants’ awareness of and ability to process complex sensory experiences increases. A number of clinical case reports have documented that children traumatized in the first year of life can demonstrate memories of their traumas months and even years after the traumas occurred (Gaensbauer, 2002, 2004a). • At 9 months of age a child was placed in foster care after suffering a skull frac- ture at the hands of his father. From the time of placement up to the time of his evaluation at 15 months, weekly visits with his biological parents reportedly went well. During the evaluation with his mother the child’s responses were consistent with those of a typically developing child, with one exception. During developmental testing the clinician reached out open handedly to encourage the child by demonstration to “put the cubes in the cup.” The child abruptly froze, grimaced with a very fearful expression, and flinched his shoulders and head as 194 T. J. Gaensbauer et al.

if he expected to be hit. With reassurance, he was able to re-engage in the testing but reacted in exactly the same way later in the testing when the clinician demonstrated with his open hand how to place different shapes in their proper places on a puzzle board. The child’s reactions suggested the triggering of frightening memories from 6 months earlier of being hit in a very specific situation (a face- to-face interaction) with a very specific trigger (an open hand) (Gaensbauer & Harmon, 1982).

Clinical Approaches

In evaluating children in the first year of life, the clinician should focus primarily on the quality of the interactions with caregivers, as described in other chapters. However, the clinician should also directly assess the extent to which the child’s internal schemata are setting the stage for healthy expectations in relationships with others. Even in the first 6 months, interacting with the child directly can be very informative. During this early period the clinician’s interactions might involve approaching the child, offering a toy such as a ball or ring that the child might grasp, and then picking the child up. In the early months, the clinician is looking for the capacity for direct social engagement and eye contact, including a smiling response and physical animation as one smiles and talks to the infant in the exaggerated lyrical rhythms and intonations that have been termed “motherese,” or infant-directed speech (Saint- Georges et al., 2013). Indications of potential problems would be the lack of smiling, failure to engage as evidenced by turning away and avoiding eye contact, or a lack of interest altogether. In contrast, overt distress and/or dramatic turning away can also be concerning, at its most extreme suggesting possible abuse or highly insensitive caregiving. • A 4-month-old infant who had been abused by her father and placed in foster care 1 month earlier was very fearful when approached by a male stranger. Playing quietly in her mother’s lap, when a male stranger entered the room and approached her she became distressed, arched away from the stranger, and made a batting motion in his direction. When the stranger picked her up the infant fussed, squirmed, and leaned toward her mother. The child did not show any of these distress avoidance reactions when approached by a female stranger, providing evidence of the specificity of this young child’s reactions toward a man as a result of her traumatic experiences with her father (Gaensbauer, 1982). By 6 months, one can expect increasing differentiation in the child’s responses to an unfamiliar person as compared to the primary caregiver. In approaching the child who has experienced healthy caregiving, a clinician would expect interest but increasing reserve with age. The expected response would eventually be positive but with a short time required to warm up and with tendencies to look at the caregiver 6 Assessing the Inner World of the Young Child 195 for reassurance. Around 8 months, this reserve not only becomes more pronounced but can be manifested in overt distress, especially as the clinician picks the child up. Although there will be variations in the degree of discomfort with the clinician depending on individual temperamental differences, cultural and familial experiences with multiple caregivers, and the child’s developmental level, one is looking for a clear indication that the child looks toward the caregiver as a source of reassurance and/or has a preference for interacting with the caregiver. To evaluate the degree of differentiation that the child shows in his or her interactions with the caregiver and with the clinician, it can be helpful to have the clinician carry out a sequential approach involving a playful interaction with a toy, an offer to pick up, and then briefly picking up the child. The clinician can then ask the caregiver to carry out the same sequence, observing any differences between the child’s reactions to a familiar versus an unfamiliar adult (Gaensbauer & Harmon, 1981). As the child becomes more comfortable with the clinician, one can attempt to play with the child in order to assess the child’s capacity for reciprocal interactions. Peek-a-boo or give and take with a graspable ring also can be useful games for engaging the child. Beyond 6 months, one can begin to use toys such as those used in developmental assessments, including cubes and a cup, not only to test the child’s cognitive and motor development but also to assess the infant’s capacity for joint attention, early imitation, and mutually pleasurable interaction. Again, concerns when working with children up to 2 years of age are raised if the child does not relatively quickly become comfortable with the new person, does not look to the caregiver as a source of security, or is not able to participate in reciprocal play. Two examples are presented below: • A 9-month-old girl was referred for evaluation because of concerns about her mother’s capacity to adequately nurture her. Observed together, the mother and child’s play was more parallel than interactive indicating the mother did not seem to have a good idea about how to play with her child. Throughout the session the child played with the toys in her own way. For example, when the clinician approached her and gave her a ball, she had little idea how to give it back. Though she would reach for items that were presented to her, she seemed oblivious to any directions or demonstrations from the clinician. Instead she would simply hold them or put them to her mouth. Her affect throughout the session was very blunted, with little show of emotion, either positive or negative. She was equally passive to approaches by the clinician and her mother. When her mother left the room for a brief period she did not look up and continued to play without any evident recognition that her mother had left. During her mother’s absence, for a brief period she played a little game of alternately patting a ball with the clinician, the first time in the visit that she showed any inclination to imitate. When her mother returned, she gave her mother a brief smile but otherwise continued to play by herself. Interestingly, when the clinician left the room for a brief period and then returned, the child’s response was more positive than it had been with the mother. Overall, the child’s behavior strongly suggested that she was experiencing significant neglect. 196 T. J. Gaensbauer et al.

• An 18-month-old girl was referred by her pediatrician for an evaluation due to concerns about a developmental delay. She presented with behaviors that were consistent with a provisional autism spectrum disorder diagnosis: her eye contact was limited, she did not respond to her name, she did not share affect with her mother or with the clinician, and she did not demonstrate joint attention when her mother attempted to engage her during her play. Her play itself was limited to visually exploring and lining up objects. For example, she picked up a small toy car and peered at its underside, then proceeded to spin its wheels with her finger, peering out of the corner of her eye. Despite her overall limited social reciprocity and repertoire, at several points during the first session, when the examiner approached her on the floor offering alternate toys, the child sought physical proximity to her mother, walking over to the chair where her mother was seated and at one point placing her hand on her mother’s knee. This proximity-seeking behavior was repeated later in the session, when she heard a door close in the hallway and was visibly startled. Overall, the child’s behavior demonstrated that although there were significant concerns about her social and communicative development, she nonetheless looked to her mother as a source of security. As this second example illustrates, the advent of crawling between 8 and 12 months introduces a whole new world of freedom and independence for the infant and thus calls for a more complex set of evaluative tools. This is a period when structured protocols that elicit the child’s reactions in a variety of situations can begin to provide a more expansive picture of the child’s strengths and vulnerabilities in the context of the child’s relationship with his or her caregiver (Crowell & Fleischmann, 1993; Gaensbauer & Harmon, 1981). The most compelling structured paradigm for assessing the 12- to 20-month-old child’s attachment to his or her caregiver is the Strange Situation, referenced earlier and described in greater detail in Chap. 4, during which young children are briefly separated from and then reunited with their primary caregiver. The child’s responses during two separation–reunion sequences reflect an organized pattern of behaviors that has grown out of the child’s caregiving history and predicts the child’s expectations in other social relationships (Sroufe, Coffino, & Carlson,2010 ; Sroufe & Waters, 1977). Secure behaviors indicate that the child expects the caregiver to provide comfort and safety. Infants show active proximity-seeking and contact maintenance with the caregiver until the infant is soothed, with an absence of any avoidance or resistance to contact from their caregiver. Signs of concern about the attachment relationship can take various forms and indicate inconsistency or rejection in his or her caregiving history. In response to caregiver rejection, infants show a lack of any indication of missing the caregiver during the separation and avoidance of the caregiver and/or lack of any approach or effort to interact after the return (Sroufe & Waters, 1977). In response to inconsistency, infants are preoccupied with their caregiver, intensely distressed during the separation, and showing anger and distress that cannot be consoled after the caregiver returns (Cassidy & Berlin, 1994). Children who experience abuse or neglect may show a variety of other behaviors that can reflect ambivalent or problematic relatedness such as active aggressiveness toward the caregiver, freezing behavior 6 Assessing the Inner World of the Young Child 197 that suggests fear of the caregiver, or mixed approach and avoidance behaviors that suggest ambivalence and disorganization in the infant’s expectations (Carlson, 1998; Lyons-Ruth & Block, 1996). In addition to separations and reunions, other structured components can easily be introduced to provide information about the child’s ability to engage reciprocally, tolerate and recover from negative affect, and use the caregiver–child relationship for regulation. These include free play and/or structured play assignments involving the caregiver, systematic approaches to the child that facilitate comparing responses to the caregiver versus an unfamiliar adult, and mild frustration tasks that assess the infant’s frustration tolerance and resourcefulness, such as the caregiver or clinician saying “no” to the infant or a toy box that is hard to open. The clinician should be aware that a freezing response to the word “no” can be a sign of potential abuse or harsh discipline. As discussed above, by early in the second year, typically developing infants begin to use dolls and toys as props for imitating what they have observed or experienced on a daily basis. At this point, play materials that are familiar and culturally relevant, such as family dolls consistent with the family’s cultural and racial/ethnic background, feeding materials such as bottles or spoons, cribs and strollers, and toilets can be used to elicit useful information. For example, behaviors suggesting patterns of positive experience might include the infant bringing a baby doll and a caregiver doll together in an affectionate hug or feeding a baby doll with the toy bottle. Banging the dolls together aggressively or failing to make use of the dolls or toys in any way could be considered potential signs of negative interactional experiences or developmental difficulties respectively. In interacting with infants in this age range, the clinician can begin to introduce scenarios involving everyday actions, such as demonstrating a parent doll offering a bottle to a baby doll and then giving the dolls to the infant to see if the infant will imitate or build upon what he or she has just observed. Such small structuring and scaffolding at this early age can begin to provide not only information about the child’s attentiveness and capacity to engage in reciprocal play but also specific knowledge about the child’s experience in the area being demonstrated. Toy props that evoke traumatic experiences can also begin to be used at this age. As children approach the age of 2 their capacity to make use of play as a vehicle for expressing their inner worlds becomes increasingly prominent and is described in detail in the next section. • A 20-month-old boy was seen for an evaluation after having been bitten on the face by a dog 1 month earlier. Although the child experienced only mild puncture wounds that had not required sutures, he was nevertheless showing a number of posttraumatic symptoms including fear of dogs and other animals, difficulty sleeping, and markedly increased aggression. This increased aggression included biting his stuffed animals and on one occasion another child, as well as scratching his father’s face in the area where he himself had been bitten. In the initial assessment session after the child seemed comfortable the clinician introduced dolls, toy furniture, and a toy dog that replicated the scene where the biting took place. The child initially gave the examiner a surprised, fearful look as he 198 T. J. Gaensbauer et al.

recognized the scene, and then moved into action. He grabbed the dog doll and used it to knock over the doll representing the child and then repeatedly had the dog jump on top of the boy doll. Soon after he had the dog jump on all of the other dolls that were a part of the scene. The clinician asked the child to show him where the boy doll had been bitten and placed a red mark on the doll’s face where the child pointed. From there, the child and clinician reenacted the kinds of medical treatments the child received, with the child acting as the doctor. The child’s active engagement in playing out his traumatic experience, including conveying the intensity with which he experienced the attack through his aggressive actions with the dog and the doll, opened the door to a successful treatment process (Gaensbauer & Siegel, 1995).

Ages 2–5 Years

Developmental Background

Between 2 and 5 years, typically developing children continue to show dramatic advances in cognitive, social-emotional, and language ability. By 2 to two and a half years, most typically developing children develop language fluency to a degree that verbalization is the primary mode of communication, albeit with significant limitations. By this age, children are also able to express a sense of past, present, and future, a development with significant implications for the creation of narratives. Language skills and comprehension develop gradually over the next several years and are supported by rapid development in children’s cognitive, working memory, and executive function abilities. All of these advances support children’s increasing self-regulation across the preschool years, as they learn to regulate their emotions and behaviors through the support of caregiving adults. Regarding the limitations of verbal communication, it is important to note that even as children’s verbal and memory skills are increasing from 2 to 5 years, the integration of language and nonverbal knowledge occurs only gradually. As described in greater detail in the clinical section, given the neurodevelopmental immaturity of language systems, children’s experiences may not be available for verbal description for a good part of this age period. Indeed, prior to age 4 experienced events are likely to be more meaningfully “remembered” through nonverbal based sensory-motor and emotional pathways than through verbal pathways. In turn, memories of specific events are often expressed more effectively and accurately through action (“playing it out”) than through words or conversation. Given these limitations, direct clinical “interviewing” is unlikely to yield the best or most complete information. Through “playing it out,” children can purposefully express their internal representations through the use of various expressive vehicles, such as dolls, toys, drawings, or play-acting, with the conscious knowledge that what is being expressed is a displaced version of something they have retained or created in 6 Assessing the Inner World of the Young Child 199 their own minds. It is at this time that symbolic play takes center stage as the primary vehicle for gaining access to the child’s inner world. As would be expected, over the period from 2 to 5 years, there are significant increases in the complexity and sophistication of the child’s use of symbolic play. Initially, play is likely to be focused on events that the child experiences directly in their daily life and played out in relatively straightforward and imitative ways. By the middle of the third year, symbolic representations become less concrete and narratives begin to be more complex and extended and include combinations of their experiences and fantasies. By the fourth year and fifth years, children are increasingly able to tell brief but complete stories utilizing multiple perspectives and acting out the words and actions of interacting characters while also serving as narrator of the story. As play scenarios become more sustained and complex, children can begin to include more sophisticated emotional states and motivations associated with the character’s actions. Children also become increasingly creative in their use of toys to represent what they want to express, and begin to use a wider range of expressive modalities, such as drawings, puppets, sand trays, and clay or play dough. It is in this 4- to 5-year-old period that verbal communication begins to take a more central role in accessing the child’s thoughts and feelings and that verbal descriptions and play action become increasingly integrated. Also occurring in this age period, growing out of children’s ability to pretend (Leslie, 1987), is the development of a capacity that has been termed Theory of Mind (TOM; Wellman, Cross, & Watson, 2001). TOM refers to the capacity to understand that others’ thoughts, feelings, desires, and beliefs may be different from one’s own point of view or outward state (Wellman, 2017). As children develop more sophisticated understandings of others’ minds and internal states, their narratives can become increasingly complex. At the same time the clinician should note that as children become aware that their storytelling might have an effect on the listener that is different from their own feelings, they may have an incentive to control the narrative by avoiding certain themes or modifying narrative content. From the standpoint of memory for past experiences it is around age 2 that children demonstrate a solidifying sense of self and the development of a clear sense of past, present, and future and what has been termed as autobiographical memory, that is, the understanding that a remembered event is an event that happened to them in the past (Howe & Courage, 1997). By two and a half years, children can describe dramatic events verbally or through play scenarios with considerable accuracy years later (Nelson & Fivush, 2004; Peterson, Sales, Rees, & Fivush, 2007; Terr, 1988). In evaluating children’s memories and narrative capacities, it is important to keep in mind that children’s autobiographical memory develops within a cultural context and varies across cultures. For example, children from Western cultures tell more detailed and emotion-oriented narratives than children from Eastern cultures, perhaps reflective of culturally varying definitions of the self in relation to others (Han, Leichtman, & Wang, 1998; Nelson & Fivush, 2004) One important clinical topic that is not explored in this chapter for reasons of space but that is important to keep in mind in evaluating children in this age group is the fact that children’s gender identity consolidates during this time period. Even 200 T. J. Gaensbauer et al. if it is not the subject of the evaluation, the clinician should keep in mind this important aspect of young children’s development, paying attention to the child’s expressed gender identity, the child’s comfort level with his or her biologic gender, and the ways in which that comfort or discomfort is expressed in his or her dress, words, behaviors, and play choices.

Clinical Applications

In an initial meeting, it would be expected that a securely attached 2- to 5-year-old child would show some initial reserve and use of the caregiver as a “secure base,” but that hesitancy to interact with the clinician or to explore the office would be relatively short, particularly if the office is set up with a dollhouse and toys clearly visible. Ongoing checking in with the caregiver on a regular basis would be expected, but would likely to occur much more often through visual and/or verbal modalities as opposed to a constant need to make physical contact. Sustained clinging to the caregiver would likely be a sign of anxiety. In this age range, the clinician should anticipate symbolic play to be a primary vehicle for communicating with the child. In facilitating creative expressive play, there are several attributes that can be helpful to keep in mind. As with younger children, the clinician needs to be patient, accepting, able to follow the child’s lead, and as much as possible enter into the child’s world. Ideally during the assessment phase, the child is directing the content and the clinician is focusing on helping the child to elaborate on play scenarios rather than introducing his or her own ideas. The clinician should pay special attention to not only to concrete play situations with dolls that appear connected to real situations in the child’s life but also to recurrent themes, particular affects, and, as the children get older, scenarios that are increasingly metaphorical and fantasy-based. In the first session, it is recommended that the child initially be given the opportunity to play freely without structuring on the part of the clinician. It is helpful to have toys that are age-appropriate for the child readily visible so that the child feels that the office is an appealing place to be. It is particularly helpful to have a playhouse with furniture and family dolls in a prominent location since these offer the most straightforward setting for the child to play out experiences at home. In addition, it can be useful to have a certain number of animals or fantasy figures that represent lovable, positive qualities (e.g., dogs, cows, teddy bears) and a number that can have negative, scary, aggressive, or sad connotations (e.g., dinosaurs, animals with teeth, snakes, sad puppets). Ideally, the toys that are initially available offer a range of possible activities, as children are likely to be drawn to play materials in accordance with gender and cultural differences. In observing the child’s free play and choice of toys, the clinician can learn about the child’s interests and the kinds of verbal and play vehicles likely to be most productive. Having obtained information from the caregivers prior to the first meeting with the child about the kinds of situations that are evoking symptoms, it can also be 6 Assessing the Inner World of the Young Child 201 helpful if the toys and dolls that are provided (or ones that the clinician has ready access to) include ones that can be used to play out relevant scenarios. If there are particular settings related to the child’s symptoms, they do not need to be part of the initial presentation, but they should be readily available in order to take advantage of any spontaneous references to these settings by the child or caregiver (see case vignette for an example). Settings and materials related to the child’s symptoms and environmental triggers might include toys related to medical treatment (ambulances, medical equipment), auto accidents (cars and trucks), animal bites (dogs and other animals), school materials (blackboards, desk tables and chairs, and playground toys like swings), two houses in cases where caregivers are divorced, never married, or of different generations (e.g., grandparent/parent), or other items linked to problematic events. To help the child accept being the focus of the clinician’s attention and to clarify a joint purpose, at some point in the first session the clinician may ask the caregiver if the child has been told why he or she is coming. If the caregiver has explained to the child that he or she is meeting the clinician in order to get help with his or her feelings, the clinician can turn to the child, validate that explanation, and explain that the meetings will involve playing and talking. If the child is accepting, the clinician can ask the caregiver to elaborate further on the feelings and/or behaviors the clinician is trying to help the child with, such as problems with anger, being scared, or having trouble sleeping. Often, caregivers have not provided any explanation to the child. In these cases, it is very appropriate for the clinician and caregiver at some point in the session to provide some kind of explanation to the child in terms that are not threatening and that the child can understand. For a 2-year-old, this can involve a simple, “I’m a person who helps children.” For older children, it can become more specific and elaborated: “I’m a person who helps children who are having troubles with their feelings, like when they feel sad.” No more needs to be said at this point as one allows the child to explore and become comfortable, but such information helps orient the child to the purpose of the sessions and hopefully promotes acceptance of more problem-focused dialogue with the clinician when problem areas are introduced. Ideally, in the first child session, the clinician does not feel pressure to introduce difficult subjects or to guide the child’s play. Rather, the focus is on helping the child to feel safe and respected. The clinician is also establishing oneself as someone who follows the child’s lead and serves as a partner facilitating the goals and themes of the child’s play, but who at the same time is allowed to ask questions and actively contribute to play scenarios. While allowing the child to take the initiative in choosing whatever activities are of interest, it is recommended that the clinician directly interact with the child around the child’s play choices right from the beginning, thus establishing the precedent that the clinician will be directly engaged in the child’s play throughout the evaluation and possible treatment. Having the caregiver present sets the stage for the caregiver as a partner in the treatment process right from the beginning. As the child is exploring and playing, there is ample opportunity for the clinician and caregiver to talk about the child. Ideally, it is evident to the child and caregiver that in sessions with the child the 202 T. J. Gaensbauer et al. clinician’s interest is primarily with what the child is doing, and that by regularly turning to the caregiver he or she is inviting the caregiver to share in that interest. Again, initial discussions should not focus on problem areas but should be more general in nature such as learning about the child’s daily life and the home environment, with an emphasis on positive aspects such as the child’s strengths, things the child likes to do, and things the child is good at. As the caregiver describes a particular characteristic or activity, the clinician can turn to the child and ask the child about the subject, gathering as much information as the child can provide before turning back to the caregiver for further description. As noted earlier, between the ages 2 and 4 years, children are unlikely to engage in prolonged dialogues or play scenarios, so turning attention back to the caregiver may offer “breaks” for the child between moments of engagement around difficult topics. One is setting in motion a pattern in which the clinician can move back and forth between the child and caregiver as appropriate, utilizing the caregiver’s information to engage the child about the subject at hand, providing a structure that promotes the child’s participation, facilitates the caregiver–child dialogue, and invites the caregiver to be curious about the child’s inner world alongside the clinician. Certainly if the child is engaged with the clinician in a sustained and meaningful conversation or play scenario, one would not want to interrupt it. In the second child session, or toward the latter part of the first session if the child appears comfortable and/or has introduced important subjects on his or her own, the clinician can begin to focus more on the presenting concern. If it has not come up naturally, information from the initial meeting with the caregiver can be utilized as one route to introduce the child to a discussion of the problems that brought him or her to treatment. For example, one can say to the caregiver, “I think you told me that sometimes Robbie gets really mad.” When the caregiver confirms this, one can turn to the child and ask, “Do you get mad sometimes?” If the child nods or says “yes,” one can follow up with questions along the lines of what makes the child mad, what the child does when they get mad, what caregivers do when he or she gets mad, how the child feels afterward, etc. Based on the child’s response, the clinician gains a sense of the degree to which the child can be an active participant in working on these issues and the degree to which verbal communication can be used in the therapeutic process. By age 4, one can expect much more in the way of active engagement and verbal responding on the child’s part. At the same time that one is exploring the child’s ability to communicate verbally, as discussed earlier it is crucial to keep in mind that even after the onset of language fluency, very young children continue to process and internally represent and express events through nonverbal mechanisms. Their experiences are “embodied” across multiple modalities, including cognitive, affective, and sensory-motor networks that will all be re-activated when memories are triggered (Gaensbauer, 2011). Even after language fluidity is achieved young children are not able to use language as the sole vehicle for obtaining a full understanding of what is going on around them. For example, descriptions of upcoming events that are given verbally without being accompanied with concrete, nonverbally based demonstrations of what is being described are unlikely to be fully understood by young children, even 6 Assessing the Inner World of the Young Child 203 if they are verbally fluent. Explanations such as “Your mother is going away on a trip for work and will be back on Saturday” or “The doctor wants you to have an X-ray,” are not likely to automatically conjure up for the child exactly what these events involve. He or she is much more likely to understand if the verbal description is accompanied by some sort of concrete play demonstration of what is happening. With this in mind the verbal explanation of the mother going out of town on a trip could be accompanied by a demonstration of a mother doll saying goodbye to a baby doll, then being put on top of a toy airplane and then being “flown” far away to the other side of the room. The child can see that the mother doll and plane have gone a long way away but they still exist and can be brought back to the child’s space after an interval of time. Such demonstrations provide the child with a concrete visual and sensory-motor experience of what is going to happen that he or she would not have were it not for the event being played out in action. Similarly, young children are able to play out memories of events they have witnessed or experienced in much greater detail through reenactments, either in their own behavior, through play, or through some other concrete expressive vehicle than through words. An example here would be the common practice when interviewing very young children about sexual abuse of using drawings that allow the child to point to areas of the body that were touched and to physically demonstrate what was done to them, as opposed to depending solely on a verbal description. Indeed, given the high states of arousal, sensory-motor stimulation, and potential dissociation associated with sexual abuse, this is one area where physical reenactments, either by using dolls to imitate the actions, through performing the actions on dolls such as poking their genital area, or through direct enactments of the physical positioning and bodily movements associated with the abuse, are likely to be the primary modalities by which the experience is manifested, both in the child’s life and in the office situation. It is important to underline that young children’s expressions through play typically represent some combination of the actual events that have occurred and the child’s interpretations of and/or fantasies about those events. The clinician’s task in these first sessions, then, is not to metaphorically sit across from the child, acting as a fact-finder to uncover the “real” sequence of events that transpired or the “real” quality of the caregiver–child relationship. Instead, the clinician’s task is to metaphorically stand next to the child, observing with curiosity alongside them what the child is communicating about their perspective. Through broadcasting an open and genuine curiosity about the child’s expressions and reflecting back what the child communicates, the clinician will be provided access to the child’s symbolized representations of events or relationships. Providing toys that have the potential to be used in thematic ways and setting an open and facilitative tone can often be sufficient for children’s free play to lead directly into the playing out of the child’s experiences, both positive and negative. However, even if children do not immediately use direct representations of themselves and their caregivers, they are nevertheless likely to either be revealing something of their inner world symbolically through their play or be playing with something that can be used as an entry point to open up access to their feelings and 204 T. J. Gaensbauer et al. expectations. For example, if the child is playing with a toy car, one can personalize the car by asking what the car likes to do, whether it races other cars (sibling rivalry), whether it stays in the lanes or goes wherever it wants (attitudes toward authority), or whether it crashes into other cars (aggression). Children up to the age of two and a half years are likely to require considerable encouragement and scaffolding through questioning or role playing in order to gain a clearer picture of what the child might be thinking or feeling. If the child is playing with dolls or stuffed animals, one can ask the child what the dolls or animals are doing, what they like to do, what they do not like to do, if they have a brother or sister, etc. One can also introduce oneself to the child’s doll either in person or in the form of another doll and ask questions about the doll and the doll’s family in that guise. Toward the end of the third year and into the fourth year, children are likely to be much more spontaneous and elaborate in their creation of play scenarios, and the clinician can more actively participate under children’s guidance. In playing out a family drama, one can play different roles based on the child’s direction. The clinician can be the caregiver doll while the child is the baby doll, with the child telling the clinician as caregiver what to say or do in response to whatever the child doll is doing. Similarly, the clinician can be the child and the child the caregiver, again providing the opportunity for the child to script the play scenario and tell the clinician how to act in accordance with what the child is feeling. If the opportunity presents itself, the clinician can play act in a way that is similar to how the caregivers or child have been reported to act in real life and in this manner elicit spontaneous reactions and expressions of feelings without the child being consciously aware of what has been revealed. This can all be done with a family of animal dolls rather than human ones. It is obviously ideal if, in the course of unguided play, the child plays out the- matically relevant material that helps the clinician to understand the child’s perspective and motivations in situations where difficulties are manifesting themselves. Sometimes this happens spontaneously and clinicians are well served to observe carefully for such potential clinical content. For example, a child experiencing problems around feeding might pick up a mommy doll and a baby doll and play out a feeding scenario that seems problematic such as having the adult doll be aggressive in the feeding process, having the baby doll turn away from the bottle, or, in one reported case, taking the bottle and repeatedly hitting the baby doll with it (Gaensbauer, 2004a). Children who have witnessed interpersonal violence might pick up a male and female doll and crash them into each other. In these instances, the clinician’s carefully scaffolded reflection can facilitate the child’s elaboration, sometimes just by describing what the child has played (“that mommy and daddy just crashed into each other!”), attending to affect (“That mommy doll seems angry. I wonder how that baby doll is feeling”), and providing opportunity for narrative development (“What happens next?”). The more common experience is that children do not engage in such clinically relevant play on their own, for several reasons. In an unfamiliar, potentially anxiety provoking setting, they are likely to gravitate toward play materials and themes that are familiar and pleasurable. Being new to the situation, they will also have limited 6 Assessing the Inner World of the Young Child 205 knowledge or experience as to how to search out or make use of play materials that could serve as vehicles for communicating memories or feelings related to their clinical problems. In addition, children’s ability to communicate their memories is significantly enhanced when cues are provided and is diminished when they are not (Fivush, 1993; Fivush & Nelson, 2004). For all of these reasons, active scaffolding or structuring of play that helps to bring the child’s play activities into clinically relevant areas is often necessary. Structured play approaches in the clinical setting have a long history dating back to the 1930’s with the pioneering work of David Levy and others (Conn, 1939; Levy, 1939; Solomon, 1938). In recent years, there has been a striking consensus among both clinicians and developmental researchers as to the value of structured play paradigms (Gaensbauer & Kelsay, 2008). In particular, paradigms in the form of what has been termed the “story stem” technique have been used to explore early representations. Systematic work on the use of story stems to gain access to young children’s inner worlds was carried out by a consortium of clinicians and developmental researchers funded by the MacArthur Foundation. This group brought together a number of prompts, termed the MacArthur Story Stem Battery (MSSB), to tap into a range of emotionally compelling developmental themes, including attachment security, responses to authority, peer rivalry, moral dilemmas, family conflict, and emotional regulation (Bretherton & Oppenheim,2003 ; Bretherton, Ridgeway, & Cassidy, 1990; Emde, Wolf, & Oppenheim, 2003). Research using the MSSB has demonstrated that the stories told by clinical or at-risk populations, such as children who have been abused or neglected, are very different from those told by children who have not been maltreated (Macfie et al.,1999 ; Toth, Cicchetti, Macfie, & Emde, 1997). The individual responses of abused children have shown remark- ably clear evidence of very specific experiences in the caregiver–child relationship (Buchsbaum, Toth, Clyman, Cicchetti, & Emde, 1992). That children in the 2- to 5-year-old age group are cognitively equipped to use such play scenarios to accurately express their understanding of what is going on around them is exemplified by the findings in a nonclinical sample that, at age 3 almost half the children could acknowledge a moral dilemma in the stories, at age 4 over 75%, and at age 5 over 90% (Oppenheim et al., 1997). This basic “story stem” research has validated the longstanding therapeutic use of structured play settings that can replicate a wide range of children’s experiences, particularly as a tool for stimulating children’s reenactment and reprocessing of traumatic events. (Benham & Slotnick, 2006; Gaensbauer, 1995; Robinson, 2007). In the clinical setting, the story stem technique involves presenting the child, using doll play and brief verbal descriptions, with a play setting that recreates situations relevant to the problems that brought the child to treatment. In most cases the presentation of the scene itself is enough to stimulate the child into action but if necessary the child is given a specific invitation to show either though play action or verbal description, “What happens next?” With this scaffolding, the child is afforded the opportunity to convey his or her own perspective on the situation that is being recreated, including their memories be they accurate or inaccurate, their emotional reaction to the scene, the reactions of other characters in the scene, and various 206 T. J. Gaensbauer et al.

coping strategies for dealing with the situation. A simple example would be a 3-year-old boy who was showing distress going back and forth between his divorced parents’ homes. Presented with two playhouses on the floor with a male doll at one house, a female doll at the other house, and a boy doll placed in between them, the child immediately took the boy doll to the male doll’s house, evidencing his more solid attachment to his father. As described earlier, it is by providing this kind of opportunity for the nonverbal expression of children’s memories and feelings that young children’s capacity to both register and remember specific details of events that have occurred prior to the onset of language for months and even years has been documented (Gaensbauer, 1995, 2002). Even more importantly, children’s elabora- tions on these kinds of structured scenarios, be they a relatively realistic playing out of a real life situation or a highly exaggerated, emotionally intense, fantasy driven version, can provide the clinician with useful information about what aspects of the situation are most difficult for the child and how these difficulties may best be approached. They also establish a platform for further exploration, both in the assessment and in subsequent treatment. In addition to story stems, other play-based scaffolding techniques can be useful for eliciting information specific to young children’s self-perceptions, social well- being, mental health, and even their own symptomatology. Using puppet-based interviewing techniques, such as those used in the Berkeley Puppet Interview (Measelle, Ablow, Cowan, & Cowan, 1998), even preschool-aged children can provide symptom based data that can enhance clinical conceptualization and contextualize caregivers’ and other adults’ reports of children’s behavior. Initially developed to assess children’s self-concept (Measelle et al., 1998), the interview has been modified to include 25 scales that elicit information across a range of domains, including emotional and behavioral problems, competencies, and social relationships (Luby, Belden, Sullivan, & Spitznagel, 2009; Ringoot et al., 2013). In the interview, the clinician holds two identical dog puppets, “Iggy” and “Ziggy,” who make opposing statements about themselves to the child. For example, Iggy might say, “I am a sad kid,” while Ziggy then offers, “I’m not a sad kid.” The “puppets” then ask the child which statement best fits them: “How about you?” Research suggests that beginning around age 4, children can report on core and basic symptoms, though not abstract ones, using this developmentally modified interview format, and that response patterns differ between clinically referred and non-referred children (Belden, Sullivan, & Luby, 2007; Luby et al., 2009). As alluded to earlier in regard to the use of pictures in interviews with children who have experienced sexual abuse, drawings can also be an extremely useful expressive modality for young children. Similar to the recreation of clinically relevant scenarios through dolls and toys, drawings by the clinician can also be a very useful vehicle for eliciting feelings about specific situations. An example would be a child whose relationship with her mother had been disturbed after she saw her mother in the emergency room following an auto accident and refused out of fear to get up on the bed to give her mother a hug. In the first session with the examiner, she drew a stick figure on a blackboard and then handed the chalk to the clinician. When the clinician drew a picture of a stick figure in a bed and a small stick figure along 6 Assessing the Inner World of the Young Child 207 side the bed, she immediately erased it, providing clear evidence that this was a difficult moment for her and one she did not want to talk about (Gaensbauer,2004b ). In another case, in evaluating a 4-year-old child who was having trouble dealing with his mother’s frequent business trips, the clinician drew a picture of his mother saying goodbye to him at school and then asked the child what he should draw next. The child told him he should draw the child with a sad face looking out the window of the school watching his mother leave. The picture allowed his mother and the clinician to empathize with his sad feelings. As children get older they will be able to draw such pictures on their own, both when they are given a specific invitation such as “draw a family” or “can you draw a picture of yourself?” or when they are invited to draw whatever comes to their mind (Einarsdottir, Dockett, & Perry, 2009).

Summary

In this chapter, we have provided a review of assessment methods for accessing the inner world of young children. We have provided an overview of general principles of play-based assessment with young children, including the general stance of the clinician, the inclusion of other adults, materials that may facilitate assessment, and a recommended structure and sequencing for sessions. We additionally specifically reviewed children’s cognitive, memory, language, and social-emotional development across years 0–2 and 2–5 and what specific tools and approaches the assessing clinician may find useful during these time periods, drawing from clinical examples throughout. Provided with developmentally appropriate supports, very young children can provide unique and meaningful information for psychiatric assessments that can be used to shape diagnosis and treatment recommendations (Table 1).

Case Vignette

Identifying Information and Description of Presenting Concerns

Elizabeth was a 5-year-old Caucasian girl whose mother was killed in an automo- bile accident when Elizabeth was three and a half years old. Her father brought her to the clinic after Elizabeth’s teacher expressed concern about whether Elizabeth had adequately grieved the loss of her mother. Concerns included Elizabeth’s difficulty talking about her mother, episodes of disengagement from the world around her, and the intensity with which Elizabeth had attached herself to the teacher. The clinician first met with Elizabeth’s father to learn about Elizabeth’s experience of the tragic events and her family background. He then met with Elizabeth on three occasions, the first with her father present and the next two with Elizabeth by herself. 208 T. J. Gaensbauer et al.

Table 1 Children’s play across ages 0–5 and how clinicians can facilitate it Play Stage Nature of play behaviors Toys to facilitate play What to watch for 0–12 months: Explores object Mouthing, Rattles, blocks, large Observing sensorimotor- properties, banging, balls, mirrors children’s behavior exploratory cause-and-effect dropping, with primary play shaking, caregiver and other rolling; later, adults, which can “dump and provide fill” or information about placing early relational objects into schemas and containers expectations and dumping them out 12– Demonstrates Holds comb Baby doll with toy Observing 18 months: understanding of to hair or cup comb, bottles, interactions with functional objects and their to mouth; blanket, bed; larger primary caregiver play typical use, pushes toy toy cars; shape and other adults; reproduces typical car; “hugs” sorters; blocks for observing the actions with stuffed stacking child’s ability to familiar objects animal engage reciprocally, tolerate frustration, use caregiver to regulate negative affect 18+ months: Emerging pretend “Feeds” baby Toys representing Observing early symbolic play reflecting doll; pretends familiar objects that rudimentary play mental to eat; uses children encounter in representations of representations; objects to routines; baby doll social relationships later, begins using represent with toy comb, that may reflect objects to represent other objects bottles, blanket, bed; how child expects other objects (e.g., block play silverware, cups, to be cared for becomes plates; blocks; (e.g., feeding baby) bottle) representational toys that may be relevant to presenting concern 30+ months: Increased Describes Play cookware, Play reflects both complex complexity of stories about tableware, and reality and fantasy. symbolic play narrative themes, family pretend food; Clinician can extended play characters in dollhouse, family structure prompts sequences, creating the characters, furniture; based on the narratives that are dollhouse; doctor kit; referral question not just can develop representational toys using story stem reproductions of narratives that may be relevant techniques. Play past experiences with multiple to presenting concern represents both but also involve points of lived experiences fantasies view and fantasies 6 Assessing the Inner World of the Young Child 209

Presenting Concerns and Background Information

As they were waiting at a stoplight Elizabeth’s and her parent’s car was struck from behind by a car traveling at a high speed. Elizabeth’s mother suffered fatal injuries and her father was knocked unconscious and did not awaken until several hours later in the hospital. Elizabeth was asleep at the moment of impact and suffered generalized bruising and a badly sprained knee. Her father reported that although clearly anxious, Elizabeth handled her brief hospitalization without overt distress. Similarly, when her father explained that her mother’s hurt could not be fixed and she had gone to heaven, Elizabeth did not show a strong initial reaction. She did, however, show significant distress as the permanence of her loss began to sink in, with episodes of crying as she wished to have her mother back. Her father would hold and comfort her during these episodes, explain about her mother being in heaven, and then try to distract her. Six months following the accident, crying episodes had greatly diminished and from that time forward she rarely talked about her mother. Concerned that dwelling on feelings of loss could potentially make things worse, Elizabeth’s father’s approach to the tragedy was to try to accept what happened and to keep going forward. He had not talked to her about any details of the accident nor actively attempted to elicit her feelings. Her father reported that since the accident, Elizabeth was “not as warm and cud- dly” as she was before and that often “a cloud seems to come over her,” especially when she observed another mother being affectionate with her child. At the same time, with the exception of her kindergarten teacher, to whom she had attached with great intensity, she drew back when other children’s mothers attempted to be affectionate with her. Her father also described ongoing intense separation anxiety (“She cannot be alone”). On the positive side, Elizabeth had not shown symptoms of posttraumatic stress disorder and with the exception of occasional increased aggression toward peers, her overall social, cognitive, and behavioral functioning was good.

Developmental History

Elizabeth was a planned child and there were no problems during the pregnancy, labor, or delivery. Her mother stayed at home with her fulltime and was described by Elizabeth’s father as a wonderful caregiver. Elizabeth’s developmental milestones were all within normal limits and there were no serious medical problems, adverse experiences, or behavioral problems prior to the accident. There was also no family history of mental illness or emotional disturbances. 210 T. J. Gaensbauer et al.

Sessions with the Child

First session: With a goal of helping Elizabeth to be comfortable, the initial focus was on Elizabeth’s current interests and activities with discussion of her mother’s death emerging naturalistically over the course of the session. She remained by her father’s side the entire session. Elizabeth’s father had brought along pictures and pieces of her mother’s jewelry that Elizabeth would play with at home, and Elizabeth was happy to show these to the clinician. She acknowledged that she frequently thought about her mother but when asked what she thought about repeatedly answered “I don’t know.” Strikingly, she denied having any memories of her mother prior to the accident. The only memories she reported about the accident itself were of being pulled out of the car by a stranger and seeing all the flashing lights and ambulances. As she talked about her mother in the session, Elizabeth became increasingly sad and withdrawn and moved into her father’s lap for comfort. Second session: Because her sadness was so evident at the same time that her verbal denial of feelings and memories was so marked, and also because of her father’s difficulties accepting her feelings, the clinician felt that individual (without the parent) sessions where she was provided the opportunity to express herself through play could be very helpful. In preparation, the clinician provided access to a variety of toys of general interest (dolls, a playhouse, drawing materials, a purse with toiletries, stuffed animals, etc.). On a side table the clinician placed some additional dolls and toys that could potentially be used for play associated with the accident including cars, trucks, and a toy ambulance with two police figures. Readily available in reserve was a box containing a wide range of police and medical doll figures, toy medical equipment, and other play objects. Elizabeth initially began to draw a colorful rainbow. However, in a dramatic demonstration of preoccupation with death, in the middle of the drawing, she picked up a “little mermaid” doll lying on the table, and said to the clinician, “She died.” After completing the rainbow and telling the clinician that she could not draw a picture of her family because she could not remember what her mother looked like, Elizabeth moved to the side table and began playing with the toy ambulance. She put the two police figures, one of whom was clearly female with a ponytail, in the front seats and asked where the chairs were for the back seat. When the clinician gave her a stretcher from the box of medical toys, she put the female police officer on the stretcher and then asked if there were any dolls that could carry the stretcher. Rummaging through the toy box, she then replaced the female police doll on the stretcher with an adult female doll and then used four police and medical dolls to carry the stretcher into the ambulance in an exact replication of how it would be done in real life. Reacting emotionally to this reenactment, she then left the ambulance scene and began punching pillows on the chair where she had initially been sitting and threw several items from the purse onto the floor. Following this aggressive play, Elizabeth went back to the ambulance table and, as if recreating the collision, began vigorously careening a toy car back and forth across the table. With the car she knocked most of the dolls onto the floor and then 6 Assessing the Inner World of the Young Child 211 hit other items on the table including a truck before pushing the car off the table onto the floor. As the car fell, the clinician provided a verbal comment on the action, exclaiming “Crash!” Elizabeth repeated the word “Crash” and very excitedly picked up the car and began bashing the car against the truck. She then moved the car up and down on the table in a violent way, as if it were driving along a bumpy road, possibly recreating the jerking sensations she would have experienced when her car was hit. She then placed the car on the bed of the truck as if it was being taken away and announced, “It’s killed!” She then again moved away from the table and quieted herself during the rest of the session by playing with a marionette puppet in a very focused and repetitive way. Third session: Elizabeth was reluctant to return for a second individual session and for most of the session played with the dolls and toy materials in age-typical, though occasionally aggressive, ways. Toward the end of the session she returned to the ambulance table. As she was holding the ambulance, the clinician suggested that her play in the previous session had reminded him of her accident and asked her if she had ever been in an ambulance. Strikingly, she answered, “Yes” in a very defini- tive way and then said, “And I wasn’t very happy.” When the clinician asked her if she was in the ambulance by herself, she said no, she was in it with her father. However, when the clinician asked in follow-up if her father was asleep (i.e., unconscious) in the ambulance she denied remembering being in the ambulance but that she knew it “Because I dreamed it.” Her father told the clinician after the session that this had never been talked about and that he did not know how he or Elizabeth had gotten to the hospital because he had been unconscious. Providing evidence that this was an actual memory, subsequently obtained hospital records documented that they indeed had been in the same ambulance.

Diagnosis and Treatment Recommendations

In this case, the play sessions with Elizabeth were pivotal in gaining access to her inner world, leading in turn to a deeper understanding of her presenting problems and a formal diagnosis. Her play reenactment of the accident provided information which would not have been obtained from her caregiver nor from Elizabeth herself, had only verbal interviews, a structured mental status exam, and/or systematic rating scales been utilized in the evaluation. The opportunity to observe and elicit Elizabeth’s memories, affects, and struggles through interactive play was a crucial component of the assessment. It was evident from these sessions that Elizabeth was struggling with ongoing feelings of grief that she was defending against by denying their existence. She avoided situations or discussions that reminded her of her loss while at the same time had intensely attached herself to her teacher in an effort to assuage her pain. Her defense mechanisms had taken extreme forms, including the conscious denial not only of any memories of the accident but of any memories of her mother, positive or negative. That memories and feelings about the accident and loss of her 212 T. J. Gaensbauer et al. mother were both present and available to be elicited was amply demonstrated by the readiness with which, once provided a nonverbal vehicle, they were expressed in her spontaneous play. Her uncertainty about whether her image of being in the ambulance with her father was real or a dream serves as an example of how young children at times can have difficulty knowing whether retained internal representations are real or fantasy. From the standpoint of diagnosis, Elizabeth demonstrated symptoms consistent with the diagnosis of Complicated Grief Disorder of Infancy and Early Childhood (DC:0–5; corresponding to DSM-5 Other Specified Trauma and Stressor-Related Disorder; ZERO TO THREE, 2016). Treatment recommendations included individual psychotherapy that would allow Elizabeth through play and talking therapy to communicate her experiences and feelings. Because these feelings were so deep and so heavily defended, it was anticipated that an extended therapy would be necessary. It was felt that Elizabeth could also benefit from participation in a peer group helping children with their grief. Ideally, Elizabeth’s father would play an active role in her therapy, but his difficulty dealing with his own pain would make it extremely difficult for him to participate directly. He would benefit from individual therapy or from meeting with Elizabeth’s therapist on his own for help with his own grieving process. Medication was not indicated at this time.

Acknowledgement The authors declare no conflicts of interest.

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Leandra Godoy, Alison E. Chavez, Rachel A. Mack, and Alice S. Carter

Introduction

Advances in our understanding of early childhood psychopathology have led to an increase in reliable, valid, and developmentally appropriate tools for infants, toddlers, and preschoolers. In this chapter we discuss the use of adult-report rating scales, including both comprehensive measures and brief screeners, in the clinical assessment of social-emotional and behavioral (SEB) functioning among children from birth to 5 years of age (referred to as young children going forward). First, the strengths and limitations of rating scales in clinical assessment are reviewed including how to select informants, gather information, and the importance of contextual and cultural factors in the selection and interpretation of rating scales. Next the goals and contexts of clinical assessment are described, and how these factors impact the clinical utility of rating scales. Guidelines for selecting measures are provided with assessment of psychometric properties, and interpretation of results. Finally, the chapter concludes with a case vignette illustrating the above points. Young children have limited verbal abilities and metacognitive capacities, making it difficult to for clinicians to directly collect information from them. Or even in the case of older preschoolers (e.g., 4- and 5-year-olds), when information can be

L. Godoy Child Health Advocacy Institute, Children’s National Health System, Washington, DC, USA Division of General and Community Pediatrics, Children’s National Health System, Washington, DC, USA e-mail: [email protected] A. E. Chavez · A. S. Carter (*) Department of Psychology, University of Massachusetts Boston, Boston, MA, USA e-mail: [email protected]; [email protected] R. A. Mack Department of Psychology, The George Washington University, Washington, DC, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 217 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_7 218 L. Godoy et al. directly collected from them, this information tends to be limited. In contrast to clinical assessment of older children, adolescents, and adults, caregivers play a central role in early childhood assessments. A caregiver is the person who assumes responsibility for meeting the child’s physical and emotional needs and may refer to biological, adoptive, or foster parents; guardians; or extended family members who care for the child on a regular basis. While the person who brings the child to the visit usually assumes this role, children often have multiple caregivers who can provide valuable information. Since young children’s behavior is more variable across contexts compared to older children, multiple caregivers should be included in the evaluation process (Clark, Tluczek, & Gallagher, 2004). It is important for clinicians to understand the strengths and limitations of rating scales and the unique considerations involved in the process of selecting caregivers and integrating data across informants.

Strengths and Limitations of Rating Scales

Strengths. A benefit of using caregiver-reported rating scales in the clinical setting is the crucial insight these individuals can provide. Caregivers have intimate knowledge of the child’s temperament, daily routines, and behaviors across settings. They are able to report on behaviors that occur infrequently and shed light on how the child functions outside the clinician’s office. Caregiver report allows the clinician to assess the caregiver’s perspective and concerns. Importantly, the caregiver’s expectations, attributions, and interpretations of the child’s behavior influence their child- rearing practices and impact the child’s development (Snyder, Cramer, Afrank, & Patterson, 2005). Assessing whether a caregiver is concerned about the child’s behavior can clarify: (a) the caregiver’s perception of the child’s current difficulties, (b) their motivation to seek help (Ellingson, Briggs-Gowan, Carter, & Horwitz, 2004; Godoy & Carter, 2013; Godoy, Mian, Eisenhower, & Carter, 2014), and (c) strategies that may be effective for enhancing buy-in with treatment recommendations (Mian, Godoy, Eisenhower, Heberle, & Carter, 2016). Caregiver perception and concern has implications for intervention targets. For example, if a parent expresses frustration or excessive concern about a child’s behavior in a domain that the clinician appraises the child as developmentally appropriate, the clinician can provide psychoeducation about normative child development. An important strength of rating scales is the efficiency with which they can cover many clinically relevant domains. As discussed below, comprehensive rating scales typically include multiple areas such as SEB functioning, cognitive abilities, language development, and trauma exposure. Thus, rating scales allow the clinician to quickly assess the young child’s functioning across several domains and can elicit important information that may have otherwise not been shared. For example, a parent or caregiver may identify their child’s presenting problem as temper tantrums and fail to report or be unaware that the child has delays in expressive language. In this scenario, a comprehensive rating scale would allow the clinician to understand 7 Rating Scales for Social-Emotional Behavior and Development 219 the child’s behavior in the context of their language development, which may be a contributing factor to the tantrums. Limitations. Despite the many benefits of caregiver reported-rating scales, there are also limitations that clinicians should be aware of during the evaluation process. One of the most common concerns is bias among caregivers, resulting in either an overly negative or overly positive depiction of the young child. There is a substantial body of research to suggest that parental affective symptoms, particularly depression, are associated with increased reports of SEB problems and increased cross-informant disagreement (Briggs-Gowan, Carter, & Schwab-Stone, 1996; Chilcoat & Breslau, 1997; Najman et al., 2000; Youngstrom, Loeber, & Stouthamer- Loeber, 2000). However, the effect sizes reported are fairly small (Richters, 1992), calling into question the applicability of this research to the clinical setting. Another concern is that caregivers may underreport problems. One reason may be fear of stigmatization or blame from the clinician and/or friends and family members. It is also possible that caregivers are simply not attending to their child’s SEB problems due to lack of awareness of normative child development or limited access to the child. These issues are more salient in the evaluation of young children when clinicians may not have access to collateral information. Measures that have a more structured format and a lower inference level required to make ratings tend to be more reliable and thus less influenced by parent biases. Finally, there are limitations associated with rating scales that measure caregiver concern. While it is an extremely sensitive predictor among school-aged children and adolescents, caregiver concern is not a strong indicator of young children’s current or future behavioral functioning (Briggs-Gowan & Carter, 2008; Glascoe, 2003). Despite the fact that they report clinically significant levels of problem behaviors, a large number of caregivers are not worried about their young children’s behavior (Ellingson et al., 2004). Therefore, assessment of caregiver concern in the evaluation of infants and young children is not always a reliable way to determine problem severity and impairment.

Selecting Informants

The clinician’s first task is to select informants. Caregivers include parents and individuals who routinely spend enough time with the child to be knowledgeable about multiple aspects of the child’s typical SEB functioning. Thus, extended family members and child-care providers who have cared for the child on a regular basis for at least 1 month are considered caregivers. (Note that some measures may list different criteria for classifying someone as a valid informant.) Gathering data from multiple informants is helpful in painting a more complete picture of a child’s functioning, especially if the child behaves differently across contexts and caregivers (see Chap. 1). It is crucial to maintain confidentiality and obtain written consent from parents or legal guardians before gathering information from non-parental caregivers. 220 L. Godoy et al.

Parents/guardians. The most common source of information on young children is a parent or guardian. The person who presents with the child at the appointment and provides consent is usually a parental figure and should be included in the evaluation process. These individuals include biological parents, adoptive parents, foster parents, and legal guardians. If guardianship is unclear or parents split custody, it is important to gather more information about these legal agreements to facilitate the inclusion of appropriate caregivers in the evaluation and understand the child’s broader care context. Non-parental family members. Clinicians should evaluate the child’s larger family context in order to identify key nonparental family caregivers. Here, the word family refers to any person, whether biologically related to the child or not, who is considered by the child or other adults close to the child to be a family member. It is useful to explore family history, including ruptures in relationships, new additions to the family, family losses, and changes in the way family members are distributed across households (see Chap. 2). This information can illuminate clinically relevant factors that are currently influencing the child’s functioning and/or development over time (Carlson, 1990; Hayden et al., 1998). Collecting family history also enhances the clinician’s understanding of a given caregiver’s perspective and may reveal potential sources of bias and avenues for intervention. An understanding of cultural norms including family structure, gender roles, linguistic preference, and parenting practices is essential for an accurate assessment of family functioning. In contrast to the traditional notion of the two-parent household and caregiving system, many children are cared for or live with relatives such as grandparents, aunts, and uncles, particularly among culturally diverse families (Ellis Simmons, 2014). Even more children may have close but informal caregiving relationships with relatives in their extended family. Thus, many children have non-parental family caregivers who should be invited to participate in the evaluation process. Childcare providers. It is useful to supplement parent reports with information from childcare providers when possible, as they have the ability to provide information on how children behave and function outside the home, with non-parental adults, in a structured setting, and when interacting with peers. Moreover, these providers often have knowledge of normative versus atypical development given their broader range of experiences caring for young children. Assessing behavior across contexts sheds light on problem pervasiveness and severity and can therefore be helpful in determining the clinical significance of behaviors (Wakschlag et al., 2007). Despite these potential advantages, there may be situations where a childcare provider is not an accurate informant about an individual child. This could be the case when the child is cared for in a very busy environment in which monitoring is low and only severe behaviors are acknowledged or due to a strength-oriented bias in which problematic behaviors are attributed to normative temperamental and/or developmental variations. 7 Rating Scales for Social-Emotional Behavior and Development 221

Contextual and Cultural Factors

Young children’s SEB functioning is highly sensitive to context and the influence of interpersonal relationships (Dirks, De Los Reyes, Briggs-Gowan, Cella, & Wakschlag, 2012; Gray et al., 2012). It is vital for clinicians to evaluate the impact of context on behavior and include these considerations in the selection, administration, and interpretation of rating scales. One especially salient context is sociocultural identity, including race, ethnicity, linguistic preference, socioeconomic status, religion, and sexuality. Clinicians must recognize the influence of sociocultural factors on child development and behavioral functioning, which may be even more pronounced during early childhood given the reliance on caregivers during this stage. Language and literacy. Language and literacy level have a direct and powerful impact on the utility of rating scales in the assessment of young children. Unfortunately, most instruments are written in English and normed on English- speaking populations. Though translations for certain scales exist, some items may lose their intended meaning as population-specific behavioral and linguistic issues may be overlooked during the translation process. Moreover, literacy level among English speakers is another pressing concern as around 17% of American adults have very limited literacy skills (Rampey, Finnegan, & Goodman, 2016). Caregivers with limited English proficiency and literacy may be unable to read and respond to text-based questionnaires. Clinicians should be aware of these potential barriers. Clinical reminder: When presenting caregivers with written materials, check in about their comfort with questionnaires and pay attention to nonverbal cues. It can be helpful to routinely offer to read brief questionnaires to parents and caregivers— indicating that some parents/caregivers prefer that the questions are read aloud, even though it may take a bit more time to complete the questionnaires in this manner. Values and norms. Sociocultural values and norms shape caregivers’ expectations of children’s SEB functioning and developmental trajectory. For example, in many cultures it is common for young children to co-sleep with caregivers, while children are expected to sleep alone from a young age in other cultures. Thus, cultural context influences whether caregivers identify behavior as negative or problematic. Sociocultural factors also inform parents’ intentions for raising their children and the opportunities and encouragement they provide. Caregivers who value independence may encourage a child to complete tasks independently, whereas caregivers who value interdependence may be more likely to encourage a child to seek and accept help. These norms and expectations will impact how caregivers respond to the questions asked on rating scales. Clinicians are encouraged to discuss the cultural validity of a particular rating scale with families (Nikapota, 2009). This process helps the clinician to: (a) understand the threshold that caregivers employ when answering the questions, (b) obtain examples of the behavior to ensure that the item was interpreted as intended, and (c) ask about the possible cultural meaning or relevance of their responses. Clinicians 222 L. Godoy et al. should not only consider the accuracy of the information obtained via caregiver report, but also whether there are areas of child functioning missing from the rating scale that would be culturally relevant such as deference to elders or participation in cultural/religious traditions. Such discussions foster engagement and rapport with the family and lead to a more comprehensive understanding of the child’s functioning. Stressors. Clinicians should consider recent and/or chronic stressors when interpreting data from rating scales. When major events have occurred in the child’s history—whether these are identified as stressors by the reporter or not—it may be useful to explicitly inquire about the child’s functioning before and after the event as well as changes since the event. For example, moving houses is a common and stressful transition for young children that caregivers may not recognize as relevant to the assessment. Family history may also reveal changes in the child’s caregiving relationships, as in the case of a child whose parents have recently moved the family into their own apartment after having lived with the child’s grandparents for the majority of her life. In such cases, it may be warranted to repeat the assessment 1 or 2 months after the change to assess the child’s functioning after a period of adjustment to the new environment. Multiple settings. In addition to collecting information across multiple informants, it is also recommended to evaluate the impact of multiple environments on the child’s presenting problems. Clinicians should consider factors such as the physical structure of the setting, the way time and activities are structured, adult-to-child ratio, number of children, behavior of other children, and level of sensory stimulation. Moreover, inconsistency in rules between home and school or childcare, such as requirements for where eating and sleeping take place and consequences for aggressive behaviors, may contribute to the presentation of behavior difficulties in young children. These discrepancies may also account for conflicting information reported across caregivers from multiple settings. Neighborhood and community. Lastly, it is important to consider aspects of the child’s context outside of their caregiving environment, including neighborhood and community factors. Research indicates that violence is more prevalent in high- poverty neighborhoods compared to more economically advantaged areas (Briggs- Gowan, Ford, Fraleigh, McCarthy, & Carter, 2010), and some studies report extremely high rates of community violence exposure among children in high-risk urban areas, with estimates ranging from 42% to 78% (Schechter & Willheim, 2009). Therefore, it is important to consider the relationship between potential trauma-exposure and young children’s behavioral, academic, and emotional difficulties, particularly among children known to live in a high-poverty/high-risk neighborhood. Clinicians will benefit from increased knowledge of the neighborhood characteristics in the communities in which they work. Even in the absence of exposure to a specific trauma, living in underresourced neighborhoods is associated with elevated disruptive behavior in toddlers (Heberle, Thomas, Wagmiller, Briggs- Gowan, & Carter, 2014). Additionally, safety concerns may impact the expectations and opportunities for the young child’s social and community engagement. 7 Rating Scales for Social-Emotional Behavior and Development 223

Clinicians should be aware of these factors and how they impact young children’s SEB functioning.

Goals and Contexts of Assessment

Consideration of the assessment goals should be at the forefront of decisions about rating scale selection. Several types of rating scales can be used to gather information from caregivers about SEB problems and competencies, including brief screening checklists and more comprehensive checklists designed to capture variation in broad domains and their subareas. Typically, SEB rating scales yield information about where a child’s score falls in relation to peers (e.g., normal, borderline, or abnormal). Tools for evaluating SEB difficulties ideally involve attention to the child’s behaviors, as well as contextual risk factors in the family and community, including exposure to violence, parental psychopathology, and neglect. Clinicians’ decisions to use a rating scale can be influenced by whether they have identified specific concerns or whether they are globally concerned and want to broadly inves- tigate a child’s functioning in multiple domains. The goals of an assessment may therefore guide the clinician’s selection of a tool.

Screening Tools Versus Comprehensive Assessment Tools

Depending on the goal and context of an assessment, clinicians may choose to use screening tools or comprehensive questionnaires. Screening tools, designed as brief measures for detecting children who may be experiencing problems or are at risk for developing problems, are most appropriate when the goal is to quickly and effi- ciently identify such children from a larger population. Screening tools can help reduce high rates of unmet mental health needs by identifying those who need mental health services but are not receiving them; mental health needs are higher among young children, children of color, and uninsured children (Kataoka, Zhang, & Wells, 2002). Given the brevity of screeners and the limited information provided, screening tools are better suited for monitoring concerns in settings that see large numbers of children (e.g., primary care), but are not as ideal for treatment planning once the need for mental health services is identified. Using screening tools to monitor concerns in “low risk” settings (e.g., primary care versus outpatient psychiatric clinic) allows clinicians to identify children that need support with their development, but whose SEB problems may not have been evident otherwise. Screening tools should be used as a jumping off point for discussions about mental health and further follow-up, such as more in-depth assessment (e.g., longer measure, clinical interview, clinical observations) to evaluate the extent and nature of the difficulties detected. Screening tools can be a cost-effective and minimally burdensome way to screen large groups of children in a manner that characterizes 224 L. Godoy et al. risk status and provides a more detailed profile of problems and competencies when risk is elevated. A clinician’s decision to continue onto further stages of screening or comprehensive assessment can be based on factors such as score profile, parent’s indication of concern, level of impairment, and clinical judgment. Agencies and providers employing multi-stage screening may wait until a more comprehensive assessment is completed to make referrals, but in many cases use the results of screening to initiate a referral or begin addressing identified concerns. For example, primary care providers (PCPs) may refer to Early Intervention (EI) following elevated developmental screening. In most cases, the places to which a child is referred will complete a more comprehensive assessment before beginning treatment. Screening can occur universally or it can be targeted. In universal screening, all children in a setting or situation (e.g., all children at their well-child visit) would complete a screening tool to identify, address, and monitor risks or concerns. In targeted screening, only children identified via other means (e.g., developmental surveillance in which parents report their concerns about the child’s behavior) would be screened. Universal screening is preferred because it does not rely solely on parent concerns or provider judgment, both of which can underestimate problems (Godoy, Carter, Silver, Dickstein, & Seifer, 2014; Sheldrick, Merchant, & Perrin, 2011; Sheldrick, Neger, & Perrin, 2012). In particular, parents of younger children exhibiting SEB problems report lower levels of worry or concern than parents of older children and often do not raise concerns with PCPs (Ellingson et al., 2004; Godoy, Carter, et al., 2014; Horwitz, Gary, Briggs-Gowan, & Carter, 2003). Differences in parent knowledge of child development vary by parental demographic characteristics like educational attainment, age, and immigrant status (Bornstein, 2004; Bornstein, Cote, Haynes, Hahn, & Park, 2010); these differences may also contribute to parents’ abilities to even recognize that they should be concerned about their child. Thus, universal screening can help to identify at-risk children more accurately than targeted screening or when screening has not been implemented at all. Universal screening can help to reduce disparities in health care because all children receive a similar assessment regardless of family characteristics and provider discretion. In contrast, when the goal of an assessment is to develop a detailed profile of a child’s strengths and weaknesses (specific areas in which a child is manifesting problems and in which behavior falls in the typical range), longer, more detailed assessments are generally most appropriate. Comprehensive assessment tools gather information at the level of broad domains and in subscales within each domain. Domain-level scores indicate a child’s overall level of problems in a broad area, most commonly the internalizing and externalizing domains first identified by Achenbach (1966). Internalizing problems include fears, anxieties, and depressive and mood problems. Externalizing problems include aggressive, disruptive, and noncompliant behaviors, as well as problems of hyperactivity and inattention. Some tools, such as the Infant–Toddler Social and Emotional Assessment (ITSEA) (Carter & Briggs-Gowan, 2006), assess functioning in other domains, such as dysregulation and social interaction. Similarly, some tools assess functioning in a single domain; for example, the Multidimensional Assessment Profile of Disruptive Behavior 7 Rating Scales for Social-Emotional Behavior and Development 225

(Wakschlag et al., 2014) is a comprehensive assessment tool that focuses exclusively on disruptive behaviors, such as noncompliance, temper loss and low concern for others. Comprehensive assessment tools also give clinicians subscale scores, indicating a child’s functioning in more specific, narrowband areas. Clinically, subscale scores can create a profile of a child that clinicians can use to pinpoint specific areas of difficulty; having this profile can be more informative for treatment planning and monitoring than guidance based on broad domain scores. For example, on the ITSEA (Carter & Briggs-Gowan, 2006) and the Child Behavior Checklist (CBCL/1.5–5) (Achenbach & Rescorla, 2000), the externalizing domain score is calculated by summing across items describing hyperactive, impulsive aggressive and noncompliant behaviors. Thus, a high score may reflect the presence of an array of problems across subscales or problems primarily in one or two subscales. An elevated domain score therefore provides an imprecise reflection of a child’s behaviors, while subscale scores provide more specific information needed to inform conceptualization and treatment planning and to monitor treatment progress. For example, if a child entered treatment with problems with hyperactivity/ impulsivity and aggression and made significant gains in the area of aggression but not hyperactivity/impulsivity, the externalizing domain score could remain elevated above a clinical cutoff even though the child’s aggressive behavior had dropped to normative levels. Clinicians should closely inspect the items that comprise subscales and domains to ensure that the tool captures the constructs of interest.

Contexts of Assessment

Differences in the nature of screenings and comprehensive assessments translate into differences in the contexts in which these assessments are typically used. As we have reviewed, the core distinction between comprehensive assessment tools is that they are longer and typically require more specialized training, while screening measures are typically brief and can be completed in multiple settings. Screening. Screening tools are selected when appropriate for use across a population and have sensitivity and specificity to detect concerns without flooding the system. Universal SEB screening, particularly in non-mental health settings, can help to de-stigmatize mental health and increase the likelihood that caregivers will raise and discuss concerns and seek treatment. Universal screening efforts can be hampered by barriers, such as difficulty integrating screening into a busy workflow, providers’ self-reported lack of confidence and training in addressing mental health issues (Horwitz et al., 2007), particularly when assessing families whose primary language is not English (Zuckerman et al., 2013), and lack of adequate early childhood mental health resources, which may prompt providers to forgo screening altogether. Despite these challenges, universal SEB screening in primary care has been shown to be feasible and effective in improving rates of referral (King et al., 2010; Schonwald, Huntington, Chan, Risko, & Bridgemohan, 2009). Universal screening 226 L. Godoy et al. is growing increasingly common within pediatric primary care settings, which can be well-suited to the task of detecting SEB problems among young children (Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health, 2009). In a US national survey of families of children 0–5 years old, 84.4% of families reported their children receive annual preventative healthcare check-ups (US Department of Health and Human, Health Resources and Services Administration, & Maternal and Child Health Bureau, 2014), suggesting that most families in the country have contact with a PCP in early childhood. PCPs, who often have long-term, trusting relationships with families, are at the front lines of identifying problems and facilitating appropriate prevention and intervention services for young children, particularly for those who are not yet in formal child care or school settings. Universal SEB screening is increasingly important given the growing list of topics PCPs are expected to cover and shorter office visits. Universal screening also is gaining popularity in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, where families obtain nutritional assessment and counseling. States like Missouri have integrated developmental surveillance programs, such as the Centers for Disease Control and Prevention’s “Learn the Signs. Act Early,” into their WIC visits with families (Centers for Disease Control and Prevention, 2017). Like PCPs, WIC staff may have trusting relationships with caregivers. A survey of WIC staff in one state found that staff frequently answered caregivers’ developmental and behavioral concerns (Zuckerman, Chavez, & Reeder, 2017), suggesting that they are trusted resources for caregivers’ child development questions. Yet, it is important to ensure that staff feel prepared to provide appropriate counseling and resources. In the same survey, only a minority of staff reported feeling connected to local pediatric PCPs or EI programs (Zuckerman et al., 2017). Not surprisingly, universal screening is gaining popularity within other early childhood settings, such as child care centers, Head Starts, and EI. There are currently no clear national estimates on how many child care centers across the USA conduct mental health screenings, but in some states, most centers report conducting universal developmental screenings (Allen, 2007). A challenge of screening in a setting like a child care center is determining how assessors will review results with caregivers, especially if they are child care workers who will continue interacting with families on a regular basis. Thus, supporting child care center staff in how to talk with parents about screening results and connect them to further resources for evaluation is important. EI is a specialized system of services for infants and toddlers with developmental delays or disabilities that is federally mandated in every US state and territory through Part C of the Individuals with Disabilities Education Act. Developmental services are accessed after children undergo a comprehensive evaluation. Although EI is federally mandated, individual EI offices vary in their approaches, including use of screening tools. For instance, in California EI was part of a statewide screening collaborative from 2007 through 2012 that trained people in sectors working with children (e.g., child welfare workers, medical professionals, early childcare 7 Rating Scales for Social-Emotional Behavior and Development 227 and education providers) to use developmental screening tools before referring to EI (Zero to Three, 2016). Given the many contexts in which children may be screened, it is important that states and local agencies work together to ensure that screening efforts are coordinated, including finding ways to discuss similarities and differences in approaches across settings and sharing results. Comprehensive assessments. The detailed nature of comprehensive assessments leads to them commonly being used in high-resource settings where clinicians are professionally trained to conduct them, such as hospitals, outpatient and medical center clinics, and EI programs. For instance, the ITSEA (Carter & Briggs-Gowan, 2006), a rating scale assessing domains of externalizing, internalizing, dysregulation, and competence, is based on parent-report but should be interpreted by a professional with formal training in administration, scoring, and interpretation of clinical assessments. Training a professional to interpret the ITSEA is a process that can be more time- and resource-intensive than training a professional to administer and interpret screening tools.

Domains of Interest

When selecting a rating scale, it is useful to consider which domains are being assessed.

Social-Emotional Functioning

Key to young children’s social-emotional and behavioral functioning is their capacity “to experience, regulate, and express emotions; form close and secure interpersonal relationships; and explore the environment and learn, all in the context of family, community and cultural expectations for young children” (DC:0- 5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, 2016). The use of validated, normed rating scales in early childhood facilitates developmentally sensitive assessment of social-emotional functioning, which may include disruptive behaviors, mood regulation/anxiety symptoms, and social-emotional competencies. Disruptive behavior typically includes assessment of activity level, physical and verbal aggression (ideally with separate ratings of aggression towards parents, non-parental caregivers, siblings, and peers), and negative emotionality (e.g., temper tantrums). Disruptive behavior problems can be reliably assessed in children as young as 1–2 years (Carter, Briggs-Gowan, & Davis, 2004) and reliably diagnosed in children as young as 2 years of age (Egger et al., 2006; Keenan & Wakschlag, 2000). Rating scales cov- ering internalizing domains can include ratings of the degree to which a child is behaviorally inhibited or shows signs of anxiety or fear; the degree to which a child 228 L. Godoy et al. is withdrawn, depressed, or sad; and the degree to which the child demonstrates problems with sleeping, eating, or sensory sensitivities. Both disruptive behavior problems and anxiety symptoms tend to be associated with later emotional problems (Baillargeon et al., 2007; Mian, Wainwright, Briggs-Gowan, & Carter, 2011). Social-emotional competencies include the degree to which children engage in prosocial behavior, are aware of their emotions, are compliant with authority figures, regulate their attention, express positive emotion, and empathize with others. Assessing competencies is critical to identifying a child’s areas of strength and to case conceptualization and treatment planning. Anxiety problems are the most common mental health presentation in early childhood (Egger & Angold, 2006), yet parents of young children are more likely to seek help for disruptive problems (Brown, Riley, & Wissow, 2007). Given the frequency of co-morbidity, assessment of mood and anxiety is useful when a child presents with concerns about disruptive behavior problems.

Trauma and Stress

There is increased acknowledgement about the prevalence and impact of potentially traumatic experiences and stressors for young children. Developmentally sensitive assessment requires that clinicians attend to a spectrum of events beyond just the (potentially) life-threatening events recognized in the DSM-5 (Diagnostic and Statistical Manual of Mental Health Disorders fifth edition (DSM-5), 2013), to include events that might not be traumatic for older children or adults, such as prolonged separations from a caregiver. Other sources of stress clinicians should attend to include neighborhood disadvantage (e.g., living in neighborhoods with higher levels of poverty and unemployment), poor quality or unsafe housing, exposure to polluted air and water, and exposure to poor quality childcare. Exposure to potentially traumatic events, environmental stressors, and adverse childhood experiences, including abuse, ruptured family relationships, substance abuse in the household, or mental illness in the household, are common among young children. For example, by age 3, nearly one in four children has been exposed to potentially traumatic events or family violence (Briggs-Gowan et al., 2010) and approximately one in five children under 5 years of age live in poverty (The Annie E. Case Foundation, 2018). Such risk factors are additive in that greater exposure puts children at increased risk for the development of psychiatric symptoms and other negative health outcomes (Briggs-Gowan et al., 2010; Garner, Shonkoff, & Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics, 2012; Heberle et al., 2014). Assessing for such contextual risk factors is critical for case conceptualization and treatment planning for a child exhibiting SEB difficulties. 7 Rating Scales for Social-Emotional Behavior and Development 229

Cognitive and Language Delays

It is critical to assess developmental domains, including cognitive and language functioning, when interpreting social-emotional functioning, given the close link- ages between these domains. For example, difficulties following instructions may be better explained by a receptive language deficit than oppositionality or inattention. However, a child’s difficulty following instructions may reflect a receptive language deficit as well as oppositionality and/or inattention. Research has documented increased rates of psychopathology among children with intellectual and developmental disabilities (Einfeld et al., 2006), language delays and specific language disorders (Henrichs et al., 2013; Ross & Weinberg, 2006), learning disabilities (Morgan, Farkas, Tufis, & Sperling, 2008; Yu, Buka, McCormick, Fitzmaurice, & Indurkhya, 2006), and sensory processing disorders (Ben-Sasson, Carter, & Briggs-Gowan, 2009; Ben-Sasson, Soto, Heberle, Carter, & Briggs-Gowan, 2017). Such developmental delays put children at risk globally, yet it is important to keep in mind that the nature of risk varies by condition (e.g., increased rates of anxiety among children with autism). While caregivers can report on children’s functioning across developmental domains, there are certain domains that can be assessed more accurately using different evaluation methods. In particular, children’s cognitive and linguistic functioning is best assessed via direct assessments, which can more accurately determine the child’s level of functioning in comparison to same-aged peers. Examiners administering these assessments, such as the Bayley Scales of Infant and Toddler Development (Bayley, 2005) and the Mullen Scales of Early Learning (Mullen, 1995), directly probe the child’s receptive, expressive, and cognitive functioning (in addition to other areas, such as gross and fine motor skills).

Caregiver Concerns

Clinical assessments that include questions about caregiver’s concern about the child’s behavior can clarify the caregiver’s perceptions and motivation to seek help (Ellingson et al., 2004; Godoy & Carter, 2013; Godoy, Mian, et al., 2014). Moreover, the nature of caregiver concerns (e.g., viewing the child as anxious or disruptive) may influence buy-in with specific treatment recommendations (Mian et al.,2016 ). While it is a good predictor among school-aged children and adolescents, caregiver concern is not a strong indicator of young children’s current or future behavior problems (Briggs-Gowan & Carter, 2008; Glascoe, 2003), as caregivers of young children are less likely than caregivers of older children to be concerned about their children’s behavior problems (Godoy, Carter, et al., 2014). Indeed, a large number of caregivers are not worried about their young children’s behavior despite the fact that they report clinically significant levels of problem behaviors (Ellingson et al., 2004). Thus, rating scales that focus on both caregiver concern and symptom 230 L. Godoy et al. presentation are critical to identifying children with mental health needs and to facilitating motivation to seek treatment.

Impairment

Evaluating impairment, or the extent to which SEB symptoms are interfering with the child’s developmental progress or participation in age-appropriate activities, is critical to the assessment process with young children (see discussion of impairment in Chap. 8). When doing so, clinicians should keep in mind the child’s developmental level to ensure that impairments are not better explained by developmental disability or delay. Yet the process of evaluating impairment varies slightly from that used for older children and adults. Specifically, for young children, impairment should be considered in the context of caregiver support (e.g., degree or number of accommodations) and functioning (e.g., caregiver distress/efficacy, ability to maintain employment), not just child-specific impairments. For example, a caregiver may limit separations from their child given the level of distress expressed by the child, but such accommodations may negatively impact the caregiver’s functioning at work and their relationships with others.

Psychometric Properties

The first step in reviewing a rating scale should be to examine its psychometric properties. Unfortunately, in both clinical and research settings, practical feasibility considerations including a tool’s ease of use related to the time required for training, administration, scoring, and interpretation as well as costs associated with use, the level of professional training required to administer, score, and interpret the instrument, and the influence of common regional practices, often outweigh consideration of psychometric properties. The following section outlines psychometric issues most relevant to parent–caregiver reports in young child assessment: reliability, validity, sensitivity/specificity, positive and negative predictive value, and standardization. Other factors that may influence instrument adoption such as cultural considerations, developmental appropriateness, and response formats are also discussed.

Reliability

Broadly, reliability refers to an instrument’s ability to consistently assess the same dimension, or the stability of the child’s functioning within a domain over time. For measures that have scale scores, the consistency of a measure is typically evaluated 7 Rating Scales for Social-Emotional Behavior and Development 231 by examining two or three aspects of reliability: internal consistency, test–retest reliability, and interrater reliability. Internal consistency is the extent to which the individual items that comprise a scale “hang together,” and appear to contribute similarly to the same construct. Usually, this is assessed with Cronbach’s alpha (1951). Scales with Cronbach’s alpha of a minimum of 0.70 are usually considered to have adequate internal consistency, whereas those with alphas between 0.60 and 0.69 are considered marginal, and those falling below 0.60 are considered unacceptable (Cicchetti & Sparrow, 1981; Nunnally, 1978). However, not all clinically informative young child measures will have acceptable internal consistency. Limited internal consistency can occur if a measure includes behaviors that rarely occur in the population (e.g., self-injurious behavior, atypical behaviors related to autism spectrum disorder; ASD) or sets of behaviors that are clinically concerning but not likely to co- occur (Achenbach, McConaughy, & Howell, 1987). For example, the ITSEA Atypical Behaviors Index and Maladaptive Index each concern a set of behaviors that are rare but clinically important (e.g., rocking, spinning, PICA, head banging). These indices are expected to have low internal consistency in a normative population (Carter & Briggs-Gowan, 2006), despite measuring multiple behaviors that may be clinically significant red flags that indicate a need for further evaluation or immediate referral for intervention, as some of these behaviors are clinically and diagnostically important in and of themselves. Thus, while internal consistency is one important indicator of reliability, low internal consistency may be tolerated if a score is based on rare behaviors that when present may be clinically informative. Therefore, understanding the base rates of occurrence for items that go into a scale and having a strong understanding of the construct the scale is designed to assess are important for interpreting internal consistency (Carter & Briggs-Gowan, 2006). Test–retest reliability reflects the stability of a measure when it is completed twice over a relatively short time frame. High test–retest reliability suggests that respondents tend to understand items in a similar way over time and that the underlying construct that is measured does not change substantially over a brief period of time. When test–retest reliability is assessed in older children and adults, a 2- to 4-week period is often used. However, a shorter time period is desirable for infants, toddlers, and preschoolers because the rapid pace of development in this period can reduce test–retest reliability. Contextual variation also could contribute to lower reliability between two assessments. For example, peer aggression scores may be quite different if a parent answers questions during a time period when the child has not had much interaction with peers (e.g., following a long vacation or period of unemployment) versus when the child routinely attends a child care program. Thus, contextual and developmental variation may contribute to lower reliability over time in young children. For interview assessments or observational measures, interrater reliability, or the consistency of the measure across informants or raters, should also be evaluated. Interrater reliability indicates whether different people who have similar information about a child tend to rate that information in the same way (Tables 7.1 and 7.2). 232 L. Godoy et al.

Table 7.1 Types of reliability Measures to which this is most Type Definition relevant Statistic used Internal How well do the items Measures with scale scores, Cronbach’s alpha (α) consistency in a scale hang together? such as screeners or checklists Test–retest How consistently does All measures Correlation reliability the tool provide the coefficients (r) or same results over time? intraclass correlation coefficient (ICC) Interrater How consistently does All measures, especially those Intraclass reliability the tool provide the where judgment is involved, correlations, kappa same results when such as semistructured different individuals rate interviews or observational it? systems

Table 7.2 Reliability statistics and rules of thumb for interpreting reliability Criteria (Cicchetti, 1994; Landis & Measure type Score types Statistic Koch, 1977) Dimensional Dimensional scores Symptom Intraclass <0.40 poor Test–retest (about the same counts correlation 0.40–0.59 fair person at different times) Coding (ICC) 0.60–0.74 good Interrater (about the same composite 0.75–1.0 excellent sample of information about scores the same person by different Scale scores raters) Dimensional scores Items that Cronbach’s <0.60 inadequate Internal consistency (how comprise scale alpha 0.60–0.69 poor/ well the items hang scores marginal together) Codes the 0.70 fair comprise 0.80 good composite 0.90+ excellent scores Categorical Categorical variables Disorder vs. Kappa <0.40 poor Interrater reliability not statistic (K) 0.40–0.59 fair Test–retest reliability Below cut 0.60–0.74 good score vs. above 0.75–1.0 excellent cut score Ordinal coding scale

In the case of a checklist measure, this might refer to agreement between parents and early educators/teachers or between mothers and fathers. In general, the more structured the assessment format and the lower the level of inference required to assign ratings, the greater the likelihood that informants will agree, leading to adequate interrater reliability. 7 Rating Scales for Social-Emotional Behavior and Development 233

Validity

Validity refers to an instrument’s ability to assess the problem, skill, or trait that it is designed to measure. Using a measure that does not have adequate validity for assessing a particular problem may lead to mistaken conclusions about the nature or severity of a child’s problems and could affect clinical decisions and care. For example, use of a measure with poor validity for assessing anxiety, perhaps because symptoms are not developmentally sensitive in early childhood, may mean that clinically impairing anxiety does not receive adequate clinical attention. More accurate, valid characterization of a child’s strengths and weaknesses can drive more targeted, tailored treatment planning and optimize outcomes. There are several types of validity that are commonly studied in the course of developing social- emotional/behavioral assessment tools. Content validity or face validity refers to whether the individual items, questions and scales appear to measure the underlying construct they are intended to measure. One aspect of this that is particularly important for young children is whether the items are developmentally appropriate for the target age range. This is often established during a measure’s development phase by an independent expert review process. Construct validity refers to how well a measure assesses the specific construct it is intended to measure. This can be assessed by comparing scores on one measure with scores on another validated measure of the same problem. Another way to evaluate construct validity is to examine how well a tool classifies children with a particular kind of clinically significant problem or disorder from both other children with other types of clinically significant problems or disorders and from those without clinically significant problems and disorders. This type of validity, between groups validity, is often evaluated in terms of the measure’s ability to accurately classify children who have the problem or disorder as well as those who either have other problems and disorders or no problems or disorders. Factor structure provides another indicator of validity, by empirically testing whether items that are expected to fit with particular constructs within a scale, or the structure of the item and construct data, fits together statistically in a manner that is consistent with expectations, based on theory or prior evidence in the area. An evaluation of factor structure can test, for example, whether different types of anxious behaviors cluster together into multiple discrete clusters (e.g., with separation anxiety items on one factor and phobic/fearful items on another) and simultaneously test whether or not the multiple discrete anxious behavior clusters load onto a higher order general anxiety factor, as has been demonstrated in young children (Mian et al., 2016; Spence, Rapee, McDonald, & Ingram, 2001). Convergent validity refers to whether a measure is positively associated with other measures of related, but different, constructs. For example, given that anxiety and depression symptoms are often correlated, one would expect that a measure of early anxiety would correlate positively with a measure of early depression. Discriminant validity or between groups validity refers to whether a measure dif- ferentiates children who are identified as having a particular problem it is intended 234 L. Godoy et al. to measure from children who do not have that problem. For example, one might examine whether children who have been diagnosed with anxiety disorders have higher scores on a measure of anxiety than children who do not have anxiety disorders. Predictive validity refers to a measure’s ability to predict the same problem over time. For example, evidence that higher anxiety scores on a measure predict higher anxiety later in childhood would support predictive validity. Demonstrating that a tool predicts later functioning is essential to showing that it captures a clinically meaningful aspect of early functioning that is not simply a transient perturba- tion in functioning that wanes with development. Validity within a longitudinal developmental context. Developmental processes also affect construct validity. As noted above, one of the steps in psychometric development is to test and establish the factor structure of a measure, or how items load on scales (e.g., aggression), how scales correlate with one another (e.g., aggression, hyperactivity, oppositional behaviors), and how multiple scales load onto higher order factors (e.g., an externalizing factor that includes aggression, hyperactivity, and oppositionality). Notably, when we are interested in following children’s development over time and are using the same measure to assess the child for developmental gains or losses, it is also important to evaluate whether the items and scales that comprise the measure are working similarly at different ages (i.e., if the factor structure is consistent for children of different ages), which is termed measurement invariance (Carter, Briggs-Gown, Jones, & Little, 2003). This is rarely reported and it can be difficult or impossible to find information about the consistency of a measure’s structure across the age period of interest. Without knowledge that a measure demonstrates a consistent factor structure across development, meaning that the items continue to assess the same underlying construct across ages, it is impossible to interpret whether longitudinal change represents a true change in the child’s level of functioning within the construct of interest or if the change reflects a change in the way that the measure assesses the construct of interest (i.e., comparing apples at the earlier assessment to oranges rather than apples that are getting bigger or smaller over time).

Sensitivity/Specificity

Another important consideration is how well a measure classifies a child hashaving a problem or not having a problem. This indicates how useful it might be for a given diagnostic or classification purpose (e.g., meets criteria for an anxiety disorder or indicates whether a child’s problems are above or below a clinical threshold indicative of problems warranting referral). Sensitivity, specificity, positive predictive value and negative predictive value are statistics that are used to determine classification accuracy. Sensitivity refers to the proportion of children who fall within a given problem group (e.g., those known to have a disorder according to another criterion), who are successfully classified by the tool in question. If a measure classifies 85 of 100 children with established anxiety disorders as having high anxiety, 7 Rating Scales for Social-Emotional Behavior and Development 235 it has 85% sensitivity. As sensitivity goes up, false negatives go down. Specificity refers to the proportion of children who do not have a particular problem who are correctly classified by the tool in question. Therefore, a measure that classifies 90 of 100 children who do not have an anxiety disorder as not high in anxiety has 90% specificity. As specificity goes up, false positives go down. A general guideline is that assessment tools used for early identification should have minimum sensitivity and specificity of 70% and false positive rates of no greater than 30% of all children screened (Cicchetti, Volkmar, Klin, & Showalter, 1995; Committee on Children with Disabilities, 2001). Positive predictive value (PPV) is the proportion of children flagged as positive by a screening tool who truly have that problem according to another criterion. Thus, if 50 of 100 children who are positive according to the tool really do have problems, PPV is 50%. PPV is correlated with prevalence rates; that is, assuming that sensitivity and specificity remain constant, PPV goes up and down with prevalence. Negative predictive value (NPV) refers to the percentage of children who screen negative that are truly negative according to another criterion. Though no minimum PPV exists for social-emotional assessment tools, tools should successfully identify a sub-population in which the prevalence of the problem is more common than in the original population (Milgrom, Mendelsohn, & Gemmill, 2011). Low PPV is usually tolerated when failure to detect a problem is associated with a very poor outcome, such as death. For example, a minimum PPV of 10% has been proposed for ovarian cancer screening because the likelihood of death when this form of cancer is not detected is high (Hensley & Spriggs, 2004). As these examples illustrate, different criteria may be appropriate depending on the purpose of the assessment and the risk of harm associated with failure to detect a problem. Generally, sensitivity should be high (and thus false negatives low) for assessment tools designed to aid in specific diagnoses or treatment recommendations (e.g., structured clinical interviews) because of the potential costs to the child and family of misclassifying a child who actually has a specific disorder asnot having the disorder (e.g., missed opportunities for early intervention). However, when the goal is to screen large samples to identify at-risk individuals regardless of their diagnostic status, it can be challenging to find a balance whereby a sufficient proportion of children with problems are detected, while maintaining an acceptable rate of false positives. False positives also bring some practical costs to the setting conducting the screening and potential emotional costs to families by raising concern or worry unnecessarily. Finally, one should not assume that a given test will have stable sensitivity and specificity across developmental periods. This is in part because the prevalence of the condition being assessed may vary with age. A test that has excellent sensitivity, specificity, and positive predictive value within one age group could function poorly in a different age group, particularly if the prevalence of the problem changes. Similarly, one should not assume that a given test will have stable sensitivity and sensitivity across regional, racial/ethnic, or cultural subgroups, as the prevalence of the condition may vary across populations. Thus, it is important to review a tool’s classification statistics for your target developmental period and population. 236 L. Godoy et al.

Standardization

The purpose of standardizing an instrument to develop age-based norms is to provide a means of comparing individuals with their age-based peer group. In many ways, the concept of norms is central to a developmental perspective for assessment. Although traditionally a norm is considered to represent the average test performance of a standardization sample, norms also represent the average, median, or modal performance of a particular developmental level or stage. This is essential at all ages but is especially important in early childhood because children’s social- emotional functioning will change with development within this domain and related domains. For example, as illustrated by the ITSEA, there were age-related changes in some social-emotional problems, from 12 to 35 months, including increases in general anxiety and decreases in separation distress (Carter, Briggs-Gown, Jones, & Little, 2003). This research group and others have also identified robust age differences in children’s social-emotional competencies/skills (Carter, Briggs-Gowan, Jones, & Little, 2003). For example, on the ITSEA linear increases in 6-month blocks from 12–17 months to 18–23 months to 24–29 months, were observed followed by a social competence leveling from 24–29 to 30–35 months. Sex differences were all identified, with greater competence in girls. Thus, a child’s competence will be most accurately assessed in relation to children who are the same sex as the child and of similar age within the developmental period from 12 to 36 months. In selecting a tool and interpreting its results, it is important to be familiar with the sample and conditions in which the normative data were collected—the more similar the normative sample is to your target population, the more relevant the norms (Carter, Marakovitz, & Sparrow, 2015). In a majority of the tests available, the most typical way to operationalize development has been based on chronological age. However, another consideration when comparing a particular child’s scores with norms is the child’s developmental functioning in other areas. Generally, social-emotional development does not exceed development in other areas, especially cognition and language. Thus, as noted already, if a child is substantially delayed in multiple areas, scores may need to be adjusted for developmental level. If a 4-year-old is functioning overall at a mental age of 36 months, then it may make sense to apply 36-month-old norms to determine whether social-emotional functioning is consistent with expectations for mental age. In an ideal world, special norm group data would be available for children with intellectual and developmental disabilities and with genetic and other conditions known to be associated with delays and deficits in social-emotional development and psychopathology. Normative data also have to be considered within the historical and societal contexts in which they are established. Historical events such as natural disasters, war, rates of poverty, or famine may impact the developmental progression of a cohort of children. Norms developed during these periods of relative variation may not be appropriate representations for children growing up in different periods, who are not exposed to these types of experiences. Thus, periodic restandardization of measures is very important. 7 Rating Scales for Social-Emotional Behavior and Development 237

Cultural Adaptation

Despite a dramatic increase in diversity in the USA and around the world, issues of cultural validity and the establishment of culturally relevant norms continues to be a challenge to the assessment of social-emotional and behavior problems and disorders in young children. Importantly, translation, even when forward- and back-translation methods are employed, is often inadequate to address issues of cultural appropriateness and validity (van Widenfelt, Treffers, de Beurs, Siebelink, & Koudijs, 2005). Ideally, measures would be developed simultaneously in multiple languages for use in different parts of the world, and examinations of psychometric properties and item and construct equivalence would be established during development. However, there is still extremely limited information about the psychometric properties of measures that have been translated or about the samples or subsamples in which translations have been employed. For example, the ITSEA item “Runs away in public spaces,” which is extremely rare in the US context, was rated as normative in Finland until the addition of “for example, in train stations” was added to the item to increase the equivalence of item across these two countries. This is a good example of the limits of translation, as different caregiving patterns and expectations across cultures may lead to situations in which the same words do not have the same meaning in relation to young child psychopathology. Moreover, few measures that have been translated have gathered appropriate normative group data that would permit easy comparisons of the range of relevant psychometric properties across cultural groups. Even when normative data are available for a child and family’s home country, these norms may not be appropriate in a new cultural context. For example, for families who have been living in a new country for some time, immigration stress and acculturation may also impact the appropriateness of the use of home country normative data among families. This is clearly an area that will require greater attention in the future.

Selecting an Appropriate Rating Scale

There are several factors to consider when selecting a clinical rating scale. These include the goals and contexts of assessment, psychometric properties of the scale, cost of the instrument, length of the tool, staffing constraints, ease of scoring and interpretation, parental literacy, cultural/linguistic appropriateness of the scale. Such considerations are relevant to assessments with individuals of any age. Tables 7.3–7.5 outline several commonly used parent-report SEB rating scales. Note that this list is not exhaustive. Tables 7.3 and 7.4 include rating scales that address a range of SEB problems and some that include competencies with Table 7.3 focused on brief screeners (25–42 items) and Table 7.4 focused on comprehensive rating scales. Table 7.5 includes domain-specific rating scales. All the tools can be completed by parents/caregivers, and in some cases child care providers, on their own. Scoring and interpretation of these instruments is relatively straightforward, but should be done by qualified individuals with appropriate training and supervision. 238 L. Godoy et al.

Table 7.3 Brief SEB screeners Screening tool Age Description Ages and Stages 3–66 months Problems are combined into one total score, though it Questionnaire: Social- covers a range of areas including self-regulation, Emotional-2 (ASQ:SE-2) compliance, communication, autonomy, and (Squires, Bricker, & interaction with others. Competencies are assessed Twombly, 2015) but responses are integrated into overall score BASC-3 Behavioral 36 months+ Problems are combined into one total score, though it Emotional Screening (18 years) covers internalizing and externalizing problems. System (BASC-3 BESS) Competencies are assessed but responses are (Kamphaus & Reynolds, integrated into overall score 2015) Brief Infant-Toddler 12– Problems are combined into one total problem score Social and Emotional 36 months though covers internalizing, externalizing, Assessment (BITSEA) dysregulation, and maladaptive behaviors. Includes (Briggs-Gowan, Carter, separate competence domain with own cut point Irwin, Wachtel, & Cicchetti, 2004) Early Childhood 18– Problems are combined into one total score, though it Screening Assessment 60 months covers a range of areas (ECSA) (Gleason, Zeanah, & Dickstein, 2010) Strengths and Difficulties 24 months + Generates total score as well as subscale scores, Questionnaire (SDQ) (18 years) including emotional symptoms; conduct problems; (Goodman, 1997) hyperactivity; peer problems, and prosocial behavior Survey of Wellbeing of 1–66 months SEB portion includes the Baby Pediatric Symptom Young Children (SWYC) Checklist (BPSC) and the Preschool Pediatric (Perrin, Sheldrick, Visco, Symptom Checklist (PPSC) depending on child age. & Mattern, 2016) Problems are combined on each measure into one overall score, though they include several domains: BPSC includes irritability, inflexibility, and difficulty with routines. PSC covers internalizing, externalizing, attention problems, parenting challenges

Interpreting Rating Scales and Sharing Results with Families

When gathering rating scale information, conflicting reports of behavior are not unusual. Contrasting information may reflect true differences in cross-situational behavior, reporter biases, and/or discord between raters. There are no clear rules for reconciling discrepant reports (Kraemer et al., 2003). Instead of searching for “the truth”, clinicians should consider each source of information as a vital piece of the puzzle needed to understand the child (De Los Reyes & Kazdin, 2006; Kerr, Lunkenheimer, & Olson, 2007). Rating scales are best used to inform clinical judgment and decision-making and to facilitate conversations with families about assessment findings and treatment planning and progress. Rating scales are not diagnostic, but rather should be used in 7 Rating Scales for Social-Emotional Behavior and Development 239

Table 7.4 Comprehensive SEB checklists Screening tool Age Items Description Behavior Assessment 24 months 175 Comprised of four broad scores: Internalizing System for Children, to 21 years items Problems, Externalizing Problems, Behavior Third Edition Symptoms Index, and Adaptive Skills. Scales (BASC-3) (Kamphaus include Aggression, Hyperactivity, Anxiety, & Reynolds, 2015) Depression Somatic Problems, Withdrawal, Attention Problems, and Atypicality Child Behavior 18– 99 Comprised of Internalizing, Externalizing, Total Checklist ages 1.5–5 60 months items Problems, and a Stress Problems scale. These are (CBCL 1.5–5) comprised of Syndrome Scales (Emotionally (Achenbach & Reactive; Anxious/Depressed; Somatic Rescorla, 2000) Complaints; Withdrawn; Sleep Problems (CBCL only); Attention Problems; Aggressive Behavior). Also includes DSM-oriented scales (Depressive Problems; Anxiety Problems; Autism Spectrum Problems; Attention Deficit/Hyperactivity Problems; Oppositional Defiant Problems) Conners Early 24– 187– Comprised of six areas: Inattention/Hyperactivity; Childhood (Conners 72 months 191 Defiant/Aggressive; Social Functioning/Atypical; EC) (Connors, 2009) items Anxiety; Physical Symptoms; and Mood/Affective problems; Developmental Milestones scales portion that includes assessment of Play, Adaptive behavior, Communication, and Motor Skills Infant-Toddler Social 12– 166 Comprised of four broad domains: Internalizing, and Emotional 36 months items Externalizing, Dysregulation, and Competence. Assessment (ITSEA) Multiple subscales within each domain and three (Carter & Briggs- indices, Social Relatedness, Atypical Behaviors, Gowan, 2006) and Maladaptive Preschool and 36– 76 Comprised of Problem Behavior and Social Skills Kindergarten Behavior 72 months items Domains. Problem Behavior scale includes Scales: Second Edition Internalizing and Externalizing scales with five (PKBS-2) (“Preschool supplementary problem behavior subscales and Kindergarten optional. Social Skills scale includes Social Behavior Scales– Cooperation, Social Interaction, and Social Second Edition,” Independence scales 2003) combination with other information, optimally with more comprehensive, multi- method and/or multi-informant assessments that include ratings from different informants across settings, observational data, and information on factors, such as cognitive and language development and attachment relationships. Rating scales can be used as a jumping off point in discussions with families about their child’s SEB development and a way to ensure that standardized information is gathered systematically. Clinical point: For some caregivers, it can be helpful to explain that rating scales allow one to gather standardized information about the child’s behavior and compare that behavior to other children the child’s age in the same way that pediatricians take a child’s height and weight and plot that information on a growth chart. 240 L. Godoy et al.

Table 7.5 Problem-specific rating scales Age, Domain/tool years Items Description Anxiety: Preschool Anxiety 2.5–6 34– Overall anxiety and specific domains, including Scale (Spence, 1998) 45 panic/agoraphobia, social anxiety, separation anxiety, generalized anxiety, obsessions/ compulsions Disruptive behavior: 3–5 78 Disruptive behavior in the areas of Aggression, Multidimensional Profile of Temper Loss, Low Concern for Others Disruptive Behavior (disregard, punishment insensitivity), and (MAP-DB) (Wakschlag et al., Noncompliance 2014) Disruptive behavior: Eyberg 2–16 36 Disruptive behavior in the areas of Child Behavior Inventory noncompliance, defiance, aggressiveness, and (ECBI) (Eyberg & Ross, impulsivity. Includes both an intensity scale 1978) (frequency of behaviors) and a problem scale (whether the rater believes the behavior is a problem) Depression: Preschool 3–5.5 16 Depressive symptoms assessed via yes/no Feelings Checklist (Luby, questions Heffelfinger, Koenig- McNaught, Brown, & Spitznagel, 2004) Trauma: The Trauma 3–12 90 Contains eight clinical scales: Posttraumatic Symptom Checklist for Young Stress-Intrusion, Posttraumatic Stress- Children (TSCYC) (Briere, Avoidance, Posttraumatic Stress-Arousal, Sexual 1999) Concerns, Dissociation, Anxiety, Depression, and Anger/Aggression. It also contains a summary posttraumatic stress scale ADHD: ADHD Rating 3–5 18 Assesses hyperactivity/impulsivity and Scale-IV: Preschool Rating inattention based on frequency ratings Scale (McGoey, DuPaul, Haley, & Shelton, 2007)

Information gathered from a single informant should be interpreted with caution given the variability in children’s behaviors across caregivers and contexts. Yet there are often challenges to using multiple informants given the low-to-moderate corre- spondence between multiple informants’ (e.g., parent and parent; parent and teacher) ratings of child emotional/behavioral issue (Achenbach et al., 1987; De Los Reyes, 2013; De Los Reyes et al., 2011). There are no clinical guidelines on how to interpret and synthesize information across informants, but De Los Reyes (2013) recommended considering three factors that may impact the magnitude of discrepancies. First, there may be true differences in cross-situational behavior, particularly given that young children’s behavior is highly situation-specific (De Los Reyes, 2013; Petitclerc et al., 2015). For example, a child may exhibit disruptive behaviors at home but not at child care. Behavior problems that occur and are impairing across multiple contexts, are likely to be more severe than problems limited to one context (Petitclerc et al., 2015; Wakschlag et al., 2007). Discrepant 7 Rating Scales for Social-Emotional Behavior and Development 241 information can provide clues as to contextual factors that may be contributing to certain behaviors can therefore be helpful in shaping recommendations. Second, reporter biases (e.g., attributions, recall) can impact how respondents perceive, weigh, and rate behaviors, thereby leading to differences across informants. Achenbach, 2011). Finally, even reliable and valid measures have error, and thus discrepancies can also reflect true measurement error (De Los Reyes, 2011). Clinically, it is helpful to consider each information source as contributing to greater understanding the whole child (De Los Reyes & Kazdin, 2006; Kerr et al., 2007). Interpreting and synthesizing information should include consideration of the contexts of behavior and the informants. When there is discrepant information across reporters, it may be useful to be open with families about the major areas of disagreement and engage in a dialog about why results may vary and what can be learned about the child from these differences. This approach, which can be culturally- responsive, may help to empower caregivers and strengthen the therapeutic alliance.

Case Illustration

The following is a clinical case description in which rating scale information was gathered to shed light on the child’s functioning and inform treatment planning.

Identifying Information and Description of Presenting Concerns

Lila was a 22-month-old African American girl referred for therapy by her developmental treatment team who presented to the outpatient treatment clinic with her mother, Ms. Wilson, due to concerns about disruptive behavior, including aggression towards others (scratching, spitting, biting, hair pulling), temper tantrums, and limited food intake and weight gain. In addition to primary concerns, Ms. Wilson endorsed concerns about externalizing behaviors (e.g., hyperactivity, impulsivity, inattention/distractibility, noncompliance), inhibition to novelty, separation anxiety, and auditory hypersensitivity.

History of Presenting Concerns

Concerns had been ongoing for approximately 1 year and reportedly worsening since onset at 10 months of age. Common triggers for behavior problems included mother not picking Lila up, Lila not getting her way, mother telling her “no”, and separations from mother. Ms. Wilson reported that temper tantrums occurred constantly throughout the day, were short in duration (roughly 30 s), and stopped when mother soothed Lila or gave her a pacifier. Aggressive behaviors occurred 242 L. Godoy et al. approximately once per day. Ms. Wilson reported trying a variety of responses, including giving Lila a hug, picking her up, and telling her “no.” She had tried time out on a few occasions, but tended not to use this strategy because of Lila’s age. Mother reported that behavior was problematic with other caregivers, including speech-language therapists and home nurses, as well as with other children. At the time of intake, Lila had been working with a community-based psychologist for 6 months on addressing concerns using a behavioral intervention approach that included coaching mother on use of praise and removal of privileges/toys. The treating clinician referred Lila to the current clinic so that Parent-Child Interaction Therapy (PCIT) could be implemented.

Social and Family History

At the time of intake, Lila lived in an apartment with Ms. Wilson, a 24-year-old African American female. The family was homeless for approximately 1 year when Lila was 8–20 months of age, staying at a hotel and a homeless shelter. Ms. Wilson had begun training as a certified nursing assistant through Job Corps, but had stopped pursuing these professional goals due to Lila’s health and behavior, and was unemployed at intake. Ms. Wilson had full custody of Lila. Lila’s father had approximately three visits with her when she was 1 year of age, but had otherwise been minimally involved in her care. Ms. Wilson reported having no social support. Several of her own caregivers, including father, paternal grandmother, and paternal great-grandmother passed away a few years before Lila was born. Family history was significant for bipolar disorder, schizophrenia, depression, and anxiety. Ms. Wilson reported a history of bipolar disorder, anxiety, and depression. She had intermittently obtained mental health including medication and therapy and was just reinitiating mental health services at the time of intake. Lila was attending a weekly socialization group where she was capable of playing well with others (e.g., gave hugs and demonstrated other forms of affection with peers) at times, but play would become more rough as she got tired during the sessions. Lila had briefly attended daycare as an infant, but was un-enrolled after experiencing health issues that required hospitalization. Ms. Wilson expressed interest in re-enrolling Lila in daycare, but had concerns about Lila’s difficulties separating.

Child Medical and Developmental History

Ms. Wilson reported her pregnancy with Lila was “very rough” due to concerns about premature labor, nausea, and high blood pressure in addition to psychosocial stressors, particularly strained interactions with Lila’s father. Lila was born full term via vaginal delivery weighing 4 lb and 12 oz. Lila’s medical history is significant for reflux, gastroesophageal reflux disorder (GERD), and failure to thrive beginning at 7 Rating Scales for Social-Emotional Behavior and Development 243

2 weeks postpartum. She was hospitalized as an infant due to feeding concerns and ultimately received a Nissen fundoplication, the standard surgical treatment for GERD and a gastrostomy-tube at 14 months of age. At intake, she was followed by G/I, Child Development, dermatology, and genetics. Ms. Wilson reported that Lila was a “good baby” and that she “spoiled” her by holding her frequently. Lila has a history of developmental delays in motor milestones: a developmental evaluation at 15 months age found her gross motor skills within normal limits, but fine motor skills at around the 12-month level. She made steady gains in PT and OT services following that evaluation and was discharged shortly after beginning PCIT. Delays were also found in expressive/receptive language and feeding skills, for which she continued to receive weekly speech therapy services concurrent with PCIT. At intake, Lila was sleeping approximately 11–12 h in a 24-h period with one nap, though her sleep routine was inconsistent.

Behavioral Observations (from Intake)

Lila smiled brightly at the examiner and waved hello when prompted. She made intermittent eye contact. She played quietly, independently, and appropriately during the hour-long interview with her mother. She occasionally made a bid for her mother’s attention by moving closer to her or showing her a toy. Lila’s mood was generally consistent with age expectations (i.e., euthymic) and her affect was full and congruent to mood. Lila said a few words during the session and would often repeat a word that her mother had just said. She demonstrated some imaginative play skills, such as feeding a baby doll. There was good social reciprocity and shared enjoyment between mother and Lila during the free play portion of the observation. Ms. Wilson asked Lila frequent questions and reflected what Lila said on occasion. Lila expressed some reluctance to follow her mother’s lead in play and to clean up toys at the end of the session, despite Ms. Wilson’s repeated prompts. Ms. Wilson reported that Lila’s behavior during the session was typical but overall better than that displayed at home.

Rating Scale Information

Given that Lila was being evaluated in an outpatient mental health setting, Her caregivers were asked to complete the ITSEA (Carter & Briggs-Gowan, 2006) to gain a more complete picture of her SEB profile. Since Lila was not in childcare, her home nurse, Ms. Jones, who spent several hours with Lila each day, was identified as an informant. Responses indicated clinically significant elevations on the following domains and subscales: Externalizing Domain (Activity/Impulsivity—Ms. Wilson only, Aggression/Defiance); Internalizing Domain (Separation Distress, Inhibition to Novelty); Dysregulation Domain (Negative Emotionality, Sleep, Eating). Thus, 244 L. Godoy et al. there was wide agreement across raters in Lila’s behavior and general confirmation of the information gathered during the intake interview. The only disagreement was on the Activity/Impulsivity scale. Upon discussion with Ms. Wilson, she indicated that the nurse “has a higher tolerance” for Lila’s activity level and had tried to assure Ms. Wilson that Lila’s activity level is age appropriate. Highlighting the discrepancy across raters led to a discussion about Ms. Wilson’s high expectations for Lila and the fact that Ms. Wilson’s own caregivers always had high expectations for her behavior and used harsh discipline techniques when she did not meet expectations. Ms. Wilson reported fear that Lila’s behaviors, particularly her externalizing behaviors, could get her into trouble when cared for by other individuals. The discussion about developmental expectations, normative behavior, Ms. Wilson’s experiences as a child and her caregiving models, and her hopes and fears about her own parenting and Lila’s experience with other caregivers were revisited throughout the course of treatment. Once Lila turned 2, Ms. Wilson completed the Eyberg Child Behavior Inventory (ECBI) (Eyberg & Ross, 1978) weekly to assess treatment progress in PCIT. The ECBI is a questionnaire that asks parents to assess the frequency of various behaviors on a seven-point Likert scale from 0 (Never) to 7 (Always) and to determine whether the behavior is a problem for then (yes/no). Responses are used to determine an overall Intensity T-Score and a Problem T-Score. For T-scores, a mean (or average) score is 50 and the standard deviation is 10 (i.e., scores between 40 and 60 are considered average). On the ECBI Intensity Scale, Lila received an Intensity score of 168 (T-score = 70) and a Problem score of 20 (T-score = 67), thus indicating clinically significant elevations. Use of the ECBI weekly allowed for a brief assessment of Lila’s progress in treatment, while Ms. Wilson was asked to complete the ITSEA every 3 months to get a more comprehensive assessment of treatment progress.

Formulation and Plan

Lila is an almost 2-year-old girl referred for concerns about aggression, temper tantrums, and feeding difficulties. Results from the parent interview and reports from both mother and her home nurse on the ITSEA indicated clinically significant elevations in internalizing behaviors, particularly separation distress and inhibition to novelty, as well as dysregulation, including negative emotionality and disruptions in sleep and feeding. While mother reported elevations on externalizing scales, particularly activity/impulsivity and aggression/defiance, these were not endorsed by the home nurse. Discussion revealed that Ms. Wilson’s high and sometimes developmentally inappropriate expectations for Lila’s behavior likely contributed to the discrepancy in scores, which proved useful for informing intervention efforts. In addition to symptom presence, Ms. Wilson reported impairment in functioning in several domains, including at home and in the community. 7 Rating Scales for Social-Emotional Behavior and Development 245

Several factors were likely contributing to presenting concerns. Predisposing factors include family history of mental health concerns and developmental delays that may make it more difficult for Lila to respond to challenging emotions in a developmentally appropriate way. Precipitating factors include psychosocial stressors, such as hospitalizations, homelessness, and parental stress. Such stressors could have had a direct impact on Lila’s behavior as well as an indirect impact through their influence on Ms. Wilson’s functioning and the attachment between the two. Given the nature of these stressors and the timing of emergence of concerns, a diagnosis of Posttraumatic Stress Disorder (PTSD) was most appropriate. Rating scale information helped to clarify and corroborate the nature and severity of presenting problems, confirming that they were clinically significant and consistent with a diagnosis of PTSD. Problem behaviors may have been maintained via behavioral factors, particularly inadvertent reinforcement that may take the form of attention from others, access to preferred items and escape/avoidance of non-preferred activities. For example, when Lila is noncompliant and tantrums, she may get increased attention from adults, which can exacerbate problems even if the attention is negative. Protective factors include Lila’s happy, sweet nature and the fact that her mother appeared to be motivated to address concerns. It is likely that concerns can be addressed through consistent parent-focused intervention that takes into consideration Ms. Wilson’s own relationship history. The following additional recommendations were provided: (1) Developmental supports and care coordination: Continue ancillary services, including speech- language therapy, physical therapy, and specialized instruction. These interventions will support SEB functioning. Care should be coordinated across providers to ensure that strategies suggested to the family are consistent across therapists. (2) Socialization: Lila would benefit from continued opportunities for peer socialization. The family is encouraged to continue attending the weekly socialization group and to consider daycare options. (3) Therapy: Therapy that can strengthen the attachment relationship and enhance parent behavior management skills, such as PCIT. Psychosocial stressors, family rituals, communication, and problem-solving can also be addressed. (4) Family support: Ms. Wilson would benefit from increased social support, including support for obtaining her own mental health services and pursuing her career goals. When caregiver needs are met, the more capable they will be in addressing the needs of their child.

Conclusions

Caregiver-reported rating scales are helpful to the assessment process because they allow for the standardized gathering of information from the people who know the most about the child’s behavior. However, some caregivers may be poor historians or present with significant biases, and when information from multiple caregivers is solicited, there may be variability across informants. Thus, rating should not be interpreted in isolation or used as the sole source of clinical information. This data 246 L. Godoy et al. should be considered in relation to several factors including knowledge about the child’s overall developmental functioning and familial, relational, and cultural contexts. Contextual and cultural factors shape not only child development and caregiving practices, but also the manner in which caregivers respond to structured questionnaires. There are several critical considerations when selecting and administering rating scales, including language, literacy-level, cultural relevancy, psychometric properties, domains covered, goals and setting. Comprehensive assessment requires multi-method assessment of multiple domains of social-emotional problems and competencies, as well as environmental risk and protective factors, cognitive and language abilities, caregiving relationships, caregiver concern, and impairment to best understand the whole child.

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Kathleen Mulrooney, Helen Egger, Stephanie Wagner, and Lauren Knickerbocker

Introduction

Infant and Early Childhood Mental Health has become a growing specialization in the fields of health and mental health. Infant and early childhood mental health can be defined as the ability to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant–family system (WAIMH Handbook of Infant Mental Health, 2001, vol. 1, p. 25). ZERO TO THREE defines infant and early childhood mental health as “the

K. Mulrooney (*) Infant and Early Childhood Mental Health, Professional Development and Workforce Innovations Department, ZERO TO THREE, Washington, DC, USA e-mail: [email protected] H. Egger Arnold Simon Professor, Chair, Department of Child and Adolescent Psychiatry, and Director, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA e-mail: [email protected] S. Wagner Clinical Assistant Professor, Department of Child and Adolescent Psychiatry, and Licensed Clinical Psychologist, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA e-mail: [email protected] L. Knickerbocker Assistant Professor, Department of Child and Adolescent Psychiatry, and Clinical Psychologist, Child Study Center, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 253 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_8 254 K. Mulrooney et al. developing capacity of the child from birth to 5 years of age to form close and secure adult and peer relationships; experience, manage, and express a full range of emotions; and explore the environment and learn—all in the context of family, community, and culture” (ZERO TO THREE, 2017). What happens when infants and young children are unable to achieve these capacities, their mental health and emotional well-being is challenged, or face setbacks? For too long there has been a reluctance to identify mental health disorders in infancy and early childhood, often resulting in accumulation of distress in the life of the child and family and delay in accessing appropriate supports and interventions. While the Diagnostic and Statistical Manual of Mental Health Disorders fifth edition, DSM-5 has adopted a lifespan approach to diagnostic classification rather than separate a diagnostic category, the DSM-5 provides relatively little attention to clinical presentation in children under 6 years of age (American Psychiatric Association, 2013; Rutter, 2012) ZERO TO THREE, a national, private, non-profit organization established in 1977 by leading experts in child development, health and mental health recognized this gap in the dominant psychiatric nosologies for mental health disorders in infancy and early childhood. ZERO TO THREE pioneered efforts to design a diagnostic classification system for this age group which are developmentally appropriate, relationship-based, contextually driven, and culturally competent. This resulted in the development of several key publications beginning in 1994 with Diagnostic Classification of Mental health and Developmental Disorders of Infancy and early Childhood DC:0-3, its revision DC:0-3R (ZERO TO THREE, 2005), and most recently DC:0-5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (ZERO TO THREE, 2016). The evolution of these publications, their contributions to the field and the expansion of our knowledge about young children’s mental health from birth to 5 years of age will be explored later in this chapter. It is considered best practice in infant and early childhood mental health to use a developmentally appropriate diagnostic system (DC0-5™) to organize the information gained from a comprehensive early childhood mental health assessment. Other chapters in this text have explored various approaches and types of assessment in the early years. The section of DC:0-5 Principles and Approaches to diagnosis provides a framework for diagnostic assessment of young children. Assessment can do much to help the clinician understand a child’s strengths, challenges, specific symptoms, individual profiles, relationship quality, developmental competence, health status, and more. Assessment emerges from a relationship with the child and family and shapes treatment directions and decisions. Assessment may identify mental health disorders. DC:0-5 is not an assessment tool. It is a classification framework for identifying and understanding the young child’s mental health and functioning. However, DC:0-5 does emphasize the importance of a comprehensive, multimodal assessment over multiple sessions (approximately 3–5 sessions). The developers of DC:0-5™ also emphasize the importance of ongoing assessment and frequent review of diagnostic presentations in these early years. The clinical processes of assessment, diagnosis and formulation will be addressed further in this chapter under DC:0-5 Principles and Approaches to Diagnosis. This review of DC:0-5 considers how assessment not only contributes to but is necessary for making a diagnosis. It may be helpful to outline some key definitions. First 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 255 the term “nosology” is defined as a naming or classification of diseases of disorders (Angold & Egger, 2009; Egger & Angold, 2006). To be meaningful, the nosology must reflect clear delineation of the boundaries between what is considered healthy and unhealthy, typical and atypical. The classification of a disorder summarizes what “it” is and has implications for how it presents and may be treated (Angold & Egger, 2009). The importance of having a categorical system to capture mental health disorders in infancy and early childhood does not diminish the importance of other dimensions of the child/family’s experience including relationships, social-emotional and other developmental competencies, physical conditions, psychosocial and environmental stressors, and culture. This is the rationale for the use of a multiaxial approach to diagnosis. A multiaxial approach provides an expanded and comprehensive perspective in assessing facets of the child’s life which would pertain to diagnosis and treatment of one or more clinical disorders. What is the definition of a disorder? A disorder is a syndrome characterized by a pattern of symptoms that have a specific level of intensity, frequency, and duration. Through implementation of diagnostic criteria, the clinician can understand emotional and behavioral patterns and decide if these patterns are within the typical or disordered/atypical level (Angold & Egger, 2009). There has been debate over whether mental health disorders are better understood categorically (e.g., making a diagnosis) or dimensionally (e.g., look at the range of symptoms without identifying a disorder) (Angold & Egger, 2009). The National Institute of Mental Health has developed the Research Domain Criteria (RDoC) which is a research framework for a dimensional approach to the investigation of mental health disorders (ZERO TO THREE, 2016; Egger & Emde, 2011). Dimensional and categorical approaches often helps understand the child’s symptom profile. Categorical approach rather than dimensional is needed to determine clinical “caseness” (e.g., does the child need treatment/services or not) (Angold & Egger, 2009; ZERO TO THREE, 2016). The goal of this chapter is to provide the clinician with historical and theoretical underpinnings of diagnostic classification in infancy and early childhood and review the approach, framework, and key content of DC:0-5™. This information is hoped to support the understanding and use of DC:0-5™ in clinical practice.

Acknowledging the Reality of Mental Health Disorders in Infancy and Early Childhood

“They’re only babies.” For many years mental health disorders in infants and very young children have been minimized or dismissed. The suffering of these children and their families has frequently gone unacknowledged, or has been seen only as a phase, or simply as a precursor (risk factors) for future mental health problems. The field of Infant and Early Childhood Mental Health (IECMH) has done much since the mid-twentieth century to bring to light the social and emotional life of the infant and young child while social sciences and medical fields have struggled to recognize, validate, and classify mental health symptoms and disorders in infancy and early childhood. Even without a diagnostic classification, families and professionals 256 K. Mulrooney et al. will categorize behavior as either developmentally typical or of concern which will result in decisions around whether the concern is sufficient to seek help (ZERO TO THREE Diagnostic Classification Task Force,2017 ). Without a developmentally sensitive, relationship-based and contextually driven classification system, children with atypical patterns of challenging behaviors or emotions are likely to be labeled with terms that have negative attributions such as “bad,” “wild,” “spoiled,” or “manipulative” and may be seen as “broken” or “undesirable.” Helping parents and professionals have a shared language that offers meaning rather than blame can help mitigate such stigmatizing language and attributions. Providing a nomenclature for clinical disorders in early childhood can provide validation and relief to parents and caregivers who have recognized problems but did not understand what it may be. ZERO TO THREE has led the field in articulating diagnostic classification systems for mental health disorders in infancy and early childhood through the three editions of its Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: DC:0-3, DC:0-3R, and DC:0-5. In 1987, ZERO TO THREE convened a task force led by Stanley Greenspan, M.D. and Serena Weider, Ph.D. to establish this pioneering effort in the field which resulted in the publication of DC:0-3 in 1994. DC:0-3 was a developmentally based approach to diagnostic classification in the first 4 years of life—birth through 3 years of age. The field of Infant and Early Childhood Mental Health (IECMH) was relatively young at that time so much of the content in this initial version was based on clinical input and perspectives rather than empirical data. The intent was to complement other diagnostic classification systems for older children and adults such as the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) and the International Classification of Diseases (World Health Organization). DC:0-3 was an important first step to define a valid and reliable psychiatric nosology for infants and toddlers (ZERO TO THREE, 1994). DC:0-3 took on a multiaxial approach that included five axes: • Axis I: Primary diagnosis. • Axis II: Relationship disorder classification. • Axis II: Medical and developmental disorders and conditions. • Axis IV: Psychosocial stressors. • Axis V: Functional emotional developmental level. As research in the field of IECMH expanded, ZERO TO THREE convened another task force to revise the initial DC:0-3 diagnostic classification system. This task force led by Robert Emde, M.D. resulted in the publication of DC:0-3R in 2005. After a decade of clinical use of DC:0-3 and growth of empirical research, it was time to revise and refine the classification. DC:0-3R incorporated new empirical findings and clinical consensus (ZERO TO THREE,2005 ). DC:0-3R expanded DC:0-3 making changes to some of the classification categories on Axis I where there was strong evidence to support such change (ZERO TO THREE, 2005). DC:0-3R maintained the multiaxial classification system established in DC:0-3 with slight revisions in the naming of the axes: • Axis I: Clinical disorders (rather than primary diagnosis). • Axis II: Relationship classification. 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 257

• Axis III: Medical and developmental disorders and conditions. • Axis IV: Psychosocial stressors • Axis V: Emotional and social functioning (rather than functional emotional developmental level) (ZERO TO THREE, 2005). In 2013, nearly 10 years after the release of DC:0-3R, ZERO TO THREE convened a third Diagnostic Classification Revision Task Force under the leadership of Charles Zeanah, M.D. to review and revise DC:0-3R. The task force consisted of nine members from various professional disciplines including psychiatry, psychology, pediatrics, nursing, social work and counseling and represented more than 100 years combined clinical and research experience. In 2013, the American Psychiatric Association also released the newly revised Diagnostic and Statistical Manual of Mental Disorders fifth edition, DSM-5. DSM-5 adopted a lifespan perspective across clinical disorders (though again this did not appear to generally represent iterations of diagnostic categories for infancy and early childhood), discontinued its multiaxial approach to diagnosis and incorporated greater content and tools around cultural formulation (American Psychiatric Association, 2013). This was an important opportunity for the field of IECMH to examine and update the approach toward diagnostic classification of mental health disorders in infancy and early childhood. The task force approached this revision in a very open manner—evaluating whether to maintain a multiaxial system; reviewing which clinical disorders should be kept, allowing for deletion of existing disorders which did not have empirical evidence and for including new disorders; and considering the age span to be covered by the revised nosology. The task force endeavored to create a diagnostic classification system which was comprehensive rather than complementary to DSM-5 or ICD-10.

TEXT BOX 8.1: The Key Revisions in DC:0-5™ Included the Following • Expansion of age range from birth through 3 years of age to birth through 5 years of age. • Extending criteria to younger ages whenever possible. • Maintaining a multiaxial approach to consider the child’s symptoms in the context of relationships, physical health conditions, psychosocial stressors, developmental competence all within the framework of cultural context. • Expanding clinical disorders in Axis I from 30 to 42 disorders organized under diagnostic categories with similar symptom clusters. • Including a diagnostic algorithm for each clinical disorder as well as text for each disorder. • Requiring distress and/or functional impairment for each clinical disorder. • Representing a free standing, comprehensive diagnostic classification system which Includes all mental health disorders relevant for infants/young children. • Greater focus and integration of cultural context throughout text. • Crosswalk to other nosologies included (DSM-5 and ICD-10). 258 K. Mulrooney et al.

The developers of DC:0-5 strove to create a diagnostic classification system which considered the perspectives of both clinicians and researchers. DC:0-5 was meant to reflect both the cautious, idealistic nature and experience of research, balanced by the pragmatic and real-world nature of clinical practice. The relationship between clinical practitioners and researchers Is bidirectional with both perspectives informing the other and together the field is moved forward. DC:0-5 is intended to be a diagnostic classification manual which is empirically derived, including disorders with solid research, and maintains a clinically meaningful perspective. The use of a nosology to adequately capture symptomatology in the early years rather than rely on classifications that were not intended for use in infancy and early childhood is an improvement in our approach toward understanding and intervening in the lives of very young children and their families. While mental health clinicians, pediatricians, and psychiatrists are treating and, in some cases, prescribing psychotropic medications for infants and preschool-aged children, they are frequently doing so without consensus about the best criteria for defining psychiatric disorders in very young children (Egger & Angold, 2006; Pine, 2002). DC:0-5 is the current diagnostic classification system that is best suited to provide the nosology and multiaxial perspective needed to understand and treat the infant/young children in the context of their key relationships.

DC:0-5 Principles and Approach to Diagnostic Classification

DC:0-5™ represents an effort to provide a classification system that addresses an expanded age group from birth to 5 years of age for whom there were not adequate comparable nosologies and to create a system that was empirically derived and clinically meaningful. ZERO TO THREE acknowledged another gap that had existed in the IECMH field due to the fact that DC:0-3 and DC:0-3R only described diagnosis for children birth through 3 years of age. Many clinicians were then either trying to apply these diagnoses up to preschool-aged children or were using other nosologies and “aging down” to preschool and earlier ages. By expanding the age range through 5 years of age, DC:0-5 provides a more comprehensive diagnostic classification system for infancy and early childhood mental health. Since research on infant and early childhood psychopathology is less robust than that of studies of psychopathology of older children and adults, the Task Force agreed to make every effort to use all available empirical evidence and to recognize that in some domains, the empirical evidence is still emerging. Therefore, in some cases, decisions to include new clinical disorders which may lack empirical evidence were made so as to align the system with clinical experiences and to foster research into these disorders. The focus of the revision was on refining the diagnostic classification system from DC:0-3R to DC:0-5, and not on prescribing clinical formulation or specific assessments. DC:0-5 is intended to be atheoretical, with the goal of providing descriptive criteria which may allow for assessments of reliability and validity 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 259

without being tied to specific theoretical ideology and constructs. DC:0-5 is aligned with the relationship-based and developmentally informed approaches reflected in the field of infant and early childhood mental health. The decision to maintain a multiaxial approach to diagnostic classification of mental health and developmental disorders reflects the special importance of context in understanding emotions and behavior in infants and young children. Likewise, the importance of understanding the very young child and their family in the context of culture was a critical element of this revision. The Diagnostic Classification Revision Task Force highlighted the fact that family cultural values, beliefs, and practices shape every aspect of the caregiving relationship and environment. In evaluating a child in infancy and early childhood, the clinician must take into account the family’s cultural background across a broad array of cultural domains including race, ethnicity, socioeconomic status, immigration experience, linguistic preference, gender, sexual orientation, religious/ spiritual practices, and other sources of diversity. Likewise, awareness of the clinician’s own cultural identity and background is key to understanding and minimizing potential bias in the diagnostic process. As in the prior DC:0-3 versions, the task force discussed the risks and benefits of providing diagnostic classification of mental health disorders. Risks such as labeling, stigma, changing developmental status of the child and limits of empirical evidence are things that need to be acknowledged and taken into account during evaluation. However, the purpose and potential benefits of diagnostic classification are also important to recognize and form the basis for the approach recommended by DC:0-5. The following describe the key benefits of having a diagnostic classification system for infancy and early childhood: • To use shared language (nosology) among professionals and families. • To guide treatment planning and intervention. • To provide access to service for young children and their families. • To seek authorization for treatment and reimbursement for services. • To support clinicians’ ability to enhance the intervention field’s knowledge around a disorder’s origination and development, course, and treatment outcomes through research. The diagnostic structures help to organize all of the information that is gathered. A principled, multiaxial approach to the diagnostic process is expected to result in an in-depth understanding of the young child’s emotional well-being, developmental functioning, physical health psychosocial stressors and supports, relational adaptations, and behavioral impairments and strengths. This is then as strong foundation for treatment planning, delivery, and outcome assessment. The DC:0-5 manual provides text and criteria to define clinical disorders and describe multiaxial dimensions which require extensive information gathering and assessment. Use of DC:0-5 is predicated on the expectation that the clinician must have developmentally specific assessment skills, experiences and training in eliciting and observing young child clinical information and interactions. The Task Force recommends that clinicians consider both the distinctions between assessment, 260 K. Mulrooney et al. diagnosis, and formulation and the important interactions between these processes. Consider the following definitions and distinctions: • Assessment: Process of gathering information from review of records, obtaining history from caregivers, and conducting informal and more structured observations of behavior. • Diagnosis: Identification and classification of specific infant/young child’s disorders. • Formulation: Way in which the infant/young child’s clinical presentation is understood in the context of the young child’s relationships, biology, social network, and developmental status (ZERO TO THREE, 2016, pp. 6–7). Comprehensive assessment guides differential diagnosis and clinical formulation. It is important to realize that it is not just about naming the disorder, but understanding how to assess changes in symptoms and presentation in order to know whether the child is improving with treatment based on our diagnosis. Diagnostic criteria then are not just for the beginning of treatment but are the foundation for all of treatment and understanding when treatment can end. To understand the existence of mental health disorder in infancy/early childhood, the clinician needs to be very familiar with the broad range of “typical” emotional and behavioral patterns in infancy and early childhood. It is with adequate knowledge of IECMH and early childhood development that the clinician considers those patterns that may signal mental health or developmental disorders. The clinician explores patterns rather than discrete examples of challenging emotions or behaviors. When assessing symptoms, the clinician does not simply identify a single instance, but rather patterns or presentations that are persistent, pervasive, and impairing. The symptoms are not typical for that infant/young child or are atypical for children of similar age/stage of development. They are pervasive across multiple settings, with multiple people and persist over time. Again these “red-flag” emotional or behavioral symptoms represent patterns that are outside of the wide range of age-appropriate or cultural norms (Parlakian & Siebel, 2002). Diagnostic assessments may include direct interaction and interview, as well as formal and informal observations and assessment measures. Direct interaction and interview should include clinician’s assessment of the primary caregiver, the infant/ young child, and additional caregivers. Clinicians should observe both the infant/ young child and the caregivers both together and apart. Observation of family functioning is recommended. Clinicians should likewise note how the infant/young child and parent dyad interacts with the clinician and the clinical setting. Throughout the assessment process, the clinician should be maintaining an awareness of his or her own subjective reactions and using those responses as clinical information in the diagnostic process. This self-awareness can be supported through reflective practice and clinical supervision. Reflective practice has been described in a number of ways, and speaks to the fact that work with infants and young children evokes strong emotions that cannot go unexamined. One definition notes reflective supervision as the process of examining, with one’s supervisor or colleagues, the thoughts, feelings, and reactions evoked in working closely with infants, young children and their 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 261 families (Eggbeer, Mann, & Seibel, 2007). Reflection is the process of stepping back, slowing down and examining what is occurring in the relationship. Reflective practice allows clinicians to be fully present in their interactions with very young children and their families by being mindful and aware of not only the behaviors and interactions they are witnessing but their own reactions and associations. Clinicians are encouraged to be reflective in the presence of the child/family but also to set aside time to reflect on their experiences after they have occurred. Self- reflection is important but reflective practice and reflective supervision are meant to be practices in which a clinician shares reflection with a trusted supervisor or colleague(s). A key concept in reflective practice is that of parallel process which is the examination of how experiences in one relationship impacts on experiences in other relationships. The DC:0-5™ manual presents five axes, starting with Axis I: Clinical disorders and ending with Axis V: Developmental competencies. In DC:0-5 training efforts, ZERO TO THREE has encouraged clinician participants to develop their diagnostic summary by first considering and articulating impressions for axes III (physical conditions and considerations), IV (psychosocial stressors), and V (developmental competence) before noting Axis II: Relational context and Axis I: Clinical disorders. The diagnostic process must include all five axes to result in an in-depth understanding of the young child’s functioning, strengths, and impairments. Diagnostic classification resulting from this multiaxial approach is then used to develop case formulation and planning.

The Contextual Framework: Cultural Context and Impressions on Axis III, Axis IV, Axis V, and Axis II

Cultural Context

Cultural values, beliefs and assumptions are the context for all infant/young child’s behavior and emotional expression as well as the parent/caregiver’s interaction with the young child including expressions of nurturance and love, expectations for the child, and ideas and practices around discipline. They shape such behaviors as where the baby shall sleep, how the baby is held and carried and when the young child is ready for toilet training or self-feeding. Because cultural beliefs and practices are so prominent in the life of the young child and their family relationships, it is imperative that diagnosis must take into consideration an understanding of the family’s cultural background including not only race and ethnicity but socioeconomic conditions, linguistic preferences, gender, sexual orientation, religious and spiritual practices, immigration status and other forms of diversity (see Chap. 2). In addition to consideration of the child and family’s cultural reference groups, the clinician must also maintain personal cultural awareness and awareness of how cultural similarities and difference between the clinician and the young child and 262 K. Mulrooney et al. their family can impact on the diagnostic process. Not only is attention to the issue of culture is key to having a better understanding of the child and family behaviors, emotional patterns and relationships, but it is also critical to minimizing implicit or explicit bias in diagnosis. Mainstream clinical attitudes, practices, and policies may or may not be aligned with those of the family’s cultural context. The clinicians view for example of what is “normal” may differ from that of the family’s or beliefs around best parenting practices can differ from what is typical in some cultural groups or family traditions. For example, expecting eye contact as a way of engaging with the infant may not be typical in cultures where eye contact between child and adult is considered disrespectful. Similarly, in the USA, parents are encouraged to have their babies sleep in a separate space such as a crib or bassinet, where co- sleeping may be more common in other cultures. Some behaviors and interactions might be misconstrued as pathological if not understood in the context of cultural norms, beliefs, and practices. On the other hand, there is a danger that efforts to be culturally sensitive might also result in cultural relativism, reducing understanding of cultural groups to stereotypes or overlooking the risks or damages to the infant/ young child as a result of culturally sanctioned practices (i.e., harsh discipline, oppression based on gender). DC:0-5 acknowledges the complexity of incorporating cultural considerations in the diagnostic process and appreciates this as an effort that unfolds over time. There can be a great deal of heterogeneity within any cultural group and many families represent a mix of diverse cultural backgrounds and identities. “Cultural considerations must honor the dynamic nature of cultures as well as the individual family member’s complex adaptation to the multiple contexts in which they operate.” (ZERO TO THREE, 2016, pp. 9–10). Throughout the DC:0-5 manual, starting in introduction with the inclusion of a table, Cultural Formulation for Use with Infants and Toddlers, and continuing throughout the text are reminders for the clinician to consider cultural implications on each of the axes. In Axis I, each clinical disorder includes text on cultural-related diagnostic issues. In the section on Cultural Formulation for Use with Infants and Toddlers Table, which was created and used with permission by Sarche et al. (2016) the following outline is provided to clinicians to assist in arriving at an overall cultural formulation for the infant/young child’s diagnosis and care. Clinicians are encouraged to consider the following domains: 1. Cultural identity of the individual: This section provides the clinician with guidance in considering the cultural identity of the child and their caregivers such as noting, for example, the ethnic or cultural reference group for the child’s parent, how the parents or caregiver’s intend to raise the child with respect to their own cultural reference group or whether there might be issues around multicultural experiences for the child and family. 2. Cultural conceptualization of distress: This section helps the clinician with accessing and understanding cultural explanations of the child’s presenting problems. The clinician is advised, for example, to note in this section whether the 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 263

problem was first noticed by a family member or by other sources and whether there is any conflict between primary caregivers’ awareness and that of extended family or outside providers. Clinicians should explore what the expectations for behavior or development of the young child might be in the cultural group/community as well as beliefs about help-seeking or treatment. 3. Psychosocial stressors and cultural features of vulnerability and resilience: This section guides the clinician’s exploration of cultural factors related to the child’s psychosocial and caregiving environments including the infant’s life space and environment (i.e., physical life space, community factors, and home factors such as who resides in the home) and the infant’s caregiving network. In assessing the caregiving network, the clinician would consider primary and secondary caregivers and not significant continuities or disruptions in the child’s caregiving network. 4. Cultural features of the relationship between the individual and the clinician: The table provides guidance for the clinician in considering the cultural elements of their relationship with the family, especially any differences in culture and social status between the child’s parents or primary caregivers and the clinician. Previous experiences with service systems and the family’s inclination or disin- clinations towards help seeking would be explored here as well (ZERO TO THREE, 2016, pp. 10–12). In considering diagnostic impressions on the contextual axes and Axis I: Clinical disorders, attention to culture and awareness of one’s own cultural lens must be considered in arriving at meaningful and accurate diagnoses.

Axis III (Physical Conditions and Considerations)

Axis III assumes that all aspects of the infant’s/young child’s lives are interrelated especially physical health, mental health and development. Axis III focuses on physical health condition and considerations noting that these overlaps and interact substantially with mental health and that these conditions are likely to influence the overall clinical presentation. Especially for pre-verbal and nonverbal children, behaviors may be primary expressions of physical experiences. A full diagnostic assessment then of the infant/young child needs to include attention to physical health and physical conditions in addition to emotional, relational, environmental, developmental, and cultural factors. The clinician must be aware of direct and indirect influence of physical conditions on mental health. Physical illnesses can directly affect development and mental health. Examples of how physical health conditions may have a direct effect include elevated lead levels affecting cognitive development and mood (e.g., irritability) or pain or medications may contribute to sleep issues and behavioral difficulties. Awareness of physiologic effects of exposure to toxins or medications, central 264 K. Mulrooney et al. nervous system insults, genetic syndromes or effects of physical symptoms such as pain or respiratory distress may have impact on emotional expression, sleep, and feeding patterns. It is also important that clinicians be aware of significant pregnancy and perinatal complication which may have direct or indirect influences on the child’s mental health and development. Physical health can affect the infant/young child’s mental health indirectly as well. Physical illness can have indirect impacts such as attachment issues due to multiple separations with caregivers over the course of an extended illness and developmental delays or social-emotional difficulties because of limitations imposed on them by a physical condition. Parental perception of vulnerability because of a child’s illness or condition can also affect development and impact on the primary caregiving relationship. Some health conditions may also reflect characteristics of the caregiving environment such as parental exposure to alcohol or substances or repeated injuries which may reflect maltreatment or neglect. Awareness of diagnosis is going to be based on parent report, medical diagnoses obtained through testing, examination of qualified specialists or through medical records. Parents may describe medical conditions in terms that are not necessarily technically accurate (i.e., water on brain) however, their descriptions can be reported as such on Axis III. Axis II should be used to note those physical health conditions and considerations not included on Axis I. The DC:0-5 manual includes a sample list of conditions across several health domains (representative but not exhaustive examples) including prenatal conditions and exposures, chronic medical conditions, acute medical conditions, history of procedures, recurrent or chronic pain, physical injuries or exposures reflective of the caregiving environment, medication effects, and markers of health (ZERO TO THREE, 2016). The clinician, after gathering information from a variety of sources would compile relevant and key examples of physical conditions and considerations from these health domains on Axis III in the diagnostic summary.

Axis IV (Psychosocial Stressors)

Axis IV provides a framework for identifying and describing psychosocial and environmental stressors and strengths. Psychosocial stressors may influence the presentation, course, treatment and prevention of mental health disorders. Research has demonstrated that stressors often co-occur and it is the number of stressors/risk factors rather than the type of the specific risk factor that is generally most significant (Felitti et al., 1998; Rutter, 1993). Psychosocial stressors may include both acute events and chronic stressors and circumstances. Similar to what was considered in Axis III: Physical considerations, stress might also be experiences as direct or indirect. Axis III outlines several categories of stressors with examples 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 265

(non-exhaustive) in each category to guide the clinician’s considerations of the child/family’s stressors. These categories include the following: • Challenges within the infant’s/young child’s family/primary support group. • Challenges in the social environment. • Educational/child care challenges. • Housing challenges. • Economic and employment challenges. • Infant/young child health. • Legal/criminal justice challenges. • Other. These categories are organized in a table which is meant to provide the clinician with a broad view of potential stressors, but is intended to be garnered over time and not used as a checklist or survey. The impact of these stressors is best understood within the context of the severity of a stressor (intensity, duration, and predictability), the developmental level of the infant/young child, and the availability of adults in the caregiving environment to serve as protective buffers and help the child cope with the stressor, contributing to resilience. The Psychosocial and Environmental Stressor Checklist is organized by category with examples under each and columns to note age of onset and comments including duration and severity. The checklist and the tables in the manual can be downloaded and printed for use with each young child/ family. However, these are for the purpose of supporting the clinician in terms of organizing their information, gleaned from observations, tests and assessment measures, and collateral reports and information. They are not meant to be used as assessment tools themselves and do not represent standardized assessment measures. Impressions of psychosocial stressors are listed in the diagnostic summary on Axis IV in a brief narrative format noting not only stressors, but protective factors as well.

Axis V (Developmental Competence)

Emotional and social capacities are present from birth and contribute to the foundation of all domains of development. Axis V uses an integrative model for understanding the infant’s/young child’s developmental competence across multiple key domains of development including emotional, social-relational, language-social communication, cognitive, movement, and physical development. Axis V helps the clinician articulate their understanding of the manner in which the young child integrates competencies in and across these different developmental domains and consider the child’s developmental profile in informing clinical diagnostic formulations. DC:0-5 manual provides two tables to help organize the clinician’s information and impressions around Axis V: Developmental competence. The first is a Competency Domain Rating Summary Table. 266 K. Mulrooney et al.

Competency domain rating summary table Competency domain Social Language-social Movement rating Emotional relational communication Cognitive and physical Exceeds developmental expectations Functions at age- appropriate level Competencies are inconsistently present or emering Not meeting developmental expectations (delay or deviance) Copyright © 2016 ZERO TO THREE. All rights reserved

The clinician gathers evidence of the young child’s developmental capacities across all the domains through a comprehensive assessment which could include several of the following: clinician observations/interviews, parent report, developmental screening (such as ASQ-SE), developmental testing (such as Bayley Scales of Development or WPPSI), or other collateral reports. The clinician could also refer to the Developmental Milestones and competency Ratings Table (outlined in Appendix A of the DC:0-5 manual) as a general resource for rating competencies in the different domains using milestone examples in each domain across the developmental range of birth through 5 years of age. The table is organized by milestone that would be expected by 3 months, by 6 months, by 9 months, etc. through to age 5. Based on all this data collection, the clinician uses the Competency Domain Rating Summary Table to note whether the young child: exceeded developmental expectations, functions at age-appropriate level, has competencies which are insis- tently present or emerging or is not meeting developmental expectations (delay or deviance) across each of the domain categories. The clinician will be looking for consistency or unevenness in competencies across domains and will provide an overall Axis V formulation based on the ratings and patterns of competencies assessed. This impression will highlight relative strengths and concerns, and also note any recent changes in competence in any of the domain areas.

Axis II: Relational Context

This axis is one that has undergone substantial revision in the latest diagnostic classification DC:0–5. The scales in Axis II require the clinician to examine the adaptive qualities of the infant/young child–caregiver(s) relationship(s) as well as the relationships within the caregiving environment. Axis II is needed to understand the broad landscape of the child’s relationships and is meant to characterize the adaptive quality of these relationships. Ratings on this axis allow the clinician to 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 267 understand the key dyadic relationships in which the child is involved as well as the child’s caregiving environment. The ratings, which will be detailed later, indicate whether the relationships may range from those which do not require clinical attention to those which are at risk to those which are indicative of clinical levels of disturbances. Assessing the relational context within which the young child develops is a critical part of any diagnostic assessment. Note that the ratings on Axis II are not equivalent with the classification of a relationship-specific disorder on Axis I. Not all children, even those with Axis II relationship adaptation ratings in the clinical range will have symptoms consistent with the criteria for relationship- specific disorder. This will be discussed further when this disorder is presented in Axis I descriptions. It is within the primary caregiving relationships that the young child develops their sense of what to expect from the world and relationships and is the context in which the young child’s development occurs. The child is likely to form relationships with several key adults (i.e., parents, key extended family, or child care providers) and it is important that the clinician assess the nature, quality and adaptive capacity of each key relationship that the child has with each parent or primary caregivers. Axis II considers the contributions of not only the caregiver in understanding the child–caregiver relationship dimension but also the contributions of the infant/young child. One of the areas of expansion for Axis II has been to consider the context of the child-caregiving environment. The caregiving environment is meant to reflect the child in the context of family which could be relatives related by blood, non-blood kin and significant relations, persons in the same home or across different homes, and may be best understood as the web of caregiving relationships that surround the child. Axis II then consists of two parts: Part A—the Caregiver–Infant/Young Child Adaptations and Part B—the Caregiving Environment and Infant/Young child Adaptation. The manual provides two tables to organize the clinician’s impressions on the Caregiver–Infant/Young Child Relationship Adaptation which are to be used by trained infant and early childhood mental health professionals in clinical settings. The first is the Dimensions of Caregiving Table which outlines 14 key caregiving dimensions including such examples as ensuring physical safety, recognizing and responding to the infant’s/young child’s emotional needs and signals, providing comfort for distress, disciplining, and showing interest in the young child’s individual experiences and perspectives. The overarching caregiving characteristics captured by this table include three main dimensions: 1. Caregiver’s consistency in emotional availability. This requires monitoring the infant/young child, reading cues, and responding sensitively and effectively. 2. Caregiver’s knowing and valuing the infant/young child as a unique individual. 3. Caregiver’s consistency in demonstrating comfort and competence in being in charge of raising the young child. This overlaps with emotional availability, but highlights the importance of setting aside one’s own needs to meet the needs of the infant/young child. 268 K. Mulrooney et al.

This table is meant to provide some structure and guidance to organize information that has been gathered over at least 3–5 sessions that may include observations of the parent–child interactions, parental attitudes and attributions about the child’s problems, structured assessment measures, naturalistic observations, and unstructured interviews and observations. The second table in Part A is the Infant’s/Young Child’s Contributions to the Relationship and considers seven child characteristics including temperament, sensory profile, physical health, and developmental status. In organizing these caregiver and child contributions to arrive at levels of adaptive functioning for the caregiving dimension, the clinician is focusing on the relationship itself—not rating either the caregiver or the infant/young child behavior alone. In both tables, the clinician would note whether they found the characteristics listed as “strength,” “not a concern,” or “concern.” The tables are not standardized assessment tools. Each of the items reflected in these tables contributes to the clinicians’ assessment of the relationships, but there are no minimum number of concerning items that correspond to a specific rating of the level of relationship adaptation. Also, the levels of adaptation represent ordinal scales rather than single point or equidistant points. Cultural context should be considered in all relational adaptation ratings. After organizing information about the caregiving dimensions and child’s contributions, the clinician will move to rate the Levels of Adaptive Functioning— Caregiving Dimension. The clinician will use the information found from the interviews, observations and assessments organized in Tables 1 and 2 (not included herein; refer to DC0-5 manual, ZERO TO THREE, 2016) to determine which of the following four levels best characterizes the caregiver–infant/young child relationship: Level 1: Well Adapted to Good Enough Relationships—these relationships do not demonstrate clinical concern and reflect adequate to exemplary relationships. Level 2: Strained to Concerning Relationships—these relationships have some adaptive qualities but some worrisome patterns in the relationship are emerging and they may require careful monitoring or possibly some intervention. Level 3: Compromised to Disturbed Relationships—these relationships are clearly in the range of clinical concern and require intervention. Relationship has very limited adaptive qualities and reflects inappropriate levels of risk, conflict, and poor engagement. Level 4: Disordered to Dangerous Relationships—these relationships convey urgency for response due to existing or potential safety issues. Adaptive qualities are lacking and relationship pathology is severe. If the young child is in potential danger, clinicians must act as required by local regulations and professional standards including possibly mandated reporting to child protective services. However, a rating of Level 4 does not imply that a mandated report must be made. Also, this rating would be made based on qualities evident during the diagnostic assessment, not only on prior history (ZERO TO THREE, 2016). It is incumbent on the clinician to attempt to assess the relationships that the child has with each of their primary caregivers when possible, not limiting to just one parent or guardian. There is evidence to support what is termed relationship 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 269 specificity (Sameroff & Emde, 1989; Stern, 1985; Zeanah & Lieberman, 2016), the notion that a child can have different types of relationships with different caregivers. Understanding the nature of the range of relationships that the child has and the adaptive qualities of these individual dyadic relationships becomes key to arriving at a multiaxial diagnosis and considering treatment implications. The clinician rates each child–caregiver relationship and notes which level rating described that relationship and key characteristics of the relationship. In approaching Part B of Axis II, the Caregiving Environment and Infant/Young Child Adaptation, the premise is that it is the stability and emotional quality of the adult caregiving relationships in the child’s caregiving environment that are predictive of the young child’s functioning. The caregiving environment should reflect both the infant/young child’s relationship with different caregivers in their primary caregiving environment and the caregivers’ cooperative coordination of their goals, values, and actions. Affective tone in the caregiving environment and adult interactions influence the young child’s emotional regulation, development of trust and contribute to their freedom to explore and learn. Stability, predictability and emotional regulation contribute to the functioning of the infant/young child. Infants/ young children develop important relationships with their primary caregivers and other family members who participate in coparenting or affect the young child’s functioning. In exploring the caregiving environment, we understand that young children are keen observers of how adults relate to one another, to others and to children. They use these observations to navigate their roles/behaviors in the caregiving environment. They often learn by imitation and adopt behaviors and emotional patterns they observe. Clinicians use the caregiving dimensions described in Table 3 (not included herein; refer to DC0-5 manual, ZERO TO THREE, 2016): Dimensions of the Caregiving Environment in the DC:0-5 manual to rate whether the following contributions to the relationship quality of the caregiving environment is a “strength,” “not a concern,” or “concern.” • Problem-solving. • Conflict resolution. • Caregiving role allocation. • Caregiving communication: instrumental. • Caregiving communication: emotional. • Emotional investment. • Behavioral regulation and coordination. • Sibling harmony. These qualities map nicely to the McMaster Family Assessment Device which is a 60 item self-report survey that is consistent with the McMaster Family Model (Epstein, Baldwin, & Bishop, 1983) and with the family systems and co-parenting concepts described by Dr. James McHale (McHale & Rasmussen, 1998). No minimum number of concerning items translates into a specific rating of a Level of Caregiving Environment and Infant/Young Child Adaptation. Dimensions of the caregiving environment are highly subject to differences within different cultures 270 K. Mulrooney et al. and subcultures. Therefore, clinicians are encouraged to consider carefully the family cultural values, traditions, and practices, striking a balance between understanding and accepting cultural variations of caregiving environments and intervening to support the young child’s development. The Caregiving Environment and Infant/Young Child Adaptation summary consists of the same four level rating system used for the Caregiver–Infant/Young Child Relationship Adaptation ranging from Level I (well adapted to good-enough caregiving environment) to Level 4 (Disordered to dangerous caregiving environment) but the descriptions of each level rating are adapted to the overall functioning of the caregiving environment versus individual relationships. Level I: Well adapted to good enough caregiving relationships, for example, would describe caregiving environment as having occasional ups and downs but caregivers who demonstrate a solid repertoire of problem-solving strategies and experience mutually satisfying allocations of caregiving roles. The infant/young child in this type of caregiving environment relational context shows comfort and ease in interacting with the different caregivers in this constellation. At Level 2, the clinician would observe increased signs of conflict and worrisome patterns regarding the caregiver’s coordination regarding the upbringing of the infant/young child. The young child in this family constellation may experience distress around negotiating interactions with different caregivers. Ratings of Level 3 and 4 reflect relationships in the caregiving environment that are in the clinical range and where there are concerns such as role allocation, emotional availability and regulation and mutual support in responding to the infant’s/young child’s needs. The child’s social and emotional development is compromised or at risk of compromise and intervention is decisively needed. Similarly, the clinician records impressions of the caregiving environment in the diagnostic summary by describing the level of adaptation and specifying some of the critical concerns and strengths.

Diagnosing Mental Health and Developmental Disorders: Axis I Clinical Disorders

After carefully considering all the information and impressions provided through the contextual axes, the clinician is prepared to consider the symptom picture with context in approaching diagnosis of clinical disorders using Axis I. When thinking about diagnosis, it is important to reconsider an earlier comment that “we diagnosis disorders, not children.” The child is not their disorder, but the child’s symptoms, which are intense, persistent, pervasive, and impairing, may cluster in such a way that we are able to apply a diagnostic nosology. In a response to a World Association of Infant Mental Health (WAIMH) Perspectives article entitled “Should we diagnose babies?” (Von Klitzing, 2017) the diagnostic revision task force for DC:0-5 published the following statement: It is precisely because of the complex interactions among multiple aspects of a child’s life that we elected to retain five axes in DC:0-5, facilitating a clinical formulation that puts 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 271

these pieces together, identifies the relations among the 5-axial characterization of the child and his/her environment, and focuses on those aspects of the family system that seem most modifiable…. In a child with hyperactivity, treatment with parent-child therapy may only lead to improvement if the child’s elevated lead level is identified as a causal factor and housing conditions are addressed through lead abatement or relocation. While acknowledging the limitations of a categorical diagnostic system, we believe that considering all five axes of DC:0-5 should facilitate rather than preclude attention to the dynamic processes that affect a child’s emotions and behaviors (ZERO TO THREE Diagnostic Classification Task Force, 2017). DC:0-5 clustered clinical disorders according to eight diagnostic categories, similar to the organization of clinical disorders in DSM-5. These eight categories are as follows: • Neurodevelopmental disorders. • Sensory processing disorders. • Anxiety disorders. • Mood disorders. • Obsessive compulsive and related disorders. • Sleep, eating, and crying disorders. • Trauma, stress, and deprivation disorders. • Relationship disorders. In addition to considering the cultural and contextual dimensions of the diagnostic formulation, the clinician should begin their Axis I impressions with a trauma- informed lens, considering whether there has been exposure to trauma, or significant deprivation or loss in the young child’s life. Each category includes several clinical disorders with the exception of relationship disorders category which includes only one disorder. Relationship-specific disorder is a new disorder to this classification system and the field. All the other categories also include the designation of an “other” disorder, such as other neurodevelopmental disorder or other mood disorder. Many of the disorders which are new to DC:0-5 have been used in DSM but are now being included in DC:0-5 since it is a comprehensive system. Examples of these disorders include Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Posttraumatic Stress Disorder, and others. Several new disorders have been configured and named in DC:0-5, and these include Early Atypical Autism Spectrum Disorder, Overactivity Disorder of Toddlerhood, Sensory Over-Responsivity Disorder, Sensory Under-Responsivity Disorder, Inhibition to Novelty Disorder, Disorder of Dysregulated Anger and Aggression, and Relationship-Specific Disorder. Table 8.1 lists the disorders in each of the diagnostic categories and the case vignette will highlight one of the new disorders, Disorder of Dysregulated Anger and Aggression (DDAA) later in this chapter. There is consistency in providing text and relevant information for each clinical disorder in the DC:0-5 manual. Most disorders include the following information as part of the text description to better assist the clinician in understanding all of the criteria, associated features and issues of differential diagnosis and comorbidity for 272 K. Mulrooney et al.

Table 8.1 Axis I: clinical disorders Diagnostic Diagnostic category Clinical disorders category Clinical disorders Neurodevelopmental Autism spectrum disorder Sleep eating and disorders crying disorders Early atypical autism Sleep disorders Sleep-onset disorder spectrum disorder Attention Deficit Night waking disorder Hyperactivity disorder Overactivity disorder of Partial arousal sleep toddlerhood disorder Global developmental Nightmare disorder of delay early childhood Developmental language Eating disorders Overeating disorder disorder of infancy/early childhood Developmental Undereating disorder coordination disorder Other neurodevelopmental Atypical eating disorder of infancy/early disorder childhood Sensory processing Sensory over-responsivity Crying disorder Excessive crying disorders disorder of infancy/early disorder childhood Sensory under- Other sleep, eating, responsivity disorder and excessive crying disorder of infancy/ early childhood Other sensory processing Trauma, stress, Posttraumatic stress disorder and deprivation disorder disorders Anxiety disorders Separation anxiety Adjustment disorder disorder Social anxiety disorder Complicated grief disorder of infancy/ early childhood Generalized anxiety Reactive attachment disorder disorder Selective mutism Disinhibited social engagement disorder Inhibition to novelty Other trauma, stress and deprivation disorder of infancy/ early childhood Other anxiety disorder of Relationship Relationship-specific infancy/early childhood disorders disorder of infancy/ early childhood (continued) 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 273

Table 8.1 (continued) Diagnostic Diagnostic category Clinical disorders category Clinical disorders Mood disorders Depressive disorder of early childhood Disorder of dysregulated anger and aggression of early childhood Other mood disorder of early childhood Obsessive compulsive Obsessive compulsive and related disorders disorder Tourette’s disorder Motor or vocal tic disorder Trichotillomania Skin picking disorder Other obsessive compulsive and related disorder these diagnoses. The following items are included in most of the disorders included in DC:0-5: • Introduction—Provides an overview of the diagnosis. • Diagnostic algorithm—Lists the criteria that need to be met, including impairment criteria. • Age—Provides the minimum or maximum age that the diagnosis can apply to, if there is one. • Duration—Lists the minimal length of time symptoms need to be exhibited to receive the diagnosis. • Diagnostic and associated features—Highlights key features of the disorder which the clinician should be considering. • Developmental features—Describes variations in expected developmental trajectories. • Culture-related and gender-related diagnostic issues—Provides expanded descriptions and examples of cultural and gender-related issues around the disorder diagnosis, providing depth and further context of diagnostic considerations. • Differential diagnosis—Describes other diagnostic considerations that should be considered and/or ruled out before diagnosing a disorder. • Comorbidity—Provides diagnostic considerations that commonly coexist with the disorder. • Links to DSM-5 and ICD-10—Briefly describes the relationship to same or similar disorder names/codes in these other nosologies or notes significant differences. ZERO TO THREE has created a universal crosswalk of each of the clinical disorders with similar classifications in DSM-5 and ICD-10 which can be found athttps:// www.zerotothree.org/resources/1540-crosswalk-from-dc-0-5-to-dsm-5-and-icd-10. 274 K. Mulrooney et al.

The descriptions of the disorders and the criteria listed in the diagnostic algorithms include language and examples of how one might see these symptoms in infants and/or young children. Criteria in many cases are set based on empirical evidence around thresholds for clinical significance. Again, diagnosis must consider knowledge of what is developmentally and culturally normative and consider the contextual factors in the child and family’s life. Axis I includes descriptions of 42 clinical disorders. In the following section, one of the new clinical disorders will be highlighted: Disorder of Dysregulated Anger and Aggression (DDAA) will be described in depth as a working example of an Axis I clinical disorder.

DDAA: Mood Disorder vs. Behavioral Disorder

One of the new disorders introduced through this new nosology is Disorder of Dysregulated Anger and Aggression (DDAA). A central task of early childhood is to develop capacities to regulate emotions and behavior. Preschoolers often have difficulty managing anger and frustration, frequently responding to limits, frustra- tions or disappointment with defiance or temper tantrums. The rate that these emotions and behaviors occur are typically higher than what we would expect in older children. However, failure to develop age appropriate capacities for emotional and behavioral are associated with impairment and psychopathology. DDAA describes the experience of a subset of young children (24 months through 5 years of age) who struggle to develop the capacity for emotional and behavioral regulation that would be developmentally expected. These patterns of emotional dysregulation (anger and chronic irritability) as well as behavioral dysregulation (aggression, tantrums) are intense, pervasive, and impairing. The key symptoms of irritability and aggression are seen in other disorders as well such as autism, depression, and ADHD and thus symptoms, not the disorder itself. DC:0–5 does not include Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) as they focus only on those specific symptoms of defiance or behavior problems but do not emphasize the child’s concurrent emotional dysregulation. Moreover, diagnosis of ODD in early childhood has been shown to predict anxiety and mood disorders in school aged children and adolescents, better than disruptive behavior disorder (Copeland et al., 2013; Tseng et al., 2015; Wakschlag et al., 2012). Children with oppositional patterns of behavior are at higher risk of internalizing and externalizing psychopathology later in life (Wakschlag et al., 2012). Children’s aggressions can be reactive (responding aggressively when frightened, threatened, etc.) or proactive (the child initiates fights, and is coercive, hurtful), or both and these patterns of aggression seem to increase risk for different outcomes. Reactive aggression increases a child’s risk for emotional disorders, whereas proactive aggression may increase risk for conduct problems. In DDAA, emotional dysregulation is as important as the co-occurring behavioral dysregulation. Accounting for co-occurring emotional and behavioral dysregulations has implications for treatment and for understanding the child’s 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 275 experiences. Rather than solely viewing the child through the lens of oppositionality and defiance, this disorder provides an opportunity to understand the young child’s emotional experience and target interventions in a more accurate and nuanced way. The diagnostic algorithm in DC:0-5 (ZERO TO THREE, 2016, pp. 71–72) is based on epidemiological studies or preschool children where cut points are set based on the distribution of symptoms and their frequency in representative populations of preschool aged children. This data-driven approach enables the identification of the top 10% of children. When guessing or inferring numbers from clinical practice there is a risk of overpathologizing age appropriate capacities and behaviors. The symptoms must be seen as persistent (present for at least 3 months) and pervasive (occurring in more than one relationship, context, or setting). This also reduces the risk of overidentifying psychopathology in young children. Below is the outline of the diagnostic algorithm for DDAA.

Diagnostic Algorithm

All of the following criteria must be met. A. The young child demonstrates a pervasive and persistent pattern of mood and behavioral dysregulation as manifested by any three symptoms from any of the four clusters: 1. Substantial anger and temper dysregulation. • Dysregulation of affect presenting as irritability. • Anger is the dysregulated emotion. • Symptoms: quick to anger, intense temper outbursts, difficulty calming down, verbally or physically aggressive toward self or others in response to frustration and/or limit setting. 2. Noncompliance and rule breaking. Symptoms: Argues, defies, does not follow routine directions, breaks rules with adult watching, and taking things from others. 3. Reactive aggression (substantial aggression when angry, upset, or scared/ under threat) Symptoms: Hits, bites, kicks or throws things at caregiver and/or other children, breaks things on purpose. 4. Proactive Aggression Symptoms: Coercive and controlling in play with peers, intentionally cruel or hurtful, frightens others, starts physical fights, and uses objects to threaten or harm others. B. Symptoms must be present in more than one setting or in more than one relationship. 276 K. Mulrooney et al.

C. The symptoms are not better explained by another Axis I disorder. D. Symptoms of the disorder, or caregiver accommodations in response to the symptoms, significantly affect the young child’s and family’s functioning. Age: At least 24 months. Durations: Symptoms must be present for at least 3 months. Specify: 1. Presence of limited prosocial behaviors and emotions demonstrated by at least two of the following: patterns present for at least 3 months, lack of observable remorse or guilt, lack of observable empathy, lack of observable concern about performance. 2. Aggression type; none, predominantly reactive, predominantly proactive, or combined proactive/reactive (ZERO TO THREE, 2016, pp. 71–72). DC:0-5 summarizes the broad differential diagnosis of children who present with the emotional and behavioral dysregulation that might be DDAA. In the process of differential diagnosis, one needs to assess whether the child’s symptoms represent typical development or whether they are present in a specific relationship suggesting a relationship-specific disorder. Other disorders to be considered in differential diagnosis include depression, generalized anxiety disorder, and Posttraumatic Stress Disorder (PTSD). Clinicians must also consider sleep problems or sleep disorders. Developmental competencies and processes must also be considered such as language delays and disorders, hearing impairment, and disorders such as Autism Spectrum Disorder or Sensory Over-responsivity Disorder. Similarly, a review of any pediatric medications which may contribute to dysregulation, including (but not limited to) oral or inhaled steroids, inhaled beta-adrenergic agonists (i.e., albuterol), and antihistamines, is necessary.

Case Report: The Following Is a Case Report that Indicates the Components to Arrive at a Diagnostic Summary Using DC:0-5

NAME: Emma. DATE OF BIRTH: 08/02/2012. DATE OF EVALUATION: 09/16/2015

Reason for Referral

Emma is a 3-year-old Caucasian female presenting with severe temper outbursts. Emma’s parents sought out the current evaluation for a second opinion after a previous private evaluator gave them feedback that she met criteria for Attention-deficit 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 277

Hyperactivity Disorder, Oppositional Defiant Disorder, and Obsessive-Compulsive Disorder. Parents had questions about these diagnoses given Emma’s age and wished to clarify diagnosis as well as recommendations for treatment. Current concerns include frequent and severe temper tantrums, physical aggression including biting her father, and problems cooperating and listening to adult requests.

History of Presenting Problem

Parents noticed concerns about distractibility and self-regulation since infancy. Her mother found breastfeeding hard due to Emma’s difficulty remaining focused on eating. Further, her difficulty self-soothing led to an unsuccessful attempt at sleep training at 9 months of age when she cried for hours, prompting parents to stop sleep training due to worry that she would throw up. Tantrums started slightly before age 2 often when she was told “no” or asked to do something she did not want to do. During tantrums, she sometimes bites her father, urinates on the floor, and throws toys. Tantrums occur daily and sometimes multiple times a day and can last half an hour or longer. Additionally, she will often insist on things being done a certain way including insisting which parent helps her with a task and will tell her mother that she’s a “bad mommy” when upset. At school, severe temper outbursts are less common. She often refuses to comply with teacher directives and is very distractible at school unless given more support to stay engaged. In response to redirection, she often shuts down or ignores the teachers. Teachers have also reduced demands on Emma to participate in cleanup and less preferred tasks to reduce outbursts. She has been aggressive on occasion with peers in reaction to disputes over toys or seating. This happens infrequently.

Developmental History

Emma was born full term weighing 6 lb and 12 oz. with no complications during birth or neonatal period. She met her developmental milestones for crawling, walking, toileting, and speech within normal timeframes. Current motor weakness has been noted in occupational Therapy and physical therapy evaluations for both gross and fine motor coordination. She currently wears glasses and is far-sighted. She does not go to sleep easily and sometimes needs 2 h to settle into sleep with frequent parent presence. She does sleep in her own bed. She does not snore or breathe loudly during sleep and typically sleeps from 8 p.m. to 7 a.m. Parents noted she has sensory aversion to tags on her clothes and dirty hands but she does not mind being wet, having her hair brushed or other sensory activities. She does not have any allergies or take any medications. 278 K. Mulrooney et al.

Education History

Emma first entered school at 2 years of age and adjusted to separation from her parents approximately 3 weeks into the school year. Last year, the school day was 2 h long and consisted of structured and unstructured activities. This year she is at school for 3 h with a mix of structured and unstructured activities. In her classroom last year and this year, she needs teacher support to play for more than a couple of minutes in one activity. She is described as self-directed and does not follow the classroom routine without a great deal of support. She does not engage with peers meaningfully in play, but she does seek some peer interaction and is observant of peer activities. Her Committee on Preschool Special Education (CPSE) evaluation suggested difficulties complying with the testing procedures without breaks, redirection, reward systems, and coaxing by multiple evaluators. She was found to have difficulties following multistep directions, trunk and extremity weakness as evidenced by crayon grasp, W-seating on the floor, and balance delays. Cognitive and speech abilities were in the Average Range. She was able to participate in limited pretend play with an adult but not a child.

Family and Social History

Emma lives in a one-bedroom apartment in Manhattan with her biological parents. Her father is a professor and her mother is a lawyer. Her father has been diagnosed with Obsessive Compulsive Disorder (OCD) which is treated with medication and her mother reported a history of anxiety and depression. Mother reports significant worry about Emma’s behavior and emotional difficulties including how it will influence her in the future. For instance, if Emma appears less hungry for several days, her mother will worry she is getting too skinny even if presented with evidence from her pediatrician that her growth is normal. Further, her mother will worry that Emma is depressed if she does not want to sit by her or resists a hug even when feedback from school suggests she is happy and engaged. Parents believe maternal grandmother who frequently babysits Emma may have undiagnosed ADHD. Emma’s mother is currently pregnant and due in a month. Additionally, her nanny just had a baby and is on leave. Parental conflict and living in a one-bedroom apartment are other psychosocial stressors. Parents previously have been in couples counseling; however, discontinued this therapy because they did not find it helpful. A significant source of conflict for the couple is disagreements about how to handle Emma’s behavior. Emma has never witnessed or experienced a traumatic or life- threatening event. Emma plays mostly by herself in playground and classroom settings. She may seek a peer out to play but then moves on to a different activity or toy without developing a conversation or plan with the peer. She appears to be “visiting” peers around 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 279 the room or playground but then running off to do something new. She can play with peers and adults with more structure and encouragement from adults.

School Observation

Teachers reported Emma shuts down when she is overwhelmed at school. She does not play with others by choice but will do so when coached by adults. During the classroom observation, she went from one activity to another not spending much time on any one task. She wanted to touch things almost in a frenzy. She was constantly seeking input and demonstrated limited danger awareness. She often refused to comply with adult requests and continued to do what she wanted to do in the classroom. She was able to be redirected to join at the Play-Doh table for a longer period of time. She spoke to peers when she encountered them at different activities but only briefly and not in shared play. She did not participate in cleanup before the rug time (circle time activity). She participated verbally and stayed in her space on the rug. She did sit with demonstrated trunk weakness and spent some of the time looking around and not attending to the teacher.

Symptom Checklists (See Chap. 7 for Details on Rating Scales)

Child Behavior Checklist (CBCL)for 1½–5-year-olds. The CBCL is 100-item parent and teacher measure assessing a wide range of child behaviors and symptoms with subscales measuring emotionally reactive, anxious/depressed, somatic complaints, withdrawn, sleep problems, attention problems, and aggressive behavior as well as broader subscales measuring internalizing problems, externalizing problems, and total problems. T-Scores over 70 are considered clinically elevated and scores between 65 and 70 are considered borderline. T-Scores below 65 are considered to be in the normative range. Emma’s mother’s responses on the CBCL indicated clinical elevations on emotionally reactive (T-score = 75), somatic complaints (T-score = 75), attention problems (T-score = 80), and aggressive behavior (T-score = 88). Teacher ratings on the CBCL indicated a borderline elevation on Emotionally Reactive (T-score = 68). Eyberg Child Behavior Inventory (ECBI). The ECBI is a 36-item measure of common behavior problems where parents rate the extent to which the behavior occurs (Intensity Scale) and endorse whether or not the behavior is a problem (Problem Scale) on a seven-point scale. T-Scores 60 and above are considered clinically elevated. Both of Emma’s parents completed the ECBI, and both reports indicated elevations in the intensity of her disruptive behavior (Mother: T-score 72; Father: T-score 73) as well as their perceptions of it being problematic (Mother: T-score 80; Father: T-score 76). The ECBI will be discussed in more detail in Chap. 7. 280 K. Mulrooney et al.

Spence Preschool Anxiety Scale (SCAS). The SCAS is a 34-item measure of anxiety symptoms in children aged 3–6 with subscales measuring OCD, social anxiety, separation anxiety, physical injury/fears, and generalized anxiety as well as a Total Score. Emma’s scores fell in the normative range on separation anxiety, generalized anxiety, social anxiety, physical injury/fears, and total anxiety. Her scores fell in the elevated range (though not clinically elevated) for obsessive compulsive disorder (T-score = 62). Dyadic Parent–Child Interaction Coding System (DPICS). The DPICS is a standardized behavioral observation system designed to assess the quality of parent– child social interaction. Observations are conducted in three 5-min situations: child-led play, parent-led play, and cleanup and assesses parenting and child behavior problems. Parenting behavior observed included positive following during child- led (which included behavior descriptions, praises, and reflections) and negative leading during child-directed (consisting of commands, questions, and negative talk) and total commands during parent-led play and cleanup. Percent compliance was coded for the child during parent-led and cleanup. Parent–child interactions demonstrated that parents had difficulty allowing Emma to lead the play during the child-led interaction and frequently used questions and commands in attempt to redirect from behaviors they perceived to be bossy or controlling (e.g., taking all of the blocks). Her mother gave some critical feedback at these moments and her father used questions and commands to try to distract her. During parent-led play, she resisted parent commands and frequently negotiated with both parents. Parents frequently repeated themselves and attempted to reason with her to gain compliance. During cleanup with her father, Emma began screaming and throwing toys (magna- tiles). At this point, he stopped trying to get her to cleanup and used questions and commands to try to calm her down.

Case Summary and Conceptualization

Emma is a 3-year-old Caucasian female who has a history of difficulties with self- regulation and aggression both at home and school. Physical aggression, temper outbursts, and noncompliance occur at a higher frequency and intensity at home with her parents. Factors likely contributing to increased difficulty at home include parent conflict, family stressors including living in a one bedroom and the upcoming birth of Emma’s sibling, and parental psychopathology. Additionally, she has developmental delays in fine and gross motor functioning, which likely increase frustration in her day. Based on her presentation, Emma meets diagnostic criteria for Disorder of Dysregulated Anger and Aggression of early childhood with predominantly reactive aggression. Other diagnoses considered and rejected included sleep disorders, anxiety disorders, and mood disorders. Developmental Coordination Disorder was considered, but because of the more recent onset of the problems in gross and fine motor development, further assessment including medical and/or neurological assessment, is suggested. Obsessive Compulsive Disorder was 8 Diagnosis in Young Children: The Use of the DC:0-5™ Diagnostic Classification… 281 considered given parental report on SPAS, past diagnosis and family history. However, at this time, parents denied compulsions and rule-based behaviors that rise to the level of impairment to warrant a diagnosis. Further Attention Deficit Hyperactivity Disorder was considered because her teachers have concern about her ability to follow routines, remain on-task, and complete multistep directions. However, at this point, symptoms are subthreshold for diagnosis and may be reassessed at a later date.

DC:0-5 Diagnostic Summary

Axis I: Disorder of Dysregulated Anger and Aggression of early childhood, predominantly reactive aggression. Axis II: Caregiving dimension: Level 3 (Compromised to disturbed relationships for both child–mother and child–father relationships). There are struggles in the parent–child relationship with each of the parents. There are power struggles where Emma tries to control her parents, and they do not appear attuned during play. Despite each trying to apply appropriate coping resources to challenging situations, they are not successful or sustained. Caregiving Environment: Level 3 (Compromised to disturbed caregiving environment). Emma’s parents are conflicted about how to handle her behavior and also have other sources of marital conflict. Parents have trouble regulating their own emotions when Emma has a tantrum. The family relationships reflect irregular engagement and some role imbalance. Axis III: Generally good health, far sighted (corrected with glasses), recent onset of motor delays, and weakness observed in fine and gross motor functioning. Axis IV: Upcoming birth of sibling, parental conflict, parental mental health problems including mother anxiety and depression and father, OCD. Axis V: Emma demonstrates normal cognitive and speech functioning. She has gross and fine motor delays being addressed with OT and PT. She has inconsistent/ emerging emotional competency, but her social relational capacity is delayed. This case report was adapted from case submitted by Stephanie Wagner, Ph.D., Licensed Clinical Psychologist, Clinical Assistant Professor, Child Study Center at Hassenfeld Children’s Hospital of New York at NYU Langone; and Lauren Knickerbocker, Ph.D., Clinical Psychologist, Assistant Professor of Child and Adolescent Psychiatry, NYU Child Study Center.

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ZERO TO THREE. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood: Revised edition (DC:0–3R). Washington, DC: ZERO TO THREE. ZERO TO THREE. (2016). DC:0–5 diagnostic classification of mental health and developmental disorders of infancy and early childhood. Washington, DC: ZERO TO THREE. ZERO TO THREE. (2017). The basics of infant and early childhood mental health: A briefing paper. Washington, DC: ZERO TO THREE. ZERO TO THREE Diagnostic Classification Task Force. (2017).Should we diagnose babies? No! Should we diagnose disorders in babies? Yes!: Perspectives WAIMH. Washington, DC: ZERO TO THREE. Chapter 9 Psychopharmacologic Considerations in Early Childhood

Julianna Finelli and Mary Margaret Gleason

Introduction

Very young children’s mental health concerns can be impairing, persistent, and cause suffering in the child as well as their families. Our understanding of these disorders and all of development is grounded in a relationship-focused approach for assessment and treatment. Within this model, there is also growing evidence for the validity of within-child disorders in children under 6. As with all aspects of development, these mental health disorders develop in a balance of risk and protective psychological, behavioral, and biological factors (Gleason et al., 2016b; Shonkoff & Phillips, 2000; Zero to Three, 2016). Many effective psychotherapeutic approaches offer the potential to decrease current burden of the disorder and mitigate future risks. These psychotherapeutic approaches are biologically safe and have the potential to change the foundation of a child’s development for life. However, access to evidence-based therapies can be extremely limited, as they require a substantial invetment of emotions, time, and sometimes finances by families, and even under optimal conditions, do not resolve symptoms or impairment in all children (as reviewed in Eyberg, Nelson, & Boggs, 2008; Gleason et al., 2016b; Kazdin, 2005). In this context, psychopharmacologic treatments warrant discussion and consideration of developmentally specific factors. Every aspect of young children’s clinical care, including consideration of medications, must occur in a developmentally specific manner, just as each element of assessment reviewed in this volume. The same developmental, cultural, and contextual factors that require specialized assessment tools influence the consideration of medications in this young age group. This chapter will present the principles of approaching psychopharmacologic treatment in young children including the important ways caregivers and providers may conceptualize the

J. Finelli · M. M. Gleason (*) Department of Psychiatry and Behavioral Sciences Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 285 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_9 286 J. Finelli and M. M. Gleason clinical problem and the treatment, the patterns and trends of prescribing for young children in the USA, and some real-world challenges to considering medication treatments in very young children. This chapter concludes with a review of disorder- specific approaches to considering psychopharmacologic treatment in young children.

Developmentally Specific Factors of Early Childhood Psychopharmacologic Treatment

General Principles

Across disciplines, published professional practice guidelines describing recommended assessment and treatment approaches are consistent in common recommendations for treatment of preschool children with significant mental health concerns (AAP, 2011; Gleason et al., 2007, 2016a). These guidelines are derived from the limited evidence supporting psychopharmacologic interventions in young children, data derived from older children, and from the generally stronger, though variable, support for psychotherapeutic approaches. This section refers to guidelines on psychopharmacologic treatment of young children published in 2007 in the Journal of the American Academy of Child and Adolescent Psychiatry, 2011 in Pediatrics, and 2016 in Pediatrics unless otherwise specified. The guidelines begin with the importance of a relationally grounded assessment that yields a clinical formulation and diagnosis described throughout this volume. Multimodal, multi-informant, multisession assessments yield the most accurate diagnoses and case formulations to guide treatment recommendations (Egger, 2010). Modes of assessment in young children can include information-gathering interviews with caregiver interactions and, when verbal, interviews with the young child, informal and formal observations of the young child and caregiver, caregiver interviews focused on the narrative qualities to understand their working model of the child, paper and pencil measures, and formal developmental and/or psychological testing. Informants can include the primary caregiver(s), other adults in the home, other caregivers including child care providers as well as the child. Assessments are done over multiple appointments because of the sensitivity of young children to context. Multiple appointments allow the clinician to see the child over multiple days, allowing the child to become more comfortable with the clinician. Multiple time points give a more nuanced view of the child, especially if some appointments happened to be scheduled when the child missed a nap, was hungry, or was reacting to other contextual factors. Multiple time points also give the family and clinician time to begin to build a relationship. It should be noted that too many assessment appointments can feel burdensome to some families, so iterative feedback is important, meaning the clinician summarizes to the caregiver some of the information gathered that day, how it helps to build a treatment plan. Even if formal 9 Psychopharmacologic Considerations in Early Childhood 287 treatment has not started, the assessment process should be considered a part of the therapeutic process and clinicians link each step to the caregivers’ chief complaint and treatment goal. Psychoeducation and parenting information may be helpful during the assessment process. The assessment is always done with attention to the child’s developmental status, not just age, and the cultural context and expectations of the family, both of which require time to appreciate. With a comprehensive formulation, a clinician is most likely to recommend specific therapies and environmental interventions, including caregiver’s treatment, that maximize the chance of clinical improvement. Interventions in the treatment guidelines begin with universal interventions to support a healthy caregiving environment. These approaches may include addressing caregiver’s mental health, basic needs deficits such as food insecurity, housing, or problems with physical safety, supporting access to safe, quality child care if the caregiver is interested, and/or supporting the family through opportunities for employment, education, and physical health care. While a single clinician may not be able to provide all these services, it is useful to be familiar with the local resources to be able to link a caregiver with supports for these basic needs. Many communities are developing warm line phone numbers that can sometimes be effective. The National Healthy Start Association provides English and Spanish lines to link parents to local services and resources (Healthy Start Association, 2013). For all early childhood mental health problems, psychotherapy is the first line recommended treatment, using linking evidence-based or evidence-informed treatment approaches for specific clinical syndromes or situations. A growing evidence base provides guidance for treatment of specific disorders. A full review is outside of the scope of this treatment chapter, but a few examples illustrate the range of approaches for very young children with mental health problems. Caregiver management training approaches like Parent-Child Interaction Therapy (PCIT), Triple P, Incredible Years, and Helping the Non-Compliant Child have been shown to be effective in treating young children with disruptive behavior problems and to a lesser extent, ADHD reviewed in (Abikoff et al. 2015; Eyberg et al., 2008; Gleason et al., 2016b; Sanders, Baker, & Turner, 2012; Webster-Stratton, Reid, & Hammond, 2004), as well as anxiety disorders (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014; Comer et al., 2012; Puliafico, Comer, & Pincus, 2012). Adaptations of PCIT also have some support in addressing separation anxiety disorder, generalized anxiety disorder, social phobia, and selective mutism as well as depression (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014; Choate, Pincus, & Eyberg, 2005). Child Parent Psychotherapy and Infant–Parent psychotherapy, and Attachment Biobehavioral Catch-up are effective for posttraumatic stress disorder and promoting healthy attachment relationships in families under stress by focusing specifically on the caregiver–child relationship and attending to both interactions and caregiver perceptions, working models, or attributions about themselves, their child, and their relationships (Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008; Lieberman, Horn, & Ippen, 2005). Developmentally specific adaptations for cognitive behavioral therapy can be implemented to treat posttraumatic stress disorder and other 288 J. Finelli and M. M. Gleason anxiety disorders (Hirshfeld-Becker et al., 2010; Scheeringa et al., 2007). Interaction Guidance and Circle of Security are widely accepted and disseminated interventions focused on building healthy caregiver–child relationships (Coates & Gaensbauer, 2009; Fardoulys & Coyne, 2016; Hoffman, Marvin, Cooper, & Powell, 2006; McDonough, 2000). Play therapy has not been studied in the same way, but may be useful in helping a child exposed to potentially traumatic event(s) to develop a cohesive narrative about their experience through play (Coates & Gaensbauer, 2009). A number of interventions, most prominently Applied Behavior Analysis and the Early Start Denver model are effective in reducing symptoms of autism spectrum disorders (AACAP, 2016). Unfortunately, for many families, these treatments are inaccessible due to clinician workforce shortage, geography, schedules, or health insurance. In such situations, nonspecific therapy based on basic principles of infant mental health of promoting healthy relationships by positive caregiver–child interactions and providing a child with positive interactions with a supportive adult can be considered and, in some cases, may offer powerful support for families and may reduce impairment. Even with a strong evidence base, no treatment works for everyone, even perfectly identified children or dyads, and symptoms and/or impairment may persist. For example, about a third of families do not complete most of the parent management training programs (Kazdin, 2005). All treatment plans should be guided by reassessment of the diagnosis and formulation on a regular basis but especially at treatment decision points. The reassessment process acknowledges that changes may have occurred with the child’s rapid development during the psychotherapy trial, as well as that the initial diagnosis and formulation may have been incomplete or even inaccurate, which can result in selection of a therapy less likely to be effective. A reassessment may guide an alternative treatment plan because of new information or may confirm the initial formulation and that the treatment selected seems like an appropriate fit. Consideration of medication trial is recommended if therapy has been insufficiently effective in addressing significant symptoms and/or impairment or in situations when therapy is inaccessible for a young child with severe symptoms and impairment. Whenever possible, psychotherapy and interventions aimed at supporting the caregiving environment should continue through any medication treatment. Caregivers are partners in the process of medication decisions and informed consent must include clear descriptions of the known and unknown benefits, risks, and alternatives. This process can be extensive and sometimes warrants an entire appointment focused on a shared decision-making process with the family. For all medications in the preschool period, most risks and benefits are unknown, rather than known, and the important “unknowns” should be reviewed with the caregivers. Specifically, there are insufficient data to predict long-term outcomes of early exposure to any psychopharmacologic agent, and even whether those outcomes are protective, adverse, or neutral. For most disorders and most medications, efficacy (outcomes in controlled research environments), effectiveness (outcomes in real world utilization), and short-term safety are also not established in rigorous research. Lastly, studies have not addressed head to head comparisons of any medication 9 Psychopharmacologic Considerations in Early Childhood 289 compared to any psychotherapy, which is a critical clinical question faced in real world practice. Information about the role medications in treating preschoolers can be provided to families from sources including the Center for Disease Control (CDC, 2014) or Tulane Early Childhood Collaborative (https://medicine.tulane.edu/ centers-institutes/tecc/provider-resources) to support the verbal information shared during informed consent. In the context of limited research, any medication initiation should be considered a systematic trial of the medication, with clear target symptoms and regular measurement of the effects and adverse effects, and a planned duration after a stable dose is achieved. Tracking of potential adverse effects should be guided by the adverse effect profile in older children, but should intentionally be broader, given the lack of data in this age group. Negative emotionality and emotional blunting should be tracked for all medications because they can be seen in young children taking stimulants and are among the most common concerns voiced by parents. Measurement of effects should certainly be done clinically through interview and observation, but can be enhanced by using structured symptom measurements, including measures presented in Table 9.1. Medication discontinuation trials should be planned with the initiation of the medication, to reassess the ongoing need for the medication. Discontinuation trials should be discussed at the start of therapy. Generally, a discontinuation trial can be considered after 9–12 months of stable symptom control and generally should be during low stress parts of the year, such as over the summer for children in school-schedule preschool classrooms. When a first medication trial is ineffective due to intolerable side effects or lack of effectiveness, reassessment of the diagnosis and formulation is again important before initiating an alternative medication. In general, monotherapy is recommended due to the total absence of data about effects of concurrent medications and the potential for interactions as well as additive adverse effects. An exception might be for a child who has previously failed trials of multiple stimulants who is now on

Table 9.1 Selected nonproprietary preschool measures Name Ages What is measured Early childhood screening assessment 18– Broad social emotional symptoms and brief early childhood screening 60 months parent concern, parent depression assessment (Fallucco et al., 2017; (Patient Health Questionnaire-2) Gleason, Dickstein, & Zeanah, 2010) Survey of child well-being (Sheldrick 2–60 months Developmental status, broad social et al., 2012) emotional symptom, caregiver concerns, family environmental Symptom-specific scales Preschool ADHD rating scale 3–5 years ADHD symptoms Preschool anxiety scale (Spence, Rapee, 2.5– Anxiety symptoms (scale only, no McDonald, & Ingram, 2001) 6.5 years clinical cutoff provided) Young child PTSD Checklist 1–6 years PTSD symptoms (Scheeringa, 2002) 290 J. Finelli and M. M. Gleason an effective stimulant but with growth or other side effects. In such a case, it may be reasonable to consider addition of a non-stimulant may as an adjunct to allow a lower stimulant dose to mitigate side effects.

Explanatory Models of Treatment and Clinical Problems

Beyond the basic principles of assessment and treatment with medication, it is important to consider the powerful meanings of psychopharmacological treatment for caregivers (and clinicians), as these meanings may influence help-seeking behaviors and engagement with various treatment recommendations. The meaning of medication for caregivers of preschoolers has not been examined in the literature (Chubinsky & Rappaport, 2006), but clinical experience suggests that psychotropic medications have at least as much meaning, if not more, in the families of preschoolers compared to older children. Medications may take on many meanings. Some commonly-seen clinical examples include that caregivers see the medication as an external locus of control for caregivers who feel overwhelmed and/or unprepared to organize their child’s emotional world, as a sign of their own caregiving “failure,” an indication or validation that their child is “broken” or “fragile” in ways that a parent could not possibly address. Additionally, for some caregivers, the medication may represent a connection between a caregiver with psychopathology and the child, a representation of the child’s similarities with other family members, or a sign of support for caregiver who is not able to elicit from others in their caregiving network (Chubinsky & Rappaport, 2006). Beliefs about medications are also shaped by community beliefs and likely by family experiences with the mental health system and medications, shaping treatment engagement (Berger-Jenkins, McKay, Newcorn, Bannon, & Laraque, 2012). Outside of clinical settings, it is not uncommon for lay reactions to the idea of pharmacotherapy as part of treatment for a child under 6 to be close to horror. It is critical that clinicians consider the potential for a recommendation of pharmacotherapy to elicit some of these representational meanings or strong, community-driven reactions and to explore what it means to the family to think about a medication for their child. These attributions may drive how the caregiver develops expectations about the medications, describes clinical responses to the medication, and tolerates discussions of discontinuations, either due to adverse effects or planed discontinuation. Perhaps because of some of these perceptions of medications for young children, most studies suggest that most caregivers prefer nonpharmacologic treatments for their children with ADHD over medication treatments (Bussing, Koro-Ljungberg, Gary, Mason, & Garvan, 2005; Bussing, Schoenberg, Rogers, Zima, & Angus, 1998; Fiks, Mayne, DeBartolo, Power, & Guevara, 2013). Importantly, these studies have not included caregivers of children with diagnosed ADHD, only general population and high-risk groups. In contrast to the research, it is not uncommon for clinicians working with highly symptomatic children, to work families who seem to be 9 Psychopharmacologic Considerations in Early Childhood 291 actively seeking a medication for their child, often because they have not seen improvement for their child and they feel like they have tried “everything.” Clinician beliefs about medications likely also drive treatment decisions. Self- awareness about these beliefs and where they come from offers families the best possible treatment. Anecdotally, nearly every clinician has in their mind a lower age limit for “appropriate” use of medications as an intervention before which they will not discuss medications. Many families arrive at infant psychiatry appointments having been told, for example, that their past provider said they were not allowed to prescribe for children under X age, often 5 years old. It is important for clinicians to consider their lower age limit and consider what factors they have used to derive it. There is no magic age at which the risk-benefit analysis is abso- lute. However, it is reasonable to consider that one nodal decision point for the risk-benefit analysis might be whether the child has an identifiable clinical disorder described in the DSM-5 (APA, 2013) or in the Diagnostic Criteria:0–5 (Zero to Three, 2016), and the degree to which the disorder has an established link with psychopharmacologic management. It should be noted that the reason for a medication seems to shape anecdotal reactions—some centrally acting medications that are carefully considered for treatment of mental health issues are commonly used in other medical specialties and raise fewer concerns about the safety issues. For example, diphenhydramine (Benadryl) for allergies or an alpha agonist for a congenital cardiac problems are used commonly in pediatrics and few people raise significant safety questions that are discussed in this chapter. Certainly, the known efficacy of these medications for mental health concerns is less than for other pediatric disorders, but the difference in response to the medications in different contexts reminds us to consider our underlying assumptions and attributions about the disorders we treat. This example is not intended to promote use of medications, but rather a call to reflect on our own thought processes. Other clinician factors also influence decision making. For example, clinicians may react to the lack of progress in psychotherapy as a reflection on their skills and feel reluctant to recommend a consultation with a physician or conversely, when working with a family with multiple needs, may feel overwhelmed by the needs and recommend psychiatric consultation earlier than usual. Being reflective about what has shaped these beliefs may ensure that children receive care that is driven by best practices rather than psychological or anecdotal factors. Treatment recommendations and decisions are also shaped by how caregivers understand the clinical concern. When caregivers and clinicians have a shared understanding of the clinical concerns, they can collaborate to develop an effective treatment plan. Thus, it is important for clinicians to consider how a caregiver understands a preschooler’s clinical presentation in order to discuss a treatment plan, especially one that includes medication. Preschool studies in this area are small, so broad generalizations would be imprudent, but these studies highlight themes that have clinical value in understanding how caregivers may define a problem and their related treatment preferences. One example is a study in which caregivers were provided with a hypothetical description of a preschool child with 292 J. Finelli and M. M. Gleason signs of ADHD. About half of the caregivers whose children had ADHD said they had not met a child similar to the one in the vignette, highlighting the importance of finding language to understand how a caregiver sees their child’s behavioral symptoms (Maniadaki, Sonuga-Barke, Kakouros, & Karaba, 2007). These caregivers reported that the ways the behaviors interfered with daily life, not their own experiences or the number of symptoms reported in the vignette, would guide them in seeking additional help. This study highlights a pattern of defining a clinical problem through functional impairment, which in turn shapes help-seeking behaviors among caregivers. Culture, race, and community likely also influence how caregivers define a child’s patterns of behaviors. Expectations about how children should develop, what they can do at what ages, and where the line is drawn to differentiate typical and atypical (and acceptable and unacceptable) are shaped by a families’ own caregiving experiences, their cultural norms, and the expectations of the community in which they are raising their child. The lens through which caregivers define their child’s emotional and behavioral growth likely shapes the kind of support they seek when the emotions or behaviors cause distress to the child or caregiver. Because each family develops in their own unique combination or caregiving experiences, cultural norms, and community expectations, generalizations from the early studies examining patterns should be drawn with caution and clinical practice should be focused on the child and family in the office at that moment. For example, one study in Florida suggested that Caucasian caregivers were more likely to use medical explanatory model of ADHD whereas African American caregivers used more behavioral or personality descriptors (Bussing et al., 1998). Similarly, two qualitative studies of Latnix mothers suggested that they may be particularly reluctant to seek treatment for their children because the medical model was seen as discordant with culturally held beliefs about young children’s hyperactivity and impulsivity (Lawton, Gerdes, Haack, & Schneider, 2014; Yeh, Hough, McCabe, Lau, & Garland, 2004). These patterns emphasize the clinical importance of being curious about how caregivers understand their child’s behaviors, so the treatment recommendations can be developed in a way that is congruent with the family’s cultural beliefs and traditions. Clinical humility is also important in building a shared understanding of the clinical problem and appropriate treatment. A qualitative study of caregivers’ perspective about help-seeking patterns for their child with an identified mental health problem revealed that caregivers perceived the clinical team’s perspective as less important than their own observations, views of their other supports, and logistical factors (Costello, Farmer, Angold, Burns, & Erkanli, 1997; Magnusson, Minkovitz, Kuhlthau, Caballero, & Mistry, 2017). As clinicians, recognizing our relatively limited influence should guide us to build relationships in which parents can share their views comfortably and consider how to communicate our perspectives in ways that have meaning in the caregivers’ understanding of the clinical problem. 9 Psychopharmacologic Considerations in Early Childhood 293

Rapid Development

The general principles of considering psychopharmacologic treatment in young children is necessarily driven by the immature status of young children and their rapid development. Central nervous system development of young children is the fastest it will be in the lifetime and somatic growth and acquisition of language, representational play and abstract thoughts are similarly changing rapidly (Shonkoff & Phillips, 2000). This rapid development influences medication treatment in a number of ways. While there are no data demonstrating either positive or negative developmental impacts of preschool exposure to centrally acting medications, the rapidly developing brain is sensitive to positive and negative environmental influences, including direct chemical exposures. In animal models, early exposure to high dose methylphenidate, but not later exposure, is associated with a reduced density of dopamine receptors in the striatum, a part of the brain thought to be involved with reward system processing, among other functions (Moll, Hause, Rüther, Rothenberger, & Huether, 2001). Early exposure to high doses of risperidone have also been shown to influence serotonin receptor density in young rats in the medial and prefrontal cortices (Choi, Moran-Gates, Gardner, & Tarazi, 2010). The clinical implications of these changes are not yet demonstrated in humans, but raise questions about whether early exposure to these medications may change brain development in a way that could influence later development. Whether these changes are insignificant, neuroprotective, or cause later vulnerabilities or some other outcome cannot be extrapolated from the current level of science and this gap is a part of informed clinical consent when discussing medications with families. The human experiences related to the earliest possible psychopharmacologic exposure, prenatal exposure, provide mixed but generally positive results about long- term developmental outcomes. Large population studies do not support associations between prenatal antidepressant exposure and psychopathology. Specifically, in cohort study of 1,580,629 live births in Sweden there was no association between antidepressant exposure and risk of ADHD or autism spectrum disorder at age 15 based on medical records, using multiple methods including paternal and maternal factors as well as sibling comparisons to attempt to control for confounding factors (Sujan et al., 2017). In a Danish prospective study that examined maternal depression status as well as exposure to antidepressants, exposure to antidepressants initially appeared to be associated with emotional and behavioral problems, but that association was moderated by maternal mood symptoms prenatally, meaning that the maternal mood, rather than exposure to the medication explained the association between antidepressant exposure and children’s emotional or behavioral problems at age 7 using a parent-report interview (Grzeskowiak et al., 2016). However, the issue remains complex and not fully understood. A 2017 meta-analysis revealed that preconception antidepressant use had a stronger association with the development of autism spectrum disorders than any period during pregnancy, emphasizing the complex confounding factor of maternal psychopathology in these human studies (Mezzacappa et al., 2017). 294 J. Finelli and M. M. Gleason

These studies highlight the need for further research on the developmental impact of psychopharmacologic agents, but they cannot answer the clinical questions families and providers face about individual children’s risks, leaving families and clinicians to weigh known safety and developmental risks of uncontrolled symptoms and the unknown impact of exposure to medications. The developmental differences in young children compared to older children may influence safety and effectiveness of medications in young children compared to older peers. Although the literature is limited, existing data suggest that medications established as effective in school-age children and adolescents may be less effective in preschoolers than in older children, perhaps reflecting physiologic, pharmacokinetic, central nervous system differences or differences in the physiology or clinical presentation of the disorder itself (Greenhill et al., 2006; Kratochvil et al., 2011). Data from randomized controlled trials and open trials suggest that rates of adverse effects are noted to be higher in preschoolers than older children (reviewed in Gleason et al., 2007). For example, in the Preschool ADHD Treatment Study, which examined methylphenidate as a treatment for ADHD, nearly one third of children had moderate-severe adverse effects (compared with 14% in the Multimodal Treatment of ADHD study) and 11% dropped out because of adverse effects, commonly due to emotionality and irritability, as well as repetitive behaviors, sleep problems, and weight loss (The MTA Cooperative Group, 1999; Wigal et al., 2006). Similar patterns were reported in the randomized controlled trial of atomoxetine in young children, in which 44% of children on atomoxetine developed emotional lability, although it was generally well tolerated (Kratochvil et al., 2011). Open label trials also provide some suggestion that young children may be more sensitive to adverse effects than older children. For example, every study that reports prolactin levels in children taking atypical antipsychotic agents reports at least a 300% increase in prolactin levels, although the clinical significance of these elevations is not known (Gleason et al., 2007). Rapid development also may impact pharmacokinetics. Dosing in preschoolers is not guided by developmentally specific research, so the adage of starting low always applies. The limited existing pharmacokinetic data from the Preschool ADHD Treatment Study (PATS) suggests that preschoolers, compared with school- age children, have higher peak plasma concentrations of methylphenidate, but information about other medications is lacking, so clinical effects must guide titration (Wigal et al., 2007). Additionally, rapid development in cognition, language, and representational capacity mean that a child’s ability to express themselves and their experience of symptoms may improve over the course of treatment, allowing the clinician to better understand the clinical problem treatment effects and side effects of treatment. With the youngest children, symptom monitoring relies heavily on caregiver report and observations, but as children’s language develops, so does their ability to verbally report their own internal experiences. Growing representational and language skills also may allow them to participate in language-based treatments such as trauma-focused cognitive behavioral therapy, expanding the possible treatment options (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011). Chapter 6 in this volume describes methods of eliciting children’s experience of emotions and 9 Psychopharmacologic Considerations in Early Childhood 295 behaviors. Children as young as 36 months are able to describe their feeling states and rate intensity of their emotions with some support and most typically developing 48-month-olds can do so (Scheeringa et al., 2007). In general, it is valuable to explicitly invite a young child to share information about their experiences and their feelings, rather than to assume they are unable to do this. For children who cannot do so, it is clear, but sometimes children can express important information that only they know.

Research Base

The research base guiding clinical decisions about psychopharmacologic treatment for young children is extraordinarily limited. For most disorders in preschoolers, there are no rigorous randomized controlled trials of medications Only two medications, methylphenidate and atomoxetine, have been studied rigorously in large controlled trials in this century (Greenhill et al., 2006; Kratochvil et al., 2011). The evidence base for specific disorders is reviewed in more detail below, but this spar- sity of randomized controlled trials in preschoolers means that they are “therapeutic orphans” with limited access to empirically supported pharmacologic treatments, despite regulatory efforts to address this problem (AAP Committee on Drugs, 2002; Assael, 1999; Food and Drug Administration, 2002). A range of factors likely influence the limited research in this age group including challenges related to Institutional Review Boards’ scrutiny to protect young children, caregiver’s wariness about medication in young children, family and clinician desire for immediate treatment (rather than systematic research processes) by the time they access mental health care, and the relatively low financial reward for industry to study this population (Assael, 1999). A range of factors likely influence the limited research in this age group including challenges related to Institutional Review Boards’ scrutiny to protect young children, caregiver’s wariness about medication in young children, family and clinician desire for immediate treatment (rather than systematic research processes) by the time they access mental health care, and the relatively low financial reward for industry to study this population. This lack of clear empiric guidance in a population with known metabolic, developmental, and central nervous system differences from older children complicates clinical decision making, requiring caregivers and providers to weigh the few known and many unknown risks, benefits, and alternatives with a myriad of unknown factors (Gleason et al., 2007).

Regulatory Factors

Selection of medications in the early childhood years is further limited by Food and Drug Administration (FDA) indications that conflict with the limited existing research. Currently, D-amphetamine (and by extension, mixed amphetamine salts), 296 J. Finelli and M. M. Gleason haloperidol, and chlorpromazine are the only medications that have FDA indications for children under 5, based on historical factors rather than established research (Greenhill, 1998a, 1998b). By contrast, methylphenidate, which has the most rigorous evidence evaluating its safety and efficacy in this age group, carries a contraindication for children under 6. This discordance may reflect a lack of financial incentives for the pharmaceutical industry to go through the process of requesting an indication for a medication, despite legislation that extended the marketing exclusivity duration, the Best Pharmaceuticals for Children Act of 2013. https:// bpca.nichd.nih.gov/Pages/default.aspx

Workforce

Workforce shortages have been posited to play a role in prescribing practices, with the assumption that higher prescription rates are seen in areas with fewer child mental health providers, although empiric evidence for this assumption is not readily available. Although estimates vary by population, a national study indicated that child and adolescent psychiatrists write about one in three psychotropic prescriptions and that the remainder is written by pediatric, neurology, and general psychiatry providers (Olfson, King, & Schoenbaum, 2016). These physicians may be writing prescriptions in collaboration with other early childhood mental health professionals, but their training, which has limited or no requirements of exposure to this age group or to child psychiatry, generally do not prepare them to practice early childhood psychiatry.

Prescribing Practices

Trends

Epidemiologically, patterns of prescribing for young children have varied substantially since the 1990s, with different patterns across time, populations, and medications. The National Ambulatory and National Hospital Ambulatory Medical Care Surveys revealed that between 1994 and 2009, rates of prescriptions for preschoolers peaked in 2002–2005, with three psychotropic prescriptions per 1000 visits, a rate which was about double the rates in 1994–2002 and 2006–2009 (Chirdkiatgumchai et al., 2013). Overall, because rates of diagnosis increased through the 1994–2009 period, proportions of children with a clinical diagnosis receiving prescriptions declined from 43% to 29%. In that claims data study, focused on 2009–2011, only 14% of these foster children who filled a prescription received psychotherapy (Zito et al., 2000a, 2003). 9 Psychopharmacologic Considerations in Early Childhood 297

In most studies, being a boy, Caucasian, and being an older preschooler were all associated with higher rates of prescriptions than girls, other races, and toddlers (Garfield et al.,2015 ). Patterns of different medications have shown different trends over time. For example, rates of stimulant prescriptions doubled in the 1990s, with up to 5.1 prescriptions per 1000 children (Zito et al., 2000b). Rates of atypical antipsychotic agent use increased in the subsequent decade, with a doubling form 1999 to 2007, up to 1.59 per 1000 privately insured preschoolers (Olfson, Crystal, Huang, & Gerhard, 2010). The recent relative stabilization of prescription rates and/or decrease is likely multifactorial. It indicates that children with mental health problems are receiving fewer prescriptions than in the past, but does not indicate that children are receiving evidence-based treatments that are likely to be effective. Changes in prescribing practices may have been influenced by media and professional attention to the rise through published treatment guidelines, policy statements, and lay and professional opinion pieces that addressed increasing rates of prescriptions without commensu- rate empiric safety and efficacy support, and treatment (e.g., Gleason et al., 2007, 2016a; Kratochvil, Egger, Greenhill, & McGough, 2006). Concurrently, a number of states have implemented prior authorization and other regulatory processes such as mandatory reviews, with variable effects on prescribing practices for young children (Barclay et al., 2017; Pennap, Burcu, Safer, & Zito, 2017; Stein et al., 2014). Research has specifically examined patterns of psychopharmacologic treatment among preschoolers with ADHD. One rigorous study linked nationally representative data from the National Health Interview Study with the Medicaid Expenditure Panel Survey. Examining children who had been diagnosed with ADHD, more (56%) preschool children received stimulants compared to school-age and adolescent youth, who had rates of 42% and 26% respectively (Rabbani & Alexander, 2009). It is possible this pattern reflects a diagnosis bias in which the diagnosis is provided in part to link to the treatment plan and less specific diagnoses are used when the treatment plan does not include medications for preschoolers.

Child Factors: Insurance, Caregiving Status, Demographics

Most studies indicate that children with publicly funded insurance receive medications at substantially higher rates than others (Zito et al., 2000a, 2003). A national study of Medicaid-covered children under 4 in 30 states reported 1.19% received at least one prescription for a psychotropic medication, with 0.17% of children under 12 months and 0.34% of children 1–2 (Garfield et al.,2015 ). In comparison, studies of privately insured children measure prescription rates in per thousand children. Additionally, prescription patterns vary by Medicaid eligibility category. Rates of prescriptions are lower for children covered by Medicaid managed care than fee for service plans. Lastly, young children in foster care and covered by social security disability insurance have similar rates of prescription use, which are substantially 298 J. Finelli and M. M. Gleason higher than children covered because of financial eligibility (dosReis et al., 2011; dosreis, Zito, Safer, & Soeken, 2001). The foster care population has been studied in more detail. One large study showed a twofold increase for every year of life between ages 3 and 6, with 23% of 6-year-olds receiving at least one prescription for a psychotropic medication and overall 12% of children under 6 receiving a prescription (dosReis et al., 2014). For all young children covered by Medicaid, a significant racial disproportional- ity shows Caucasian children receive higher rates of prescriptions than African American children. The difference varies by eligibility category, with twofold difference among children in foster care and SSDI and three- to fourfold among children covered by Temporary Assistance to Needy Families and State Child Health Insurance Plan (Zito, Safer, Zuckerman, Gardner, & Soeken, 2005) The racial disparity in prescriptions may be related in part to differences in rates of identification. Despite similar prevalence in epidemiologic studies, Caucasian children are diagnosed with ADHD at higher rates than children of color (Morgan, Staff, Hillemeier, Farkas, & Maczuga, 2013). Factors that may contribute to this disparity include access to quality medical and mental services, family level of trust in medical and mental services, caregiver explanatory models about early childhood emotional and behavioral patterns, stigma about mental health, and interpersonal and institutional racism, among many others (Morgan et al., 2013). Among preschool children in foster care, a large study in Maryland showed that overall exposure to medication did not statistically differ by race, with 9% and 12% of Caucasian and African American children 2–6 years old receiving a medication. However, prescription patterns for specific medications differed significantly. African American children in foster care were about half as likely to receive an atypical antipsychotic agent, nearly three times as likely to receive an antidepressant, and equally likely to receive an ADHD medication as other races (dosReis et al., 2014). It seems likely that the medication choices reflect the clinical symptoms and the provider and caregiver attributions or interpretations of the symptoms and clinical context.

Treatment Recommendations

ADHD

Attention Deficit/Hyperactivity Disorder (ADHD) occurs in about 5% of preschool- age children and over 80% continue to have functional impairment into late childhood, even with intervention (Egger & Angold, 2006; Lee, Lahey, Owens, & Hinshaw, 2008). The majority of medications prescribed for preschoolers are stimulants, with most prescribed by primary care providers (Danielson et al., 2017; Gleason et al., 2007; Zito et al., 2007). Despite this, there are limited data regarding psychopharmacological treatment of preschool ADHD. 9 Psychopharmacologic Considerations in Early Childhood 299

Given the limited information about the efficacy and safety, especially the potential effect of psychopharmacological interventions on brain development of young children, there is wide clinical consensus that psychotherapeutic interventions should be tried first in preschoolers with ADHD after a comprehensive assessment that rules out other causes of inattention, hyperactivity, and/or impulsivity (AAP, 2011; Gleason et al., 2007). This recommendation is explicitly described in both guidelines for pediatrics and child psychiatry practice. Family-focused therapeutic approaches like parent management training are considered the first-line intervention in preschoolers with ADHD, with stimulants reserved for consideration in preschoolers with ADHD and severe impairment and for whom behavioral interventions are inadequate or unavailable (AAP, 2011). These parent management training approaches are founded on the basic behavioral principles of positive reinforcement and selective attention, but vary by the ways these approaches are shared with caregivers. Parent-Child Interaction Therapy uses in vivo coaching and tracks symptoms and caregiver skills regularly, Triple P is more parent-driven and parents select the specific approaches they think will be most helpful and report back using symptom measurements (Eyberg et al., 2008). Incredible Years offers groups for parents, teachers, and children focused on emotional regulation and parent management training (Webster-Stratton, 2011). The Helping the Non- Compliant Child offers coaching and skill building (McMahon & Forehand, 2005). The data supporting these interventions has primarily focused on generic disruptive behavior patterns, including impulsivity and hyperactivity, with less data focused on ADHD specifically. Although these interventions are not specific to ADHD, they have been proven to result in reductions in symptoms lasting up to 6–8 years (Hood & Eyberg, 2003). Psychopharmacological treatments for preschoolers with ADHD for whom therapy has been ineffective or unavailable can be approached using a three-step process that begins with methylphenidate followed by a trial of mixed amphetamine salts, and then a trial of a non-stimulant, atomoxetine or an alpha agonist (Zito et al., 2005). The rationale for this order of medication trial is derived from the relative weight of evidence in preschoolers and the relative effect sizes comparing stimulants and non-stimulants in older children. For some children, there may be a compelling clinical reason to start with a mixed amphetamine salt before methylphenidate, such as a negative response to methylphenidate in family member. In such case, given the relative comparability of the stimulant classes in older children and no compelling reason to believe the different stimulants would act substantially differently in younger children, clinical judgment should be applied. Similarly, for children with a clinical contraindication for stimulant use such as cardiac contraindication, clinicians use clinical judgment to guide treatment planning. As noted above, psychotherapeutic interventions and family support should be continued during psychopharmacologic treatments. Symptom tracking for preschoolers with ADHD can be done with an ADHD- specific measure, the Preschool ADHD Rating Scale or a general measure such as the Brief Early Childhood Screening, Brief Infant Toddler Social Emotional Assessment, the Preschool Pediatric Symptom Checklist (Briggs-Gowan & 300 J. Finelli and M. M. Gleason

Carter, 2002; Fallucco et al., 2017; Murphy et al., 1996). The general measures may be especially valuable for tracking symptoms in children with comorbid conditions. Measures should be completed by the primary caregiver as well as, when applicable, at least one other reporter, such as a child care provider or other family caregiver.

Methylphenidate

Methylphenidate has the strongest empirical evidence in preschool children with ADHD, and is considered first-line psychopharmacological treatment because of the strength of its empirical support, and an absence (not negative trials) of the same quality studies with other medications (Charach et al., 2012; Gleason et al., 2007; Greenhill, 1998a, 1998b) (Table 9.2). The most rigorous evidence comes from the Preschool ADHD Treatment Study (PATS), an NIMH-funded, six-center, randomized controlled trial, which examined the efficacy and safety of methylphenidate in children aged 3–5.5 years with ADHD who had failed to respond adequately to parent management training. Compared to placebo, methylphenidate at doses 1.25– 7.5 mg TID was associated with significant decreases in ADHD symptoms, although effect sizes (mean 0.54 (parents), 0.66 (teachers)) were smaller than those observed in school-age children on methylphenidate (0.61, 1.31 respectively) (Greenhill

Table 9.2 ADHD psychopharmacology trials since 2004 (mean age <6 years) Treatment Study (dose) Participants Design Results Side effects Greenhill MPH 165 children RCT 21% 11% discontinuation et al. (2006) 1.25–7.5 mg 3–6 years following remission rate for irritability, TID old trial of MPH vs. 13% emotionality, social PMT withdrawal, poor appetite Kratochvil ATX 22 5–6 years Pilot open Response rate Mood lability, et al. (2007) (0.5– old trial nearly 72% decreased weight 1.25 mg/kg) Kratochvil ATX 101 5–6 RCT 40% 41% adverse effects et al. (2011) (0.5–1.8 mg/ years old “improved” with ATX (mood kg) or “much changes predominant) improved” vs 21% on PCB Short, MAS 28 4–5 years Open trial 82% response Commonly reported: Manos, (5–30 mg/ old rates decreased appetite, Findling, and day divided increased irritability, Schubel BID) OR rebound symptoms (2004) MPH (5–15 mg/ day) MPH methylphenidate, PCB placebo, ATX atomoxetine, MAS mixed amphetamine salts 9 Psychopharmacologic Considerations in Early Childhood 301 et al., 2006, 2001). More than one in ten preschoolers discontinued methylphenidate due to adverse effects, which included appetite decrease, irritability, emotional outbursts, difficulty falling asleep, and repetitive behaviors/thoughts (Wigal et al., 2006). In the only comparative efficacy study of methylphenidate and parent management training, methylphenidate was more effective than PCIT at reducing disruptive behaviors in 35 preschool children who had already failed a behavioral intervention (van der Veen-Mulders, van den Hoofdakker, Nauta, Emmelkamp, & Hoekstra, 2017). Though the study is small, it suggests that in treatment-resistant cases, adding a medication may offer a benefit over continuing psychotherapy. The study’s findings do not guide decisions about children who have not had a trial of behavioral treatment. The PATS study, published in 2006, used immediate release methylphenidate because extended release medications were not extensively available when the study began. For preschoolers, initiating treatment with an immediate release medication is appropriate to establish tolerability and an effective dose. Doses can be titrated as quickly as weekly with close follow-up from caregiver and, when available, teacher reports using a standardized measure, which are described below. Once an effective and tolerable dose is established, transition to extended release formulation is appropriate to increase ease of full-day coverage with the stimulant and reduce stigma or logistical challenges associated with midday dosing, especially in a school setting. The PATS study was limited to 7.5 MG TID dosing by the IRB, but the PATS showed no evidence that methylphenidate doses are related to a child’s weight, making it more reasonable to use effectiveness and adverse effects to guide titration rather than the arbitrary limits in the PATS. Discontinuation trials of stimulants should be scheduled for low stress periods for the family, such as vacation times. Unplanned days without the medication should not be considered adequate discontinuation trials because these days are often associated with more family stress or disorganization that results in the unplanned missing of the dose.

Amphetamine Salts

Because there are no large, rigorous, controlled studies for other stimulant or non- stimulant medications in preschool ADHD, if methylphenidate is ineffective, pharmacological treatment decisions are guided by data extrapolated from school-age children. Reassessment of diagnosis, formulation, and adequacy of psychotherapeutic approaches should be assessed prior to switching to an amphetamine formulation. Only an open trial of 28 preschoolers has examined the effect of amphetamine, but inadequate sample size (only nine children received mixed amphetamine salts) precluded comparison with placebo or methylphenidate (Short, Manos, Findling, & Emily, 2004). However, an amphetamine formulation is generally the next recommended step, based upon data in older children, which suggests that amphetamine is at least as effective as methylphenidate in treating ADHD (Faraone, Biederman, & Roe, 2002). 302 J. Finelli and M. M. Gleason

As with methylphenidate, dosing should be started low with immediate release medication, generally 1.25 or 2.5 mg per dose, dosed BID. Once a dose is established, the comparable extended release medication can be prescribed.

Non-stimulant Medications

When methylphenidate and amphetamine formulations are ineffective, poorly tolerated, or contraindicated, alpha-agonists and atomoxetine may be considered after reassessment of the diagnosis and formulation as well as reassessment of the psychotherapeutic interventions. In a double-blind, placebo-controlled randomized clinical trial of 101 five- and six-year-olds with ADHD, atomoxetine was associated with significant treatment gains on parent and teacher symptom report measures although not global response or severity (Kratochvil et al., 2011). Doses were initiated at 0.8 mg/kg and titrated up to a maximum of 1.8 mg/kg and both the placebo and atomoxetine groups received behavioral support as well. The study found that nearly 30% of subjects on atomoxetine experienced weight loss, decreased appetite, sedation, and gastrointestinal discomfort, but that no subjects discontinued the medication as a result. There are no randomized controlled trials of alpha-agonists that focus exclusively on preschoolers, although they are effective in treating ADHD in school age children and adolescents (Hirota, Schwartz, & Correll, 2014). One case series reported decreased hyperactivity and other symptoms among maltreated preschoolers treated with clonidine (Harmon & Riggs, 1999). Information about safety of alpha agonists is demonstrated by extensive use in infants, toddlers, and preschoolers with cardiac problems. Studies in older school-age children have described adverse effects including sedation, irritability, bradycardia, and hypotension (Connor, Fletcher, & Swanson, 1999; Scahill et al., 2001). In overdose, these medications cause sedation, hypotension, or death, with rising rates of unintentional pediatric exposures reported to the National Poison Data System between 2000 and 2011 (Rachmiel, Johnson, & Daneman, 2006). This data highlights the importance of careful discussions with parents regarding safe storage and use of alpha-agonists when they are considered. Doses for alpha agonists generally start at 0.25 or 0.025 mg of guanfacine or clonidine respectively and can be titrated up based on symptom tracking and monitoring of adverse effects, including blood pressure. Summary: Psychopharmacologic treatment for preschoolers with ADHD for whom psychotherapy or behavioral strategies have been insufficient or is unavailable should begin with a stimulant, with non-stimulants being third and fourth line interventions. Tracking of symptoms can be done with an ADHD-specific measure like the preschool ADHD rating scale or a general symptom scale, depending on the child’s clinical presentation and co-occurring conditions or concerns. Trials of medications should be accompanied by ongoing psychotherapeutic interventions and family supports. 9 Psychopharmacologic Considerations in Early Childhood 303

Autism Spectrum Disorders (ASD)

The core symptoms of ASD include impairments in social communication and interaction, as well as the presence of repetitive/stereotyped behaviors (APA, 2013). Children with an ASD may present with significant emotional reactivity or tantrums, difficulties with peers, or developmentally atypical behavior patterns and often may experience comorbid ADHD, anxiety, and mood symptoms. The most recent data from the CDC identified an overall ASD prevalence rate of about 1 in 59 school-age children (1.5%) (Baio et al., 2018), and tracking data from five communities across the USA identified prevalence ranges of 8.5–19.7 per 1000 four-year- olds (Christensen et al., 2016). First-line treatment for children with ASD is multimodal early behavioral intervention including speech and language, occupational, physical therapy, and an ASD-specific intervention like Applied Behavioral Analysis, Floortime, or Early Start (AACAP, 2016). These interventions focus on promoting positive social engagement using discrete trials and positive reinforcement as well as promoting emotional regulation in the face of transitions. While effective, they do require substantial time investment for the child and family. Young children with ASD have high rates of exposure to medications in the community. One nationally representative study of children covered by Medicaid reported that 18% of children under 2 and 32% of 3–5 year olds had at least one claim for a psychopharmacologic agent (Mandell et al., 2008). Despite these high rates of exposure, there are limited data to support these high rates of medication use. Additionally, some children with ASDs are developmentally unable to participate in evidence-based psychotherapeutic treatments for their comorbid disorders, resulting in earlier use of medications. Finally, the high rates of exposure to medications likely reflect the high levels of impairment that can be related to ASD in young children. Tracking of effectiveness depends on the specific target of treatment. Studies examining the core symptoms of ASD have used rating scales such as the Childhood Autism Rating Scale (CARS) or the Child Psychiatric Rating Scale (CPRS). These measures which includes items relevant to ASD (such as withdrawal, underproductive speech, unspontaneous relation to the examiner, rhyth- mic motions, anger/uncooperativeness, and hyperactivity). Another commonly used tool to measure outcomes in ASD populations is the Aberrant Behavior Checklist (ABC), which includes subscales for irritability/agitation, lethargy/ social withdrawal, stereotypic behavior, hyperactivity/noncompliance, and inappropriate speech. The existing literature suggests that the symptoms that may be most responsive to pharmacological treatment are those related to behavioral control, affect regulation, and aggression. Working with caregivers to identify target symptoms of greatest concern can help determine whether medications can offer meaningful benefit (Arnold et al., 2003). 304 J. Finelli and M. M. Gleason

Atypical Antipsychotics

Two small randomized-controlled trials have reported some improvements in the core signs of autism, including social reciprocity and stereotyped, repetitive behaviors with risperidone, a finding different from those in older children (Luby et al., 2006; Nagaraj, Singhi, & Malhi, 2006). One of these studies was complicated by significant differences in the control groups, and reported no differences in groups at any of the single four time points, but did report what the authors described as a “minimal” change from baseline to the end of the study (Luby et al., 2006). Both studies reported substantial weight gain in children taking risperidone compared to placebo. Luby and colleagues also reported a threefold increase in prolactin associated with risperidone (Table 9.3). Additionally, an open label study of 53 preschoolers reported that nearly half showed global decreases in psychiatric symptoms, including hyperactive and impulsive patterns as well as social engagement patterns, but 52% discontinued risperidone (with 22% discontinuing due to adverse effects) (Masi, Cosenza, Mucci, & Brovedani, 2003). The weight of evidence supporting behavioral approaches like ABA and other approaches are far more robust than these two small randomized controlled trials and the adverse effect profiles for therapy are substantially less than for risperidone. For these reasons, guidelines do not recommend using risperidone to try to address core symptoms of autism in preschool children. Risperidone and aripiprazole have been approved for children with autism and severe irritability and/or aggression as young as age 5 and 6 respectively. Because of the potential for adverse effects including metabolic and endocrinologic, doses are generally low to start with careful monitoring of responses to titration. Monitoring of the adverse effects with close follow-up, parent history, and monitoring of growth parameters and laboratory values as recommended is important in this population.

Table 9.3 Randomized controlled trials of medications for preschoolers with autism spectrum disorders Treatment Study (dose) Participants Design Results Side effects Nagaraj RISP 1 mg 40 2–9 years 6-month 63% RIS with 2× weight gain RIS et al. daily old (mean age RCT 20% compared with PCB (2006) 5) improvement vs. transient sedation; 0% PCB transient mild dyskinesias Luby RIS 24 2.5–6 6-month RIS 8% change Transient sedation, et al. 0.5–1.5 mg years old RCT in CARS vs. increased appetite, (2006) daily (mean (mean age 4) PCB 3% hypersalivation dose 1.14 mg) RISP risperidone, RCT randomized controlled trial, PCB placebo, EPS extrapyramidal symptoms 9 Psychopharmacologic Considerations in Early Childhood 305

Other Medications

Psychotropic medications are frequently used to treat co-occuring conditions in preschoolers with ASDs. Children with ASD can have associated hyperactivity, aggression, tantrums, self-injury, impulsivity, and may also be at risk for anxiety disorder (AACAP, 2016). In general, children with neurodevelopmental disorders have higher rates of atypical or less robust responses and adverse effects (AACAP, 2016). For example, in a large study of school-age children, fewer than half responded to methylphenidate (RUPP, 2005). Similarly, although selective serotonin reuptake inhibitors (SSRIs) have been shown to be somewhat effective in reducing repetitive behaviors in some studies of children and adolescents, rates of adverse effects with SSRIs in children with autism are higher than neurotypical children (Lee et al., 2015; West, Brunssen, & Waldrop, 2009). For co-occurring symptoms, therapy is first line, but some of the evidence-based therapies that are first line for neurotypical children may not be effective or may need substantial adaptations, some of which are being developed (e.g., Masse, McNeil, Wagner, & Chorney, 2007) For example, adaptations for PCIT show prom- ise in reducing disruptive behavior patterns in young children with ASD. When therapy is not appropriate or is unsuccessful, pharmacologic treatment of comorbid conditions should follow recommendations for that disorder. Summary: First-line treatments for young children with ASD are behavioral interventions, and early detection and intervention is key in maximizing treatment response. While some studies have demonstrated improvement in core symptoms of autism with risperidone, it is not recommended to treat core symptoms; rather, it can be used as a second-line treatment strategy to treat associated severe irritability or aggression. As children with autism may be more sensitive to adverse effects of psychotropic medications, it is important for providers to use low doses and monitor carefully for side effects. Working with caregivers to identify target symptoms can help in deciding whether to initiate pharmacologic treatment, and in setting realistic goals.

Anxiety

Anxiety disorders are common in preschoolers, with an estimated prevalence between 10% and 20% (Bufferd et al., 2011; Franz et al., 2013; Wichstrøm et al., 2012). Despite the prevalence, there are very few studies examining the use of any treatments for preschool anxiety disorders. Psychotherapeutic approaches have some empiric support in addressing preschool anxiety disorders. Modified cognitive behavioral therapies (CBT) as well as modified parent management approaches have been shown to reduce anxiety in preschoolers in randomized controlled trials as well as open trial (Comer et al., 2012; Donovan and March, 2014; Hirshfeld- Becker et al., 2010). 306 J. Finelli and M. M. Gleason

Response to treatment of preschool anxiety can be tracked using the Preschool Anxiety Rating Scale (PARS) (Spence et al., 2001) or the Screen for Anxiety and Related Emotional Disorders (SCARED) (Birmaher et al., 1999). Neither should be used as a clinical screen, because the PARS does not have a defined clinical cut-off and the SCARED is not validated in this age group and therefore should only be used to track symptom change direction.

Medications

Strikingly, only a few case reports document the effects of pharmacotherapy in treating preschoolers with anxiety disorders other than Obsessive Compulsive Disorder (Table 9.4). Of eleven publications included in a 2014 review addressing psychopharmacological treatment of internalizing disorders in preschool children, nearly all were unsystematic case studies, most commonly of selective mutism (Barterian et al., 2014). Fluoxetine was the most commonly prescribed medication, followed by sertraline. Other medications included phenelzine, haloperidol, and buspirone. Based on this review, the authors concluded that there is inadequate

Table 9.4 Case studies of medications for preschoolers with anxiety Treatment Study Diagnosis (doses) Participants Results Side effects Coşkun, OCD, Escitalopram 11 3–5 OCD: 5/6 Behavioral Öztürk, & PTSD, (2–10 mg) years old improved disinhibition Zoroğlu Anxiety Anxiety: 3/3 (5/11), appetite (2012) disorders improved PTSD: disturbance (6/11), 3/3 improved sleep disturbance (3/11) Coskun & OCD Fluoxetine 6 3–5 years 5/6 much–very Behavioral Zoroglu (5–15 mg) old much improved disinhibition (5/6); (2009) decreased appetite, sleep, GI, headache (all 3/3) Harvey and Selective Fluoxetine 5 years old “speaking freely” “minimal” Milne mutism 20 mg (1998) Oner and OCD Sertraline 3 girls 4–5 Improvement on Behavioral Oner (2008) 25–50 mg years old CY-BOCS disinhibition (2/3) Ercan, OCD Fluoxetine 4 2–5 years Improvement on Behavioral Kandulu, 5–20 mg old CGI, CY-BOCS disinhibitiona and Akyol Ardic (2012) Harmon OCD Clonidine 7 3–6 years Improved Sedation on oral and Riggs 0.05–0.1 mg old aggression, peer clonidine (4); mild (1996) relationships skin irritation (7/7); PTSD (5/7) aRisperidone added to treat behavioral disinhibition 9 Psychopharmacologic Considerations in Early Childhood 307 research to support psychopharmacologic interventions in the preschool population. Since that study, a series that included three preschool-age children with anxiety disorders other than OCD or PTSD reported positive response to escitalopram (dose range 2–10 mg/day) in all three children (Coşkun et al., 2012). Nearly half of the 11 children in the trial that also included children with OCD and PTSD developed severe behavioral disturbances associated with the medication exposure. Additionally, a retrospective chart review of 39 children under 7 who took an SSRI, mostly for anxiety, reported that over one fourth experienced at least moderate severity adverse effect and nearly one fifth discontinued the medications due to the adverse effect (Zuckerman et al., 2007). Of the children who discontinued the SSRI due to adverse effects, all but one experienced behavioral activation. With this limited support for pharmacological interventions for treatment for preschool anxiety, clinicians and parents must weigh safety, efficacy, suffering, and impairment in making decisions. Psychotherapy is the recommended first line treatment, using a model that supports the family in exposure experiences, whether through cognitive behavioral approaches, parent management training approaches, or some adaptation. Attention to possible parental psychiatric referral may be especially important for preschool anxiety disorders, given strong probability of family history of anxiety and the need for parents to participate in exposure-based treatment (Gleason et al., 2007). If, after a psychotherapeutic trial, anxiety continues to be severely impairing, pharmacological treatment may be considered (Gleason et al., 2007). Although the guidance from published literature is limited, SSRIs would be first-line treatment in such cases, extrapolating from data in older children and the limited case reports in young children. Fluoxetine has been reported the most commonly and has the strongest safety profile in older children but sertraline or (es)citalopram may be considered if there is a compelling clinical consideration or family preference reason (Bridge et al., 2007). Dosing information from the reported cases seem to guide towards the smallest possible doses as starting doses with titration to effect. A number of published reports describe 2 mg/day fluoxetine as the starting dose, with doses from 5 mg/day up to 20 mg/day described as the effective doses (Dummit et al., 1996; Harvey and Milne, 1998). Summary: The limited data focused on treatment of preschool anxiety disorders is striking, with high rates of adverse effects in the small numbers of patients studied on an SSRI. However, based on data in older children, if psychotherapy is ineffective and a child has severe impairment or suffering, an SSRI would be considered first line pharmacologic treatment, with close monitoring for adverse effects, especially activation.

Posttraumatic Stress Disorder (PTSD)

In preschool PTSD, there is strong empirical evidence supporting psychotherapeutic interventions including both cognitive behavioral therapy (CBT) approaches as well as the more relationally based child parent psychotherapy or infant parent 308 J. Finelli and M. M. Gleason psychotherapy (Cohen et al., 2004; Lieberman et al., 2005; Scheeringa et al., 2011). CBT can be adapted for use in children as young as three using visual aids, developmentally appropriate measurements for feelings scales, and parent involvement (Scheeringa et al., 2007). Child parent psychotherapy and its partner infant parent psychotherapy are dyadic interventions which aim to support and strengthen the relationship between parent and child as a vehicle for improving the child’s behavioral, cognitive, and social functioning (e.g., Cohen et al., 2004; Lieberman et al., 2005; Scheeringa et al., 2011). If these treatments are not available, play therapy— which has not been supported by randomized controlled trials—is still recommended before medications (Coates and Gaensbauer, 2009; Gleason et al., 2007). This recommendation is guided by some reports of effects of play therapy for PTSD in the development of a cohesive narrative and also because of the lack of empirical evidence for medications for PTSD in older children (Cohen et al., 2007; Robb et al., 2010). Treatment of PTSD also requires ensuring safety, and environmental interventions. Practice guidelines do not offer psychopharmacologic recommendations in cases when psychotherapies and safety do not reduce signs of PTSD because there are no data suggesting medications are effective in preschoolers or older children with PTSD. Anecdotal experiences suggest clinicians tend to select SSRIs to target anxiety or alpha agonists to address the autonomic reactivity in young children with PTSD. SUMMARY: Psychotherapeutic approaches to preschool PTSD are recommended. Pharmacologic treatments of co-occurring disorders are recommended before consideration of pharmacologic treatment of PTSD, for which no data exists.

Obsessive Compulsive Disorder (OCD)

There is somewhat more information regarding pharmacotherapy for OCD in preschoolers than other anxiety disorders. While the prevalence of childhood-onset OCD is about 1–2%, there is limited data regarding the prevalence of OCD among very young children as the major epidemiologic studies have not included OCD (Bufferd et al., 2011; Egger and Angold, 2006; Wichstrøm et al., 2012). However, case reports have described OCD symptoms in children as young as 2 years (Ercan et al., 2012). Compulsive patterns in young children often present with impairing emotional outbursts related to the disruption or interruption of the compulsion and must be differentiated from other disorders including disruptive behavior through careful assessment. While the Child Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997) has not been validated in preschoolers, it offers a comprehensive review of possible obsessions and compulsions and a structured way of measuring severity, so may be useful in tracking symptoms in children being treated for OCD. Family-focused CBT has been rigorously studied for 5–8 year-olds with positive findings, but literature reviews do not reveal rigorous trials or even case reports of 9 Psychopharmacologic Considerations in Early Childhood 309

CBT for preschoolers with OCD (Freeman et al., 2014). On the other hand, numerous case reports and series describe the psychopharmacological treatment for preschoolers with OCD (Coskun and Zoroglu, 2009; Ercan et al., 2011, 2012; Oner and Oner, 2008). These four case series and retrospective chart reviews of up to 14 children 26–63 months old, report improvements in most children on sertraline or fluoxetine, but also high rates of behavioral disinhibition, often resulting in polypharmacy and or discontinuation (Coşkun et al., 2012; Coskun and Zoroglu, 2009). When possible, CBT with exposure–response prevention is first-line treatment due to safety and durability considerations. Extrapolating from the successful approaches in young school age children, parent involvement in treatment plays an important role in preschool adaptations of CBT for OCD. Additionally, after therapy, pharmacologic treatment of comorbid conditions, including ADHD, should be considered before considering a medication for OCD, given the limited efficacy data and high rates of disabling activation reported with SSRIs (Zuckerman et al., 2007). When a medication is considered to treat a preschoolers’ OCD, fluoxetine, escitalopram, and/or sertraline may be considered. Dosing generally starts very low and is titrated with close monitoring for behavioral disinhibition as well as other adverse effects. Avoiding polypharmacy to treat adverse effects is recommended. With treatment failures, reassessment of symptoms and formulation is warranted, reconsideration of access to therapies, and ultimately, a second SSRI trial may be considered. Summary: Guidance for OCD treatment in preschool is limited, but CBT is recommended as first line treatment, followed by cautious consideration of an SSRI.

Sleep

Sleep problems in preschoolers are very common, with recent studies finding prevalence rates close to 20% in this age group, although specific criteria for disorders vary across disciplines and research studies (Steinsbekk et al., 2013). The differential diagnosis for sleep problems is broad, and includes sleep hygiene, environmental factors, restless leg syndrome/periodic leg movement disorder, psychiatric disorders, medication side effects, and obstructive sleep apnea (OSA), which has an estimated prevalence of 1–5% of children. The American Academy of Pediatrics recommends that all children be screened for snoring, and that polysomnography be performed in all children with snoring and signs/symptoms of OSA (Marcus et al., 2012). Sleep disorders can also be related to other psychiatric disorders, especially depression, generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and ADHD. Tracking of sleep problem treatment response can be done with sleep diaries and careful histories about bedtime, sleep latency, and nighttime arousals. For preschool children with sleep problems, parent education is the first step. The conversation includes discussion of developmental sleep patterns and potential risks of OTC medications (Morgenthaler et al., 2006). Additionally, sleep hygiene 310 J. Finelli and M. M. Gleason and behavioral interventions should also be implemented as first-line treatments (Mindell et al., 2006). Behavioral interventions may include approaches such as graduated extinction for children with sleep association problems in which they have learned to fall asleep only if a caregiver is physically present. For behavioral interventions, a brief trial of at least 4 weeks is recommended. Medications to treat insomnia are not well studied in young children (Licis, 2017). If behavioral treatment fails, however, and the child’s daytime functioning is impaired, a short course of medication can be considered in combination with ongoing behavioral interventions (Owens et al., 2006).

Melatonin

Several studies in school-age children have demonstrated reduced sleep latency when melatonin is given at bedtime (Smits et al., 2003; Van der Heijden et al., 2007; Weiss et al., 2006). Although empiric basis for dosing recommendations are unavailable, starting doses of 1–3 mg have been recommended in preschoolers with a trial of about 10–14 days (Weiss et al., 2006). Need for continuation of medication should be reassessed after one month (Gleason et al., 2007).

Clonidine

Clonidine is commonly used in children for sleep problems, although with limited empiric support. Case series in older children describe improvement in sleep problems in school-age children with sleep problems and comorbid psychiatric conditions (Ingrassia and Turk, 2005; Prince et al., 1996). One systematic chart review included children between 4 and 17 years of age with ADHD, finding improved parent reported CGI-S scores in 85% of subjects (Prince et al., 1996). Side effects in these studies were generally mild, and included morning sedation and fatigue. Importantly, clonidine has a narrow therapeutic index with toxicity associated with ingestion, including respiratory depression and hypotension (Rachmiel et al., 2006). Careful discussion with parents about safe storage and administration of clonidine is recommended due to this narrow therapeutic window.

Diphenhydramine

Diphenhydramine is a familiar medication for families of young children due to its use for allergic reactions and is also used commonly for sleep. A study of 50 children 2–12 years of age published in 1976 reported diphenhydramine was superior to placebo in reducing sleep latency and night awakenings (Russo et al., 1976). However, more recently a study of infants 6–15 months of age showed no effect of diphenhydramine on sleep and a study of older children showed no acute effect for children with cough and sleep problems. (Merenstein et al., 2006; Paul et al., 2004). 9 Psychopharmacologic Considerations in Early Childhood 311

Young children may experience a “paradoxical effect” of antihistamines, resulting in higher energy and emotional dysregulation, which must be part of any informed consent process related to use of diphenhydramine for sleep. Summary: Sleep problems are among the most common concerns of parents and cause significant distress and suffering as well as exacerbate other conditions, pharmacologic interventions for sleep are poorly studied. Behavioral strategies have more support for efficacy, but require a substantial investment on the part of parents. For children for whom these interventions have not been effective or cannot be implemented, melatonin may be the option with the fewest known risks and some data supporting its use. Some children may benefit from diphenhydramine, but the research support is extremely limited and contradictory. Clonidine has notable safety risks related to safe administration but may have some efficacy as well.

Disorder of Dysregulated Anger and Aggression

Problems with mood and behavior regulation are among the most common reasons young children present for mental health services. The Disorder of Dysregulated Anger and Aggression (DDAA) is presented first in the Diagnostic Criteria:0–5 (DC: 0–5) (Zero to Three, 2016). DDAA describes a syndrome of problematic regulation of mood, resulting in a presentation characterized by both dysregulated mood and behaviors (Zero to Three, 2016). Prevalence is expected to be fewer than 10% of the general population, based on existing data. The children meeting the diagnostic criteria are impaired, with problems functioning in multiple relationships and contexts. Because the syndrome was only defined in 2016, there are no published studies of treatment for the specific syndrome. However, treatment of disruptive behaviors disorders has been examined extensively. A robust literature describes the efficacy of parent management training (PMT) approaches (Eyberg et al., 2008). These approaches generally support parent child interactions that promote positive behaviors through positive reinforcement, withdraw support for inappropriate but not unsafe behaviors, and implement consistent, safe consequences for unsafe and unacceptable behaviors. Despite the robust support, these programs generally report drop-out rates of approximately 30% and families often have limited access to them even if they are interested in the treatment (Kazdin, 2005). Symptom tracking for DDAA or other categorical descriptions of similar patterns may be done using general early childhood symptom measures presented in Table 9.1 or proprietary tools, such as the Eyberg Child Behavior Checklist (Eyberg and Pincus, 1999). There are no rigorous studies that examine the efficacy of pharmacotherapy for the signs of DDAA, oppositional defiant disorder, conduct disorder, or mood disorders in preschoolers. Case reports and case series of pharmacotherapy offer some information about clinical efforts to address disruptive behavior problems in young children. While these reports are valuable descriptions of experiences, they cannot 312 J. Finelli and M. M. Gleason offer information about the relative efficacy of the pharmacotherapy compared to placebo or psychotherapy and rarely offer rigorous information about safety. These case series have included children, often with a range of diagnoses and sometimes including a number of different medications including stimulants, antiepileptics, and antipsychotic agents (Cesena et al., 2000; Coskun and Zoroglu, 2009; Staller, 2007). The most rigorous was an 8-week prospective open-label trial of risperidone titrated to a mean of 0.8 mg/day in 12 preschool children with conduct disorder (Ercan et al., 2011). All children experienced a decline in symptoms of disruptive patterns and overall improvement on a global scale. Although generally well tolerated, this group showed an asymptomatic sevenfold increase in prolactin levels. Following the principle of primum non nocere, stimulants offer the lowest physiologic risk of medications that have been used for aggression in older children and may be helpful in reducing impulsive dysregulation in preschoolers with DDAA. Alpha-agonists have been effective in some preschoolers as well as older children in reducing aggression and may be considered in families able to administer as prescribed, meaning not likely to change the dosing timing or number of pills without discussing with the clinician (Harmon and Riggs, 1999). Summary: Balancing the relative weight of safety and efficacy data for PMT and pharmacotherapy for DDAA, family-focused therapy is first line treatment. PMT can address aggression and may be promising for mood regulation as well.

Depression and Mood Problems

Depressive disorder in the preschool period is well validated and well-described. It occurs in 1–2% of preschool children (Egger and Angold, 2006; Wichstrøm et al., 2012). Depression in preschoolers can cause substantial impairment and can be associated with physiologic markers as well. Interestingly, little research has examined treatment for this impairing disorder. One study has examined the efficacy of a modified parent management training approach, Parent-Child Interaction Therapy-Emotional Dysregulation, and demonstrated a large effect on depression as well as decreases in both internalizing and externalizing symptoms (Luby et al., 2011). Treatment effects for depression can be measured using the Preschool Feelings Checklist, which was specifically developed for this purpose (Luby et al., 2004). Interestingly, no studies have examined the effects of pharmacotherapy on depression, which may reflect anecdotal experience that depression often responds to nonspecific treatments and psychotherapy. Importantly, two retrospective chart reviews have described adverse effects of SSRIs in preschoolers, with discontinuation rate of up to 20% due to adverse effects (Lee et al., 2015; Zuckerman et al., 2007). Therefore, for preschool children whose depression does not respond to supportive interventions, including parent support, parent psychiatric treatment as indicated, supportive play or dyadic therapy, and whose depressive symptoms continue 9 Psychopharmacologic Considerations in Early Childhood 313 to be impairing, SSRIs can be considered with caution, recognizing the risk of adverse effects including activation and emotional side effects. In contrast with depression, the validity of bipolar disorder criteria in preschoolers remains controversial in the field, despite efforts to validate the criteria (Luby and Belden, 2006). The only epidemiologic study of preschool psychopathology that examined rates of bipolar disorder (n = 1250 preschoolers) found no children who met criteria for bipolar disorder (Wichstrøm et al., 2012). In contrast, in a sample of US preschoolers selected for mood problems, 8.5% met criteria for mania, although many clinicians and researchers continue to question the application of these criteria in this age group (Gleason and Teverbaugh, 2016; Luby and Belden, 2006). Strikingly, there are many more reports describing pharmacologic treatment of presumptive bipolar disorder, despite lack of validation of the criteria in this age group. Of these, one is a randomized controlled trial (Kowatch et al., 2015) in which 46 preschoolers were randomized to risperidone, valproate, and placebo with significantly greater decreases on the Young Mania Rating Scale on risperidone compared to the other two arms of the study. Children who took risperidone also had significantly higher weight gain and increases in prolactin, for which the authors urged caution in using this medication in this population. Other published reports and case series focused on other atypical antipsychotic agents and mood stabilizers in combination with other classes of medications have been less systematic in selection of medication as well as in diagnostic approach and therefore offer little guidance to families and providers (Biederman et al., 2005; Pavuluri et al., 2006, 2002; Scheffer and Niskala, 2004). Clinicians considering the diagnosis of bipolar disorder are encouraged to consider peer consultation and a broad differential diagnosis, given the lack of bipolar disorder identified in the epidemiologic study that examined it. Should the diagnosis seem to best describe the clinical situation, clinicians are encouraged to consider some of the same approaches that are recommended for DDAA, given that the impairment from both disorders would be expected to come from overlapping symptom profiles. In the case of non-response to therapy and after reassessment of the formulation and confirmation of the diagnosis through a careful reassessment process, pharmacotherapy would follow similar recommendations used in older children, with attention to the high rates of adverse effects in preschoolers. The DSM-5 Dysregulated Mood Disorder with Dysphoria (DMDD) is explicitly not applicable to preschool-age group according to the DSM-5, although about 3% of preschoolers meet all but the age criteria (Copeland et al., 2013). To date, no pharmacologic studies examine treatment of these children in the preschool age and it is recommended that the diagnosis be reassessed, with attention to effective treatment of the comorbid conditions. Summary: Preschool depression is likely to respond to psychotherapeutic approaches. Although no rigorous data support the efficacy of SSRIs in this age group to treat depression, these medications would be first line if medications were considered. Bipolar disorder remains controversial and without well accepted validity in this age group. DMDD cannot formally be applied to this age group. 314 J. Finelli and M. M. Gleason

Case Vignette

Identifying information: Wendy is a 58-month-old African American English- speaking girl with a history of gastroschisis (congenital gastrointestinal malformation) and ongoing paresis (delayed emptying of the stomach) presenting to specialty mental health program with her mother. Her mother reported that she was concerned about signs of impulsivity and irritability. History of Presenting Concerns: The symptoms had been present for as long as her mother could recall but seemed to worsen after each abdominal surgery. Her mother reported that Wendy is impulsive, climbing on furniture, interrupting in play and in conversations. She cannot sit in circle time at school or for meals at home or at school and loves to read with her mother but only sits through about half a book. When she wants a toy in her childcare center, she takes it from other children, but tries to comfort them if they get upset. She has hit other children when they take toys she is playing with. Her impulsivity has resulted in her running into the street and her child care providers have said that she is not learning because she runs out of the classroom regularly. Additionally, her mother described what feel like intense emotional reactions to small events like not being able to get a treat she wants, sometimes yelling or stomping her foot. She has tantrums that last under 1 min and then she then returns to baseline.

Social and Family History

Wendy lives with her mother, father, and 7-year-old brother in an urban neighborhood in the southern USA. Her extended family lives in the same neighborhood and provides support to her parents by watching her after school. The extended family gathers weekly on Sunday for a family dinner and identifies as Catholic, and Wendy and her family do not attend services regularly. Her family history is notable for maternal PTSD related to exposure to Hurricane Katrina as well as PTSD symptoms associated with Wendy’s medical procedures. Her brother was diagnosed with ADHD at age 5 and her father was never diagnosed with ADHD, but he reported that he thinks he should have been because he never could pay attention or finish homework even though he had known the material. She has attended Head Start since she was 3. She enjoys playing with other children.

Child Medical and Developmental History

Prior to her referral, she had been treated with three ineffective stimulant trials for “behavior” by her pediatrician and a neurologist, an alpha agonist trial which made her more irritable, promethazine, antihistamines for episodic sedation on plane rides, and melatonin. At the time of referral, she was taking a stimulant and guanfacine for impulsivity, and DDAVP for primary daytime enuresis (prescribed by her pediatrician). She had not received any psychotherapeutic interventions. 9 Psychopharmacologic Considerations in Early Childhood 315

She was born full term with prenatally diagnosed gastroschisis and spent 8 weeks in the NICU after repair of her abdominal congenital malformation. She had multiple procedures in the first years of her life. She has met developmental milestones on track except for walking at 16 months and is cognitively on track.

Behavioral Observations

Dyadic: In the office, Wendy explored the toys vigorously while her mother cautioned her repeatedly about “being careful” and “don’t touch that.” Wendy tended to touch things more as her mother cautioned her and her mother’s volume increased as her play became more vigorous. She did seek comfort from her mother when a toy fell on her and she was easily consoled. Family: Her father was not able to participate in the assessment and her brother refused to come in the room because “we always go to her appointments.”. In the waiting room, he appeared impatient with his sister and made little eye contact with the interviewer, but knocked on the door during the evaluation to ask his mother for snacks and her phone. Individual: Wendy was active but redirectable in the office and could sit and talk about her feelings with the interviewer when high doses of positive reinforcement were used. She interrupted regularly and avoided answers about feelings. Her speech was clear with full sentences when describing her friends, her favorite games, and her desire be a doctor when she grows up. The assessment also included the Crowell parent–child interaction procedure and the Working Model of the Child Interview (WMCI). In the Crowell, Wendy led the play throughout and was somewhat controlling in free play. In the bubbles sequence, they shared joy genuinely. Her mother was encouraging with difficult puzzles and Wendy did not persist in trying the puzzles that were hard for her. At separation, she voiced loud distress and at reunion she approached her mother but was not easily consoled. The WMCI was notable for preoccupations around medical concerns and themes of Wendy’s vulnerability as well as overly positive narrative compared to the level of concerns shared in the remainder of the interview.

Diagnosis, Formulation, and Plan

Assessment was conducted over multiple appointments and throughout the treatment course, using relationship assessments, clinical observation, and detailed history taking to inform diagnostic formulation (with attempts made to involve multiple informants when possible). This comprehensive assessment resulted in diagnoses of ADHD and previously unidentified posttraumatic stress disorder related to a hurricane, as well as parent–child relationship disorder fueled by parental PTSD related to the congenital malformation and ongoing perception of the Wendy’s extreme medical vulnerability, as well as Wendy’s emotional and behavioral dysregulation in the context of maternal distress. It seemed that, in addition to addressing observable 316 J. Finelli and M. M. Gleason patterns of symptoms, the medications represented a way that this mother was trying to protect her child, whom she saw as vulnerable and requiring intensive medical intervention. Intervention included Parent Management Training with a focus on encouraging self-regulation and age-appropriate autonomy as well as individual therapy focused on maternal perceptions of the child’s vulnerability. Wendy’s mother demonstrated improved ability to identify Wendy’s emotional needs and to use positive parenting techniques. Although the parent–child relationship improved, Wendy continued to demonstrate impulsive and hyperactive behaviors, which at times interfered with her functioning in the home and preschool setting. After careful discussions with Wendy’s caregivers regarding the indications, risks, and possible side effects of medications, the decision was collaboratively made to gradually discontinue medication, decreasing the dose as the effects of therapy were evident, including improved impulsivity, sleep hygiene, and parental self-efficacy related to sleep. DDAVP was also discontinued, as age-appropriate toileting was encouraged by using behavioral approaches and supporting maternal acceptance of age-appropriate autonomy. She was discharged back to her primary care provider with a school transition plan. Conducting a comprehensive assessment over time, with care given to evaluating the quality of the parent–child relationship and providing simultaneous psychoeducation and rapport building, allowed for a more well-rounded and patient-centered clinical formulation. By providing intervention to support the parent–child relationship and promote positive caregiving interactions, maternal distress decreased, allowing for decreased reliance on pharmacotherapy. This case example does not represent algorithmic-based treatment, as the child was on medications prior to psychotherapeutic interventions. Had she been seen in an infant mental health treatment site for initial evaluation, first line treatment would have been a psychotherapeutic approach. Had a psychotherapeutic intervention been insufficiently effective, monotherapy would have been the next recommended approach, with a decision about whether sleep or ADHD was causing more impairment and/or was more likely to respond to medications. When meeting a child already on medications, clinicians must consider the appropriateness of the medication to the clinical presentation, potential risks related to the medication, the reported benefits associated with the medication, and the risks of discontinuing the medication. Among the most important risks associated with abrupt discontinuation of a treatment parents view positively is the alliance with the family. If a medication does not match the clinical presentation, has significant risks and/or no reported benefit, discontinuation is easy to do. However, in the case of medications not inappropriate to the clinical presentation, medications with few risk factors and/or substantial benefit reported by the family, it is important to understand the meaning of the medication for the family to shape discussions around decreases or discontinuation. In this case, as is especially common in children with significant medical conditions, medical intervention was seen as the “go to” intervention approach that had saved their child’s life as it pertained to the congenital GI malformation and the medical experiences had also reified a belief in the parents that they 9 Psychopharmacologic Considerations in Early Childhood 317 did not have the skills to contribute to her medical care. Thus, the therapeutic alliance and therapeutic work was necessary to create the trust in the clinician and the self- efficacy in the family to move towards decreasing medication.

Summary

Consideration of medication treatment in very young children is a multistep process. The first step in the process requires careful assessment of the child’s clinical presentation, a multiaxial, relationally based diagnostic approach that identifies community, family, relationship, and developmental targets of treatment as well as the child’s individual within-patient diagnosis. The clinical context is influenced by a range of factors including access to primary and specialty care, health care disparities, regulatory issues, insurance status and involvement in foster care, rapid development, parental and clinician attributions, and a limited evidence base. Guidelines exist to support clinicians in considering psychopharmacologic treatment. Clinical experiences suggest that medications can play valuable adjunctive roles in a comprehensive treatment plan when other interventions are insufficiently effective. For children and families with limited access to evidence-based interventions, or for whom therapeutic interventions have limited benefit, psychopharmacological approaches can be considered. Because of the many unknowns involved, however, clinicians must have a solid understanding of the evidence and gaps in the evidence when discussing medication trials with parents during an informed consent process. Because developmental differences in young children may influence both effectiveness and safety, clinicians start with low doses, monitor closely for side effects, consider the effects of rapid development on therapy effectiveness, track outcomes systematically, and plan a discontinuation trial. In this as in other aspects of clinical care, clinicians use information from a quality assessment, practice guidelines in combination with reflective practice and professional humility to partner with families to develop effective treatment plans for the youngest patients (Fig. 9.1).

Mul-modal, mul-informant, mul-session assessment should guide the process Informed consent is a collaborave process that includes review of exisng data, unknown risks & benefits, and enough me for a caregiver to truly consider opons Selecon of medicaon should be directly linked to a carefully derived diagnosis and formulaon and follow exisng evidence in young children, and when not available, in, older children Medicaon trials should be iniated with clearly defined outcomes and plans for tracking outcomes and adverse effects Ineffecve medicaon trials should trigger reassessment of diagnosis and reconsideraon of therapeuc opons Medicaon trials should be finite with a well-defined meline for disconnuaon

Fig. 9.1 General principles in approaching psychopharmacology in young children 318 J. Finelli and M. M. Gleason

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Vivian L. Tamkin, Bhavin Dave, Adeela T. N. Whittaker, and Karen A. Frankel

Following a comprehensive assessment, clinical formulation and treatment planning are key elements required in providing sound treatment. A direct link from the comprehensive assessment, the clinical formulation provides an overall summary of the presenting concerns reported and experienced by the family. Following the completion of the clinical formulation, the treatment plan then helps to organize and direct the therapist’s approach to addressing concerns of the caregiver. This chapter provides an overview of case formulation and treatment planning, as well as an understanding of the significance culture plays in developing a joint case formulation and treatment plan with a caregiver. Further, this chapter presents a brief overview of interventions, both therapy and pharmacological, which can be considered with young children as part of the case formulation and treatment planning process.

V. L. Tamkin (*) The Department of Counseling Psychology, University of Wisconsin-Madison, Madison, WI, USA e-mail: [email protected] B. Dave Infant and Toddler Mental Health Program, Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC, USA e-mail: [email protected] A. T. N. Whittaker JAW Solutions, LLC, Atlanta, GA, USA K. A. Frankel Department of Psychiatry, Irving Harris Program in Child Development and Infant Mental Health, University of Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2019 327 K. A. Frankel et al. (eds.), Clinical Guide to Psychiatric Assessment of Infants and Young Children, https://doi.org/10.1007/978-3-030-10635-5_10 328 V. L. Tamkin et al.

Approaches to Clinical Case Formulation

Defining Clinical Case Formulation

Before delineating approaches to case formulation, it is important to know how this clinical skill is defined since there are various interpretations. In their third edition of Persuasion and Healing, Frank and Frank (1991) asserted principles that are essential in all definitions of clinical case formulation. First, there has to be a direct connection between the conceptualization of the problem and the interventions. Second, the value of the treatment plan is gauged by its usefulness in resolving the client’s concerns. Ingram (2016) defined a clinical case formulation as a “conceptual scheme that organizes, explains, and makes sense of large amounts of data and influences treatment decisions” (p. 96, as cited in Ingram, 2016). Eells (2007) defined case formulation as “a hypothesis about causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems (p. 4). Case formulation has also been described as “an element of an empirical hypothesis-testing to clinical work” (Persons & Tompkins, 2007, p. 291),” as well as “whole point…the development of interventions that will achieve certain therapeutic goals” (McWilliams, 1999, p. 11). Further still, case formulation has also been characterized as “an explanation of how the client’s problems have developed and what maintains them, as well as what can be done in therapy to address them” (Goldman & Greenberg, 2015, p. 3). Despite several descriptions of case formulation, there is no single agreed upon definition; however, “there is consensus on its purpose in clinical practice: to explain the child’s problems and provide guidance for treatment planning” (Ingram, 2016, p. 233). A source of confusion for clinicians is that the terms case formulation and case conceptualization, are frequently used interchangeably. A distinction, however, is that “the conceptualization, based in theoretical knowledge and access to the scientific literature is just one component of a formulation” (Ingram,2016 ). Ingram (2016) states further that outcome goals are a part of the formulation, however, are separate from the conceptualization: “clinicians from different theoretical schools should agree on the outcomes goals for a clinical case but are likely to differ in their conceptualization” (p. 234). There is difficulty in interpreting the literature on case formulation, given the various forms are often clustered together. However, there are a number of distinctions made. One distinction is between idiographic (created for a specific individual) and nomothetic (applied to individuals who are members of an identified group) (Ingram, 2016). An example of a nomothetic formulation is an empirically supported treatment (EFT), which assumes to fit all individuals who meet the inclusion criteria for a single DSM V or DC:0-5 diagnosis. Another distinction made is between explicit and implicit formulations. Many clinicians are likely guided by understood (or implicit) rather than clear or overt (explicit) formulations. On occasion the case formulation literature purports that certain schools of therapy, for example, humanistic, avoid formulations; however, 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 329

“all therapists rely on implicit formulations” (Ingram, 2016, p. 234). Ingram adds further that when case formulation is understood as a theoretical model that explains child’s problems and presenting concerns and leads to treatment results, no diligent therapist would function without one. Product versus process is another distinction made in the case formulation literature and can refer to either a written or verbal report of findings (Eells,2007 ; Ingram, 2016). Irrespective of the end product, developing a clinical case formulation is a continuous process, and especially in infant and early childhood mental health should be a collaborative experience between the family and the clinician. Several theoretical approaches to case formulation exist and a thorough examination of each is beyond the scope of this chapter. However, it is important to provide a brief overview that the major theories of personality development, that is, psychodynamic and cognitive, have each established case formulation perspectives. For example, psychodynamic approaches focus primarily on unconscious mental processes and relational conflicts (Perry, Cooper, & Michels,1987 ; Summers, 2003) and a cognitive therapy formulation might focus on core and intermediate beliefs and maladaptive coping skills (Beck, 1995; Freeman, 1992). Comparatively, a behavioral formulation might focus primarily on the individual’s learning history and a functional analysis related to environmental contingencies of reinforcement and model/learned behavior (Haynes & O'brien, 1990; Wolpe & Turkat, 1985). In infant and early childhood mental health, clinical case formulations can use any of these theoretical approaches; though, what is key is the inclusion of a relational approach, that is, contextualizing the formulation from the child-and-caregivers’ relationship at the forefront. Another approach to clinical case formulations includes cultural formulations which lend greater context to a child’s and caregiver’s lived experiences and shared understanding of presenting concerns. The use of a cultural formulation is a means by which the caregiver and therapist coconstruct additional understanding of presenting concerns in relation to the family’s racial/ethnic status, immigration story, as well as psychological residuals of racism and oppression (Boyd-Franklin, 2006; Comas-Díaz, 2012; Hardy, 2008). One widely used method to gather information on the family’s understanding of culture on presenting concerns is the Cultural Formulation Interview (CFI) (APA, 2013). The CFI assists the caregiver and clinician in developing a shared understanding across several domains: (1) Cultural definition of the problem; (2) Cultural perceptions of cause, context, and support; (3) Cultural factors affecting self-coping; and (4) Cultural factors affecting current help seeking. Why is this important? Having an increased understanding of families lived cultural experiences bolsters the therapist’s clinical case formulation, which thereby leads to individualized, strengths-based treatment plans. Another widely used method to gather information the family’s understanding of culture on the presenting concern is the use of the “Five Ps” approach to clinical case formulation. While not as explicit in posing direct question as the CFI, a general Five P clinical case formulation approach will also lay the foundation in increasing the therapist’s and family’s understanding of cultural underpinnings of a child’s presenting concerns. Macneil, Hasty, Conus, and Berk (2012), presented five 330 V. L. Tamkin et al. domains with which a clinician integrates to develop a bridge between assessment and treatment planning. The Five Ps are: 1. Presenting problem. This first P goes beyond just simply stating a child’s diagnosis. A clinician and a family work together identifying difficulties and understanding how the presenting problem is impacting the child’s daily routine and overall functioning. Asking caregivers to provide details on when, under what conditions, and how frequently the problem is occuring lends increased support toward targeted, individualized, and culturally relevant interventions. 2. Predisposing factors. This consists of identifying possible biological factors (e.g., complications at birth), genetic susceptibilities, (e.g., familial mental health history), environmental factors (e.g., trauma history), as well as sociocultural factors (e.g., racism, discrimination), which may contribute to the child’s current presenting concerns. 3. Precipitating factors. This includes obtaining clarity on the event or series of events which elicited the presenting concerns, as well as understanding the “why now” for the child and family. It is important for the therapist to know such things as the following: Why is the child coming for assessment at the current time? Has the child experienced the presenting concerns previously? If so, what is different this time? 4. Perpetuating factors. This includes factors that maintain the current presenting problem. Repeating behavioral patterns, untreated mental health needs, avoidance, and perceived racism are examples of perpetuating factors. 5. Protective/positive factors. There are several strengths that will assist a child and caregivers in meeting therapy goals. Families may be members of support or church groups to whom they turn for help. Families can be resilient, able to problem-solve with support, and possess a desire for symptom relief. A joint exploration of strengths instills hope in both the family and therapist, which can contribute to a more collaborative therapeutic alliance.

Age-Related Considerations in Case Formulation

Clinical case formulation is especially important in infant and early childhood mental health where young children have a limited repertoire of behaviors or symptoms which they use to express a wide range of distress. Very young children, in particular, possess neither the ability to self-reflect and identify symptoms nor language skills to express those symptoms verbally. As a result, whether the etiology is Attention-Deficit/Hyperactivity Disorder (ADHD), anxiety, depression, trauma, developmental delay or psychosocial stressors, the final common pathway of presentation is likely a nonspecific pattern of symptoms, emotional outbursts or distress, withdrawal and or challenging behaviors. These nonspecific presentations can cause great consternation in caregivers, who are left to manage these outbursts, distress and disruptive behaviors without any 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 331 insight into what may be causing them or any direction in how to solve them. This often leads caregivers to develop their own causal explanations of the behavior based on misinformation from family, friends, or popular mythology. When caregiver explanations miss the mark, subsequent ineffective or frustrating attempts to deal with the emotional distress and disruptive behaviors finally lead to helplessness and desperation. Caregiver hopelessness and desperation is the most likely cause for families to seek professional help. In this context, an explicit comprehensive clinical formulation accounting for psychopathology, contributing medical factors, temperament, attachment patterns, developmental stage and/or psychosocial factors, is represented in the context of a “story” (ZERO TO THREE, 2016). It is organized in an accessible and collaborative fashion, should provide clarity, transition from nonspecific presentations to specific etiologies, and provide a pathway to resolution that is otherwise unavailable to the caregiver.

Cultural Considerations in Case Formulation

Cultural considerations are crucial in case formulation. The American Psychiatric Association (2013), defines the concept of culture in the following manner—culture “refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations” (p. 749). Sarche, Tsethlikai, Godoy, Emde, and Fleming (2018) add that “Culture can be defined as meaning that is shared by a group of people—with shared values, assumptions, beliefs, and practices that are transmitted across generations and are brought to life through the daily behavior and interactions of people within a group (italics added).” Broadly defined culture includes, though is not limited to: language, race, ethnic practices, religion, spiritual- ity, morals, family systems, cuisine, social habits, and values (Sue & Sue, 2016). It is through parenting that culture is transmitted intergenerationally. But culture also shapes caregiving practices and behaviors, values, goals and aspirations, and in turn, shapes the caregiving that then passes along culture (Sarche et al., 2018). Culture impacts how caregivers understand their children’s behaviors, thoughts and intentions. Since it is impossible to understand the young child outside of the context of their primary parenting and caregiving relationships, understanding the impact of culture on these relationships, and on the child, is paramount. It is critical to incorporate a family’s report of their customs and values in a case formulation, as well as in all of the assessment/evaluation activities that have preceded it. It just is not plausible to contemplate effective clinical work without the consideration and impact of a family’s self-identified culture. Sarche et al. (2018) offer a framework for assessing and formulating the cultural components of evaluating and treating very young children and their families. They describe eight general features that form a background for assessment, several of which are especially important to consider when constructing the case formulation with young children. For example, the authors assert that “culture is transactional,” 332 V. L. Tamkin et al. meaning that cultures change in reaction to circumstances, technology, events (e.g., immigration) and influences of other groups. This reminds the clinician to think deeply with and about each family’s unique experience of their cultural identity when formulating the family’s experience. Second is the concept that “culture is experienced subjectively,” which in the case of young children means “intersubjec- tively” between the caregiver and child and this should be a focus of the clinician’s understanding and formulation. It is incumbent upon the clinician to attempt to understand the intersubjective cultural perceptions of the dyad. The concept they note that “culture operates silently and with voices” dovetails perfectly with the assessment/formulation principle that the young child and family are understood by what they do and by what they say. In case formulation, information from observations, interviews, stories and behaviors are all considered. Finally, the notion that “culture influences expressions of distress” is central to case formulation. The limited repertoire of behaviors with which very young children express their suffering is shaped by cultural influences (ZERO TO THREE,2016 ). Sarche et al. note that many clinical syndromes involve dysregulation of emotion; this is especially true in infant and early childhood mental health. How dysregulated emotions are expressed, tolerated, and understood varies greatly by culture. The Sarche et al. chapter puts forth a Cultural Formulation Adaptations for Infant and Toddler Mental Health Assessment which has been adopted for us in the DC:0-5™ Diagnostic Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood (see Chap. 8). This framework directs the clinician to consider four specific aspects of the young child/family and their relationship with the professional (see DC:0-–5™, ZERO TO THREE, 2016, pp. 10–12 for details): 1. Cultural Identity of the Individual. 2. Cultural Conceptualization of Distress. 3. Psychosocial Stressors and Cultural Features of Vulnerability and Resilience. 4. Cultural Features of the Relationship Between the Individual and the Clinician. These four factors are used to determine an overall cultural formulation which should be included as part of the young child’s final case formulation.

Constructing the Joint Clinical Case Formulation

Construction of the joint clinical case formulation is one of the most fundamental elements of the evaluation of very young children and requires that the clinician understand the caregiver’s perspective. The use of the term joint clinical case formulation is intentional to highlight that in infant and early childhood mental health, the clinician and family work collaboratively to understand and make meaning of the presenting situation and together form a plan of treatment. The clinical case formulation is likely to be constructed when the caregiver is in the most vulnerable and desperate state and at a delicate time when they have provided intimate 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 333 information about their lives without yet receiving much reward. While the case formulation ideally ought to lead to relief and acceptance, some families and caregivers might not yet be prepared to receive and process the clinician’s insights regarding emotionally charged and possibly difficult information about diagnosis and prognosis. Caregivers might feel further despair, anger, or guilt. Clinicians who construct the case formulation independently of the family might subsequently be met with continued resistance, denial, and disagreement. Furthermore, the clinician must anticipate that he or she might be the caregiver’s first experience with mental health treatment, subsequently having a critical role in shaping the caregiver’s perspective on the continuation of services. It is incumbent upon the clinician during this vulnerable and desperate time to demonstrate empathic understanding, genuine validation, and expert guidance/collaboration throughout the working relationship with the family, so that the evaluation and treatment process feels less intimidating. This empathic and inclusive approach is especially crucial when coconstructing the case formulation. A mechanism by which the clinician can understand and include the caregiver’s perspective is by utilizing a collaborative framework for the development of a joint clinical formulation. A joint clinical case formulation implores that the caregiver and clinician (and sometimes the child) work together to gather, organize, and make sense of the information needed to work on the presenting problem, that the clinician is clear with the caregiver why a formulation is important and how it is constructed (i.e., Why do we use the five P’s?), that conceptualization of the presenting problem is constructed in an explicit (not implicit) and inclusive manner so that the clinician is open to questions, observations and feedback during the formulation process. The clinician’s conclusions are therefore updated in real time as the caregiver provides feedback to the clinician, finally providing a clear pathway from the conceptualization to treatment plan. The co-construction of a comprehensive joint clinical formulation should: • Give reason to what might be perceived by the caregiver as an intrusive intake process (“It must seem that this information is very personal and private, but every bit of information you provide is important in understanding your child’s difficulties. For example, your history of postpartum depression is crucial in understanding your bonding experiences.”). • Take into account the information provided by the caregiver, acknowledge caregiver opinions and address caregiver expectations (“I hear what you are saying, here is why it is important, I agree with “x” and here is where my clinical experience can help clarify what doesn’t make sense.”). • Clarify etiology to the best of the provider’s ability in an accessible language without the use of jargon (i.e., use of the terms “really scary experience” instead of the word “trauma”). • Provide psychoeducation without judgement, with opportunity for questions and with the goal to destigmatize mental health (“It’s not your fault that your child has ADHD, and despite what you may hear, ADHD is not the product of bad parenting, badly behaved or lazy children, it can happen to anyone.”). 334 V. L. Tamkin et al.

• Demystify the treatment that is to follow (“What you are dealing with is real and not your imagination, and there are real things that we can do to help.”). • Attempt to identify any disparities caused by lack of access to resources (“Help me understand what is getting in the way of getting to the clinic.”). • Create either a positive seminal experience or corrective emotional experience regarding treatment of mental health (“The things we can do can make a real difference and I am here to help in any way I can.”). • Achieve the crucial “buy-in” of the caregiver, without which treatment is likely to fall short of expectations. A joint clinical formulation which achieves all of these goals requires patience, thoughtfulness, time and commitment to collaboration, all of which may be challenged by the often urgent nature of the presentation and or internal pressure from the clinician or a caregiver’s own preconceived conceptualization of the child’s difficulties. A desperate mother, crying in the office about a child who is constantly hitting her; a grandparent angry at a child who does not follow directions and who has been expelled from three daycares; or a foster parent who risks losing their employment after leaving work frequently to pick up a child who has daily outbursts in school may lead to the natural urgency to skip the joint clinical formulation process or even to provide an abridged version and to proceed directly to treatment planning. Internal pressures from the clinician may also contribute to skipping the joint aspect of clinical formulation. For example, many clinicians have been trained in a medical model for providing mental health care which views the clinician as the “expert” responsible to declare etiology to the “patient” and subsequently place “orders” as interventions. Caregivers who present with their own formulations which seem inaccurate (e.g., ascribing anxious resistant behavior to being manipulative), harsh (e.g., “he’s just bad, he doesn’t listen or care about anyone’s feelings”) or culturally unfamiliar to the clinician (“she just has to do what I say without talking back, sassing or crying’ or “it’s normal she sleeps in my bed with me every night but she won’t go to sleep until I come home from work at 11 pm”) can stymie clinicians, cause pessimism about the possibility of changing caregiver attributions and therefore lead to avoidance of attempts to understand these ideas and feelings. Clinicians may be subsequently tempted to dismiss caregiver formulations, which may still provide crucial insight into the presenting concerns and therefore may still be important to include in the joint formulation. Clinicians may instead attempt to counter or use “psychoeducation” to change caregiver’s views and behaviors. Failure to construct the joint clinical formulation due to these barriers risks sac- rificing caregiver insight, losing caregiver buy-in, and the chance to truly include the caregiver in a collaborative, informed approach to care. In constructing the joint clinical case formulation, a clinician must set the tone. Gottman and DeClaire (1997) discusses a concept of a soft start up, which is the notion of introducing a topic gently, without judgement or blame, so that the words and concepts are more easily heard. A soft start up begins at the first point of contact with a caregiver—over the phone to schedule the appointment or in the waiting area 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 335 upon greeting, and includes the tone of voice, eye contact, body language and nonverbal cues utilized by the clinician to welcome the caregiver to the session and to engage the caregiver in direct conversation about the clinician’s impressions of the information provided. The welcome should include assessing the caregiver’s affect and nonverbal cues, crucial elements in identifying and managing the caregiver’s emotional responses, that is, transference. Caregiver transference may occur not only in reaction to the information presented but also may be generated by the caregiver’s personal life experiences, cultural and or religious background or previous contacts with mental health providers. Caregiver transference which is appropriately acknowledged, validated, and explored helps to establish provider–caregiver–patient rapport and subsequent buy-in. Concomitantly, the welcome also includes the clinician’s management of their own personal reactions to the caregiver and child, that is, countertransference (Sue & Sue, 2016) which may be driven or modified by the provider’s own personal life experiences, cultural and/or religious background, political beliefs, ethical principles, conflicts of interest, and the provider’s own training or professional experiences. Countertransference such as fear of the caregiver’s emotional response, anger toward perceived abusive or neglectful caregivers, sadness about diagnosis or prognosis, overidentification with caregivers of similar cultural background or excessively positive feelings toward a caregiver might impair the collaborative framework toward which the clinician is working. Construction of the joint case formulation includes information which spans broadly from identifying information (such as date of birth) to more personal information (such as a maternal history of depression or substance abuse, a history of intimate partner violence, and sexual abuse). Some caregivers might not understand why clinicians require extensive detail and personal information, and subsequently might appear hesitant or defensive to a clinician. Utilization of the soft start and subsequent soft formulation can further help caregivers feel at ease through tone of voice and use of nonjargon terminology, such as using the caregiver’s own language and terminology when constructing the formulation. Genuinely reflecting back what the caregiver contributes to the case formulation communicates that the clinician is an active listener, values the caregiver’s knowledge of the child, and respects the caregiver’s position of authority in the child’s life. This requires that the clinician have and demonstrate a genuine curiosity about and compassion for the caregiver’s experience and point of view. Use of the soft start up and subsequent soft formulation, particularly use of nonjudgmental language and careful avoidance of any language which may assign blame, may further help to neutralize caregivers’ negative feelings toward their child; to counter internalized negative opinion and judgment caregivers may have received from family, friends, school staff, daycare providers, primary care physicians, or popular media who cannot empathize with their experiences; to extinguish the belief that the child’s difficulties are a result of poor parenting or neglect; and to dispel the minimization of behavioral and emotional disruptions as “just a phase.” Subsequently, the soft start up/formulation helps caregivers become more available 336 V. L. Tamkin et al. to presentation of viable and thoughtful etiologies by way of joint formulation and helps to destigmatize mental health treatment. While a soft start up, gentle tone of voice, use of nonjargon technical language, and avoidance of blame are helpful factors in coconstructing the case formulation, an additional component in construction of the joint case formulation is consistent and routine invitation to the caregiver to explore the meaning of assessment findings with the clinician (“Am I making sense? What does this information mean to you? Do you have any questions about what we have discussed so far?”). A safe forum for caregivers to ask questions about the clinician’s assessment is crucial for development of an inclusive process of joint case formulation and results in a more fully satisfying experience for the caregiver.

Constructing the Joint Treatment Plan

As several theoretical approaches to clinical case formulation exist, the same is true for treatment planning. Instead of reviewing the various approaches to treatment planning (CBT, family systems, multicultural, etc.), it is important to review what treatment planning is and its significance in assessment and mental health service provision. Following the detailed intake assessment and clinical case formulation, a clinician and family then develop a treatment plan, which is a clinical guide that directs the focus and approach to treatment. Substance Abuse and Mental Health Services Administration (SAMHSA, 2005) defines treatment planning as “a comprehensive set of staged, integrated program placements and treatment interventions for each disorder that is adjusted as needed to take into account issues related to the other disorder” (p. 1). Treatment plans help separate the child from their problem and allows the child/family and therapist dyad to make positive changes with purpose. Treatment plans may vary depending on the level of care provided, therapeutic orientation used, child’s contribution, as well as lack of progress. Just as in clinical case formulation, cultural considerations can also challenge treatment planning. Sue and Sue (2016) assert that potential treatment goals and expected outcomes can cause a disagreement between a family and clinician when they are from different cultures. Additionally, research has suggested that getting the family’s help or “buy-in” with the treatment plan increases their likelihood of being active in sessions and successfully completing the goals of the plan (Barnett & Bivings, 2002). The above-described collaborative approach can create a strong therapeutic alliance and make the family feel empowered. A comprehensive treatment plan is expected to naturally arise from a well- organized and jointly constructed clinical case formulation. For each domain of assessment, an identified concern should result in a thoughtful solution, communicating to the caregiver that a multifaceted approach to care provides the best possibility for positive outcomes. Presenting interventions in the context of the original chief complaint provides purpose for the caregivers. The chief complaint represents the 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 337 central concern which drives the caregivers to present for evaluation, encompassing their core fears, desperation, and needs, a central concern which can be tempered, dissipated, and sometimes forgotten in the course of multiple hours of evaluation in a strange setting. While answering the questions posed by the chief complaint can involve a multifaceted and complicated treatment plan, any intervention presented will maintain relevance and urgency if it can be linked back to the chief complaint, increasing the caregiver’s investment in working with the clinician to implement the intervention. Furthermore, setting goals with the caregivers will be more effective when those goals have a direct impact of reducing the behavioral or emotional disruptions identified by the caregivers as most impairing. While attention to the chief complaint helps to focus the treatment plan, consideration of the full scope of goals is crucial in constructing the joint treatment plan. Caregivers may present with fears for their child’s well-being in the short term (“Will my child be expelled from preschool?”), intermediate term (“Will my child be able to have a normal childhood?”), and long term (“Will my child be able to care for themselves when they become an adolescent/adult or when I am gone?”). When long term fears overwhelm caregivers and lead to obfuscation of the immediate well-being of the child, identification of short, intermediate and long-term goals helps provide perspective on how immediate interventions may impact achievement of intermediate and long-term goals. Ongoing use of gentle, empathic, nonjudgmental soft approaches applied to introduction of interventions is crucial to maintaining “buy-in” during the treatment planning phase. With this “buy in,” a treatment plan can be more successfully presented with a team-oriented approach, with the caregiver as the primary conduit and agent of change and with the clinician as the guide who will help the caregiver navigate the confusing web of interventions, which may include multiple providers from multiple disciplines, multiple treatment modalities, and multiple community agencies. Development of the joint treatment plan also accounts for the caregivers’ challenges and strengths. Caregivers’ access to resources and supports, cognitive capacity, and mental health contribute to their ability to implement interventions (Hirshberg, 1993). For example, a mother who is depressed might be unable to implement a multitiered behavior treatment plan at home as compared to a mother who is not depressed. A family of four living in a two-bedroom apartment with thin walls might not be able to readily provide the safe space for time-out that is afforded by a family of four living in a single-family home. A caregiver with ADHD may be unable to successfully call multiple agencies, organize and follow through on multiple referrals. Conversely, identifying and employing a caregiver’s strengths empowers the caregiver, generates confidence and further strengthens his/her investment in the treatment plan. For example, a father with strong constructive artistic skills may be more well suited to building a visual schedule by hand and with crafts while a grandparent with strong technological skills may be more well suited to creating a visual schedule via PowerPoint. By identifying these caregiver strengths and challenges, and implementing interventions with these in mind, the clinician and caregiver can work together to construct the best possible treatment plan. According to Maruish (2002), though there are many different formats of treatment plans 338 V. L. Tamkin et al.

Table 10.1 Goal component Specific: Specific is the What, Why, and How Measurable: Goals should be measurable so that you have tangible evidence that they have been accomplished Attainable: Goals should be attainable yet challenging so that you push yourself to reach them Realistic: Goals should measure the outcomes of the treatment, not the activities used to reach the goal Timely: Goals should have a realistic time frame in which they are to be achieved Adapted from O’Neill, Conzemius, Commodore, & Pulsfus, (2006)

(i.e., the clinical document that directs the course of therapy), most common components include the following: • Referral source and reason for referral. • Presenting complaint and additional/related concerns. • Provisional diagnosis. • Collaboratively developed treatment goals, objectives, and directly linked interventions. • Length, duration, and pace/frequency of treatment. While being mindful of the family’s contribution to the therapeutic process, it is also helpful to use the wording, in the construction of the treatment plan, which is universal and can be easily understood by the caregiver. SMART goals (see Table 10.1) can be used to assist professionals in composing treatment goals that can be easily understood, realistic, and attainable (O’Neill, Conzemius, Commodore, & Pulsfus, 2006). The below chart is the breakdown of the SMART acronym and can be used to help with the wording of goals when completing a culturally aware treatment plan. In sum, joint treatment planning proves to be vital to infant and early childhood mental health clinicians who wish to provide effective treatment. The production of joint treatment plans also helps in fostering a strong therapeutic alliance between families and helping professionals because they are developed in a collaborative effort where the family is able to be the expert on their life and presenting concerns and what to do about them. When the alliance or rapport is built between the child, their family, and the clinician it can provide additional information for the clinician to formulate interventions that will be used to assist the child in meeting their respective treatment goals.

Approaches to Interventions

Once the formulation and working diagnosis have been clarified, the next task is choosing an intervention. While the current volume does not focus on intervention, it is important to note that there are several evidence-based and promising practices 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 339 that have been shown to be appropriate to address the behavioral, emotional, and psychiatric problems of young children. As with assessment and evaluation, intervention must also be embedded within the child’s primary relationships, appropriate for the child’s developmental level and culturally congruent or sensitive to the child’s and families’ values and experiences. Several of the more well-known therapies are reviewed briefly below [Reprinted by permission from Springer Nature: Current Treatment Options in Pediatrics, Update on Screening, Referring and Treating the Behavioral, Social, and Mental Health Problems of Very Young Children by Bekman, John-Larkin, Paul, Millar, and Frankel (2017)].

Child Parent Psychotherapy

Child Parent Psychotherapy (CPP) is a relationship-based intervention for children birth to 5 years old who have experienced a traumatic event (e.g., physical or sexual abuse, neglect, exposure to intimate partner violence, accidental injury) and are experiencing problems including PTSD, or other manifestations of traumatic stress including externalizing problems (i.e., aggression, defiance, tantrums, noncompliance) and internalizing problems (i.e., separation anxiety, sleeping difficulties, and social/emotional withdrawal). CPP is a dyadic treatment that views promotion of the parent–child relationship [using the terminology of the model the label “parent” is used in the following discussion but is inclusive of all caregivers] as the most expedient and enduring path to healing of young children. Families are seen in weekly joint parent–child sessions, in either the family home or clinic, typically for a 12-month course; individual sessions with the parent are scheduled when indicated. CPP focuses on promoting emotion regulation in both the child and parent; the resolution of child trauma-related symptoms and maladaptive parent–child interaction; supporting developmentally appropriate interactions; coconstruction of a trauma narrative and reestablishing the child’s trust in the parent as a source of safety and protection. CPP uses several treatment modalities including (1) promoting developmental momentum through play, physical contact, and language (2) providing unstructured developmental guidance, (3) modeling appropriate protective behavior for the parent (3) interpreting feelings and actions, (4) providing emotional support and empathic communication and (5) providing crisis intervention, case management, and concrete assistance with problems of living. CPP has strong empirical support and is listed in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices as an evidence-based treatment. Clinical trials demonstrate numerous positive outcomes including improved attachment security; improvements in children’s decreased behavior problems, traumatic stress symptoms, and diagnostic status of PTSD; increases in children’s cognitive performance; and improvements in self and maternal representations. 340 V. L. Tamkin et al.

Parent–Child Interaction Therapy

Parent–Child Interaction Therapy (PCIT) is an evidence-based behavioral parent training program that treats disruptive behavioral problems in children aged 2–7 years. It targets disruptive, noncompliant, oppositional, defiant, and aggressive behaviors. PCIT has been shown to be effective with a number of special populations including physically abusive/maltreating parents, children with intellectual disability, and child witnesses to intimate partner violence. In addition, a modified version of PCIT delivered in the home has shown promising effects for infants from high-risk families who scored high on screens of behavior problems during a pediatric primary care visit. What makes PCIT unique is its method of delivery: PCIT uses a ‘bug in the ear’ approach where caregivers are coached while playing with their child. The clinician provides behavioral parent coaching in real time, usually from behind a one-way mirror, to help parents have successful, positive interactions with their young children. Treatment is delivered in two sequential phases: child directed interaction (CDI) and parent directed interaction (PDI). CDI, known as the relationship enhancement phase, teaches parents to follow their child’s lead, praise, describe and imitate the child’s appropriate behaviors, and reflect their child’s positive language to create a strong, warm, mutually enjoyable parent–child relationship. PDI, the discipline portion of PCIT, teaches parents effective behavior management strategies to promote children’s compliance with parental commands and decrease aggressive/disruptive behaviors. While originally developed to treat externalizing behavior disorders, there have been recent adaptations of PCIT to treat anxiety and mood disorders in young children (for a review see Carpenter et al., 2014) such as, separation anxiety, preschool depression, and selective mutism.

Trauma-Focused Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based treatment for children aged 3–18 years that treats posttraumatic stress disorder and other trauma-related symptoms. TF-CBT is the most well-established trauma treatment for children, with randomized clinical trials consistently demonstrating large effect sizes in treating symptomatology related to a wide variety of traumas (sexual or physical abuse, exposure to intimate partner violence, medical trauma, war, etc.). Scheeringa and colleagues have shown TF-CBT’s feasibility and efficacy with preschoolers (aged 3–6 years). Their randomized controlled trial demonstrated a large posttreatment improvement in PTSD symptoms as compared to a waitlist control, with additional gains seen at 6-month follow-up. Primary caregivers are incorporated into several sessions and when not in the treatment room with the child, caregivers observe the child’s sessions (i.e., via one-way mirror or TV) to promote attunement (see Scheeringa 2015, for full treatment protocol). 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 341

Incredible Years

Incredible Years (IY) is a widely researched set of three complementary, developmentally based group training curricula for parents, teachers, and young children that are effective in promoting positive parenting practices and treating young children’s disruptive behavior problems. The programs have been disseminated both nationally and internationally and are included in SAMHSA’s National Registry of Evidence-Based Programs and Practices. At the heart of IY are the BASIC parent training programs. These parenting programs are available for caregivers of children aged 0–12 years and are grouped according to age: babies (0–12 months), toddlers (1–3 years), preschoolers (3–6 years), and school age (6–12 years). Groups are delivered in 10–20 weekly group sessions, typically at mental health centers or childcare, and rely heavily on the use of videotaped vignettes of real-life situations that demonstrate targeted skills. Sessions focus on strengthening parent–child interactions, providing nurturance, reducing harsh discipline practices, strengthening parents’ ability to promote their children’s social, emotional, and language development, and reducing conduct problems. There is a Small Group Dinosaur Therapy for children aged 4–8 years with clinical disorders including oppositional defiant disorder, ADHD, and internalizing problems. A recent meta-analysis (reviewing 50 studies) of the parent training program deemed the parent training program to be effective in reducing disruptive child behavior and increasing prosocial skills in a diverse range of families. Furthermore, a study by Seabra-Santos et al. also demonstrated caregiver improvements in parenting practices and self-confidence.

Attachment and Biobehavioral Catch-Up

Attachment and Biobehavioral Catch-up (ABC) is a parent-training intervention aimed primarily at children between 6 and 24 months of age and their caregivers. ABC targets young children who have experienced early adversity, such as maltreatment or disruptions in care, and addresses several issues that have been identified as problematic among children who have experienced early adversity, including behaving in ways that push caregivers away and behavioral and biological dysregulation. The program works with parents or other caregivers to help them learn how to (1) behave in nurturing ways when children are distressed; (2) follow their child’s lead to behave in delighted ways when children are not distressed; and (3) avoid behaving in frightening or intrusive ways. This feedback is expected to enhance the parent’s understanding of the session content and support the parent in developing the target behaviors. Sessions are videotaped to highlight parents’ strengths and challenges, and celebrate changes in their behaviors; the videotaped sessions are also used by parent coaches for supervision purposes. 342 V. L. Tamkin et al.

Circle of Security

Circle of Security (COS) is an attachment-based group intervention for caregivers of children aged 0–5 years designed to promote children’s attachment security by increasing caregivers’ sensitivity and responsiveness to young children’s emotional needs. The original COS intervention is comprised of 20 small group sessions in which 5–6 caregivers meet weekly with a clinician. The intervention is organized around the use of the “COS graphic” which depicts children’s attachment and exploratory needs (i.e., secure base/safe haven phenomenon) in a user-friendly way that promotes parental understanding of attachment theory. The intervention includes use of individualized video clips of caregivers interacting with their young children to increase caregivers’ awareness of their children’s emotional cues. Although the COS intervention is firmly grounded in well-established theory, it is currently not considered an evidence-based treatment by SAMHSA’s National Registry of Evidence-based Programs and Practices. However, several recently published studies lend support to the intervention’s efficacy in improving caregiver– child relationships, with randomized controlled trials underway. The creators of COS have more recently condensed the content of the original 20-week intervention into two other abbreviated protocols: the COS-Parenting DVD and COS-HV4 (i.e., four home-visiting sessions). Empirical research of these protocols remains limited at this time.

Theraplay

Theraplay is a form of parent–child psychotherapy that targets children aged 0–18 years who demonstrate the following behaviors: withdrawn, depressed, noncompliant, regulatory problems, Attention-deficit/Hyperactivity Disorder (ADHD), or attachment issues/complex trauma. Theraplay is used with both biological and foster families, for high-risk and preventive cases, and in a variety of treatment settings, including domestic violence shelters, psychiatric hospitals, and residential centers. Drawing on a combination of attachment theory, neurodevelopmental theory, and object relations theory, Theraplay purports the following assumptions: The primary motivating force in human behavior is a drive toward relatedness; early interaction between parent and child provides the foundation for self and personality development; the caregiver’s playful, empathic, sensitive responses to the child’s needs for comfort and a secure base are essential to healthy development; and the capacity to understand/empathize with others depends on early experiences of empathy and coregulation between caregiver and child (Table 10.2). The core components of Theraplay focus on providing appropriate levels of structure, engagement, nurture, and challenge to the child, qualities which are also inherent in parent–child relationships. Through a series of 18–25 weekly sessions with four follow-up sessions at quarterly intervals over the next year, the therapist guides the parent and child through playful, fun games, and developmentally 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 343

Table 10.2 Approaches to intervention with young children and their families Name Age Length Target population Goals/comments Attachment and 6–24 months Ten Children who have Works with parents or biobehavioral sessions experience abuse, other caregivers to help catch-up neglect and/or them learn how to (1) http://www. disruptions in care behave in nurturing ways abcintervention. Treatment delivered when children are org/ dyadically focusing distressed; (2) follow on caregiver skills their child’s lead to and representations behave in delighted ways when children are not distressed; and (3) avoid behaving in frightening or intrusive ways Uses videotaped interactions Child-parent Birth to age 52 weeks Children and primary Support and strengthen psychotherapy 5 caregivers who have the caregiver–child http://www. experienced intimate relationship as a vehicle cebc4cw.org/ partner violence and/ for restoring and program/ or trauma protecting the child’s child-parent- Treatment delivered mental health. Treatment psychotherapy/ dyadically through focuses on contextual detailed play and factors (e.g., culture and psychodynamic socioeconomic and interpretation immigration related stressors) Circle of security Birth to 20 Dyads with relational The intervention is http://www. 5 years sessions and attachment organized around the use cebc4cw.org/ difficulties of the “COS graphic” program/ which promotes parental circle-of-security- understanding of parenting/detailed attachment theory The intervention includes individualized video clips of caregivers interacting with their young children to increase caregivers’ awareness of their children’s emotional cues Incredible years Birth to 10– Children with Parent program uses http://www. 12 years 20 weeks disruptive behavior videotaped vignettes to cebc4cw.org/ disorders demonstrate targeted program/ skills of providing the-incredible- nurturance and reducing years/detailed harsh discipline Child program delivered in small groups using dinosaur puppets (continued) 344 V. L. Tamkin et al.

Table 10.2 (continued) Name Age Length Target population Goals/comments Parent–child 2–8 years 10–20 Children with Therapist coaches parents interaction sessions disruptive behavior while they interact with therapy disorders their children, teaching http://www.pcit. caregivers strategies that org/ will promote positive behaviors Requires a “bug-in-the- ear” and one-way mirror or video surveillance Theraplay Birth to 18–25 Children who are Focus on providing https://www. 18 years old weekly depressed, appropriate structure, theraplay.org/ sessions noncompliant, engagement, nurturance, 4 regulatory problems, and challenge to the child follow-up ADHD, or Therapist guides the sessions attachment issues/ parent and child through complex trauma playful, fun games, and emotionally nurturing activities Trauma focused 3–18 years 12–18 Children who have Program integrates cognitive sessions experienced traumas, cognitive, behavioral, behavioral therapy including intimate interpersonal, and family https://tfcbt.org/ partner violence, therapy principles as well traumatic loss, war, as trauma interventions. sexual exploitation, Works with child and the and/or multiple and child’s nonoffending complex traumas caregivers Provides parallel individual sessions with children and primary caregivers; then joint parent–child sessions challenging and emotionally nurturing activities. The goal of treatment is to create a secure, attuned, joyful relationship between children and their parents or primary caregivers. For example, for a child in residential treatment or in a school setting, the goal is to establish such a relationship with one special staff person. For children with autism and developmental problems, the treatment aims to address the social interaction problems associated with these challenges. Psychopharmacologic intervention may be considered in young children but requires great care and thoughtfulness (see Chap. 9). After following all of the recommendations regarding behavioral therapies, if the consideration has turned to discussion about the appropriate use of medication in early childhood, several critical and overarching themes are briefly highlighted and include the following: 1. Comprehensive assessment of the child to identify the most accurate differential diagnosis possible (Gleason et al., 2007) to minimize the risk of multiple medication trials and provide the best opportunity for positive outcomes. 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 345

2. Consideration of medication in conjunction with other treatment modalities, including those noted above, when those treatment modalities have not provided desired results (Gleason et al., 2007). 3. Lack of a strong evidence base with nearly all medication classes to establish data driven treatment parameters and an evidence base which may not correlate to FDA approvals (Greenhill, 1998). 4. “Start low, go slow,” as established dose ranges for older children do not apply (Gleason et al., 2007). 5. Structured and measured tracking of medication response as best as possible, including use of appropriate rating scales at baseline and with any dose changes (Gleason et al., 2007). 6. Consistent and diligent monitoring for side effects, as young children are more susceptible to medication side effects (Greenhill et al., 2006; Martin et al., 2000; Wigal et al., 2006). 7. Rigorous documentation for better continuity of care, and for accurate review of ongoing, discontinued or completed medication trials (Gleason et al., 2007). 8. Practicality of administration (e.g., liquid vs. crushed tab vs. sprinkles) to maximize compliance and possible instruction about swallowing pills (Beck, Cataldo, Slifer, Pulbrook, & Guhman, 2005). These overarching themes should be discussed with caregivers when medication is considered as part of the treatment plan in the form of a detailed discussion of risks, benefits and side effects. Using these guiding principles to provide thoughtful and safe prescribing can enhance responses to other interventions.

Case Vignette

Identifying Information

Name: BJ. Age: 3 years and 6 months. Cultural Identification: African American. Language: English. Information Source: Patient, biological mother.

Caregiver Description of the Problem/Chief Complaint

A 3-year and 6-month-old male with seizure disorder, BJ presents to clinic with mother for evaluation of emotional outbursts, behavioral difficulty, and inability to focus. 346 V. L. Tamkin et al.

Mother reports a history of emotional outbursts beginning at about 2.5 years old after a head injury (see below), often triggered when he is asked to share with peers, with limit setting, when he is asked to engage in nonpreferred activities and occasionally when his needs are not met immediately. Behaviors during outbursts include aggressive behaviors (swatting), spitting (at school), screaming, cursing (recent), and throwing objects. There is no self-injurious behavior during outbursts. Outbursts last between 2 and 5 min at home but can last longer at school. Time outs help him to de-escalate. Since mother first noted the outbursts, they have occurred with variable frequency. Outbursts gradually worsened in frequency and intensity for several months but began to reduce in frequency and intensity after he was diagnosed with seizures and initiated on Trileptal. For the next several months, outbursts occurred about once per week. However they increased again in the month prior to the evaluation and currently occur 2–3 times per week, peaking the week prior to evaluation, during which they occurred daily. Mother cannot identify any new stressors or triggers in the past month. Outbursts are typically worse when he is with a large group of people. Outbursts are also worse when he is tired. Mother also reports a history of aggressive behaviors (hitting, shoving and snatching toys roughly from peers) which are often impulsive and reactive, for example, when he and a peer are competing for the same toy. She reports frequent climbing on furniture and jumping off of furniture. He exhibits difficulty keeping his hands to himself. He runs away from his mother in public places. He has eloped from the classroom and has attempted to elope from the home. He has run into the street without looking for oncoming traffic. He is restless, fidgety and hyperactive. He cannot remain in his seat during structured classroom activities such as circle time, and he wanders around the room instead, taking toys off the shelf without permission. He exhibits difficulty remaining seated during meals. He can rarely watch television for more than 10 min. He is impatient. He is verbally impulsive and frequently interrupts others. There is occasional excessive talking. Mother reports short attention span. He exhibits difficulty engaging in learning activities. He requires frequent reminders and redirections to complete multistep directions. He is forgetful, often immediately forgetting directions given to him. He is disorganized, often misplacing important items, making large messes when he plays with toys and when he eats, without ability or patience to clean afterward. Mother feels that he stands out from his peers in his activity level and inattention. Teachers are frustrated with his inability to comply with directions and have called mother regularly regarding his behavior, requesting that she pick him up early from school. She states that family members, such as his aunts and uncles, will often refuse to watch him. Mother reports a past history of excessive caution but this has mostly resolved. She reports a history of separation anxiety in past school settings but none currently. He does exhibit some fearfulness and hypervigilance in new surroundings and with unfamiliar people. He is more clingy and more reluctant to explore the environment. For example, at birthday parties, he will mostly remain at his mother’s side and will be reluctant to engage with peers. Mother reports that he has exhibited some exces- 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 347 sive need for routine, organization and specificity in the past, causing some emotional escalation. There is no report of anticipatory anxiety. There is no history of nightmares. There is no report of obsessions or compulsions. Sleep is disrupted by excessive latency, up to 60–90 min, and as a result he sleeps less than 10 h per night. He is sensitive to loud, noisy, crowded environments, loud vacuum cleaners, blenders and smoke detectors. The family has not been seen in outpatient, inpatient or emergent psychiatric evaluation. BJ did receive behavioral therapy at about 2.5 years of age when mother first noted outbursts. Mother feels this was helpful. Mother saw a behavioral specialist at her pediatrician’s clinic once several months later, just after his 3-year-old birthday, and behavioral strategies were discussed. Mother reports variable success of behavior strategies. She has recently reestablished contact with his prior therapist to initiate in-home therapy.

Social History

BJ lives in a two-bedroom condominium in a large, metropolitan neighborhood, with his mother and father. He has no siblings. Mother reports that everyone is getting along well. There are no pets. Both maternal and paternal grandparents live nearby and watch him regularly. Several other maternal and paternal extended family members live nearby and are considered supportive but do not spend much time with him regularly. BJ attends daycare/school full time, 5 days per week. The family is of African American origin. They speak only English in the home. They are Christian Baptist and describe themselves as spiritual. They attend church every Sunday. There is no history of trauma, physical or sexual abuse. There is no history of child protective or social services involvement.

Family History

Mother is 32 years old. She has no psychiatric history. She attended therapy for a brief period to address life stressors in her early twenties and feels it was helpful. She has no medical, substance abuse or legal history. She works at a bank in a management position. There is no report of any psychiatric diagnoses in the maternal extended family. Father is 33 years old. He was treated for Attention-Deficit/Hyperactivity Disorder (ADHD) during his childhood. He was briefly prescribed medication, possibly Ritalin, and mother is unsure if it was helpful. He is treated for chronic peri- carditis. He has no substance abuse or legal history. Father works as a trash truck driver. Paternal uncle takes Adderall for ADHD, and mother is unsure if this is helpful. He has never seen a mental health clinician. Paternal grandmother is treated for epilepsy. 348 V. L. Tamkin et al.

Medical History

BJ experienced a head injury after a fall when he was 2 years and 4 months old. He did not lose consciousness but experienced a seizure afterward. He was evaluated by a neurologist. No seizure disorder was identified at that time. An overnight EEG was completed when he was 2 years and 10 months old, and he was diagnosed with a low threshold for seizures, according to mother, and initiated on Trileptal at 2 years and 11 months of age. There have been no seizures since. An MRI was also completed at 2 years and 10 months of age and no major structural abnormalities were identified. Food allergies include soy, shellfish, nuts, and eggs. He is prescribed an Epipen but has never required it.

Current Medications

Trileptal 6 mL qam.

Developmental History

Mother reports that the pregnancy was complicated at week 35 of gestation by pre- eclampsia, treated conservatively. There were no negative outcomes. She received regular prenatal care. There is no report of any in-utero exposures. The patient was born at 39 weeks gestation via normal spontaneous vaginal delivery. There were no complications during the delivery. He weighed 7 lb and 1 oz. He had a normal discharge from the hospital at 2 1/2 days. Mother reports that he was an easy baby who enjoyed people, being fed, slept and bonded well. There is no history of maternal postpartum mental health issues. He sat without support at 5 months of age, crawled at ~8- to 9 months of age and walked at 13.5 months of age. He began using single words at 5 months of age and 2- to 3-word sentences at 2 years of age. He completed toilet training at 3 years of age.

Behavioral Observations

BJ was a neatly dressed and groomed, well-nourished boy who appeared his stated age. There was no fearfulness, and he transitioned well to the interview setting, appropriately explored toys. There was no overt shyness as he exhibited appropriate social reciprocity with the interviewer, was able to engage in direct one-on-one conversation for about 15 min, was able to answer close-ended questions about his 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 349 home environment, school environment, about rules and about basic emotions, mostly with brief, 1- or 2-word answers. He appropriately sought reassurance from mother early in the session prior to feeling fully comfortable in the surroundings, as evidenced by his ability to seek mother’s help when he did not know an answer to a question. On occasion, he was able to seek affection from mother by climbing into her lap or hugging her leg when he felt frustrated about being asked questions. He was able to engage in one-on-one play with the interviewer without mother in the room. He exhibited no separation anxiety and was able to rejoin with mother appropriately, running to her and hugging her, when she reentered the room after one-on-one play session. He engaged in both verbal and nonverbal forms of communication. He made fair eye contact. He was restless, fidgety, impulsive, distractible, and inattentive, and he exhibited brief responses to redirections. There were no oppositional or defiant behaviors. His play was concrete and he exhibited difficulty focusing on one toy. He did not develop any narratives in his play and tended to mostly bang objects together. There were no overt aggressive, sexual, or traumatic themes. However, he did exhibit a need to direct the play and exhibited some mild irritability when the interviewer did not comply with his specific directions. Gross and fine motor skills appeared intact. His speech was spontaneous, and though he did not speak much, there were no repetitive patterns of speech or echolalia. His affect was full and stable. He exhibited fair frustration tolerance. During an observation period from behind a one-way mirror, he exhibited warm interactions with his mother. Interactions were more spontaneous. He was more verbal without the interviewer in the room, speaking easily in multiword sentences, with excellent ability to take turns in conversation and with above average vocabulary. He engaged in one-on-one play with his mother very well. Mother played on the floor with him and was able to help him engage in more fully developed and mildly more symbolic play; though, he continued to exhibit frequent need for redirections to remain on task. He exhibited a similar need to direct mother and moder- ately increased irritability when mother did not comply with his demands; however, there were no emotional escalations. Mother was able to calmly validate and redirect emotional reactions, and he was responsive to her redirections.

Clinical Case Formulation

The clinical case formulation begins with the Cultural Formulation Adaptations for Infant and Toddler Mental Health Assessment. The cultural identity of the individual is quite interesting in this case when considering the child in the context of his cultural background, and how mental health treatment fit into their cultural construct, complicated by the apparent internal cultural conflict the family was experiencing. The mother intimated that she suspected several maternal and paternal family members may have undiagnosed mental health issues, stating “they don’t do that,” implying with her tone of voice that mental health treatment was an alien “other.” With this simple statement, she also implied, by what was perceived as a 350 V. L. Tamkin et al. sarcastic tone of voice, that mental health treatment was not readily accepted in her community. The paternal uncle was receiving medication, but he was an outlier in that he was the only family member who maintained treatment. Whether he was fully compliant was unclear, and he was prescribed medication by his primary care provider and not by a mental health provider, suggesting lack of access to, dismissal of and/or some mistrust of the mental health system. The father had received mental health treatment when he was a child, suggesting that the paternal grandparents, at least at some point, had sought treatment. The father discontinued his treatment while he was still young and never resumed treatment, suggesting that there was never full “buy in.” As to the cultural conceptualization of distress, when mother initially presented with the child, she appeared to be the lone member of the family who was supportive of the idea that there may be mental health concerns. As his clinical formulation was discussed, it became even more apparent that she was dealing with some stigma of mental health treatment from within her own family, that is, grandparents, aunts, and uncles often described him as a “boy being a boy” and dismissed her concerns. This bore out when rating scales completed by other family members were drasti- cally different than those completed by the parents and school providers. While extended family members acknowledged that his behaviors were difficult to manage as evidenced by high ratings in impairment in function, they did not believe this was out of the norm as evidenced by low ratings of actual symptoms of ADHD. The father, while acknowledging that symptoms were present and were impairing, was reportedly skeptical about treatment based on his own history of treatment. Mother and school providers were in agreement that symptoms were present, impairing and caused distress to the home and school systems, respectively. When considering the psychosocial stressors and cultural features of vulnerability and resilience, disparities in mental health diagnoses, particularly ADHD, in cultural minorities are well known and multifactorial (Morgan, Staff, Hillemeier, Farkas, & Maczuga, 2013), and include decreased access to mental health care, decreased seeking of mental health services, decreased likelihood of referral by school providers, decreased ability to manage health care costs and stigma regarding perceived disability. Furthermore, in the context of this particular child and family, a vulnerability to impairment in function was clearly present in the family-culture-based normalization of possibly pathologic symptoms and led to underreporting. Culture-based stigma toward and mistrust of mental health care experienced by this family led to chronic social stressors such as nonempathetic school environments. Culture-based resilience in the African-American community includes (Stevenson & Renard, 1993) “helpful extended relatives, transmission of cultural child rearing values, influence of a religious worldview, and family communication about surviving societal racism struggles, educational achievement, and Black pride and culture.” Cultural resilience exhibited by this family included a strong spiritual and faith-based support network which appeared to infuse mother’s inner strength and father’s commitment to care despite his misgivings. Finally, the cultural features of the relationship between the individual and the clinician were directly addressed in this case. Father was seen later, and he was 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 351 indeed skeptical but more open minded and willing to “buy in” against the stigma than anticipated. This may have occurred because the acuity steeply escalated between the first and second sessions as the daycare was now threatening to expel the child from the program. This challenged BJ’s father to set aside his own history and culturally based approach to mental health treatment in order to trust the clinician. In retrospect, there may have been some identification with the clinician as a person of Asian descent (Loya, Reddy, & Hinshaw, 2010) and a person of color, perhaps borne from empathy with him due to a shared cultural stigma toward mental health treatment. During two feedback sessions the clinician and parents were able to construct a joint clinical case formulation. The importance of constructing the formulation was communicated to the family by reflecting that emotional outbursts are an extremely common problem in young children but that in order to make the most sense of the cause and what to do, the issues needed to be examined from all angles, including all of the detailed information provided. The importance of a joint construction was relayed to the family as the most likely method to affect change, to jointly identify all the contributing factors, to organize them in a way that made sense to the family and to jointly identify solutions to each of the challenges that were presented.

BJ’s Challenges Were Organized Using a Five P’s Approach

Presenting concerns: 1. BJ presented with a history of hyperactivity, restlessness, inattention, impulsivity and impatience, suggesting a possible diagnosis of ADHD, combined type, contributing to behavioral noncompliance, negative interactions with teachers and caregivers and development of maladaptive coping mechanisms/emotional outbursts described by the family. 2. BJ also presented with a history of avoidance of unfamiliar environments and excessive organization, excessive need for routine and excessive specificity suggesting a possible anxious temperament, further contributing to oppositional and defiant behaviors as well as maladaptive coping mechanisms/emotional outbursts described by the family. Predisposing factors: 1. Genetic predisposition to ADHD as evidenced by family history of ADHD in both immediate and extended family members. 2. ADHD symptoms can predispose to difficulty following directions, poor compliance with rules and reduced ability to manage emotions and behaviors, leading to negative interactions with caregivers, teachers and peers and increased risk for emotional outbursts and possibly aggressive behaviors. Symptoms can lead to dangerous and reckless behavior which BJ was exhibiting. Symptoms can disrupt development of age-appropriate skills. 352 V. L. Tamkin et al.

3. Anxiety can predispose to impaired functioning by leading to poor frustration tolerance when exposed to anxiety provoking triggers and when needs are not met to exact specifications. Anxiety can further impair a child’s ability to develop and employ adaptive coping skills. Excessive need for control can contribute to oppositional and defiant behaviors. Over time, anxiety without the ability to develop adaptive coping skills can place this child at risk for mood symptoms, for inability to develop peer relationships and for suboptimal academic performance. 4. A history of head injury and seizures, if untreated, could predispose to irritability, poor attention span, poor executive functioning and subsequent inability to manage behavioral expectations or to utilize adaptive coping skills. He has thus far responded well to treatment of seizures and they are therefore less likely to contribute to his current presentation. Furthermore, no structural damage was identified. 5. A history of early life medical issues can predispose to maladaptive coping if those medical issues disrupt age-appropriate bonding and attachment. 6. Culture-based stigma toward and mistrust of mental health care can lead to chronic social stressors such as nonempathetic school environments, further predisposing to behavioral and emotional disruption. Precipitating factors: 1. Increasingly aggressive outbursts across all environments. 2. Increasingly dangerous impulsive behaviors such as eloping from the home and school and running into the street. 3. Increasing frustration by school staff who are threatening to expel the child from the daycare. Perpetuating factors: 1. Lack of appropriate accommodations and school based services to manage ADHD symptoms appropriately. 2. Low empathy from school staff leading to misinterpretation of rigid behaviors as oppositional rather than driven by anxiety, further leading to ineffective intervention strategies. 3. Sensory sensitivities, such as excessive sensitivity to loud noises can perpetuate poor frustration tolerance and poor coping due to an inability to appropriately process environmental stimuli. Sensory avoidant behaviors can perpetuate high- risk behaviors and inattention, and sensory seeking behavior could perpetuate disruptive and impulsive behaviors such as climbing and jumping on furniture, distractibility, and inability to follow directions. 4. Recently disrupted sleep patterns which are correlated to a recent increase in irritability and hyperactivity. Protective/positive factors: 1. A supportive family who has sought intervention despite being immersed in a family culture which is suspicious of mental health treatment, suggesting strong cultural resilience. 10 Constructing a Joint Clinical Case Formulation and Treatment Plan with Families 353

2. Early intervention. 3. Secure attachments with parents. 4. Intact cognitive abilities. 5. Positive response to past therapeutic interventions suggesting strong internal resiliency in the child. Finally, one particular point of discussion highlights why the joint clinical case formulation is so crucial. As the formulation was discussed, the evidence became increasingly apparent that the parents had been susceptible to some of the popular mythology about mental health issues. Even though the mother (1) had been so proactive about treatment, (2) was such a great advocate for her son, (3) clearly had great attachment and a warm relationship with her son, (4) was observed to be quite adept at managing his behaviors and emotions, and (5) was the most psychologically minded in her family, and despite father being reluctantly supportive, it was clear there was a significant amount of self-blame occurring—that somehow BJ’s issues were their fault. This self-blame was not elicited during the history gathering portion of the evaluation, and it was only made apparent when the behaviors were linked to the possible diagnosis of ADHD, and when the clinician and family further discussed the possibility that his rigidity and perseveration may be the result of an anxious temperament (maybe because of his history of early life medical issues). When the parents’ self-blame was identified and reframed, a palpable “whoosh” was let out of the room, as if suddenly the mother could breathe. In retrospect, the use of a soft start up was crucial here: use of nonjudgmental language, great care to avoid blaming the parent, gentle tone of voice, reading the mother’s cues to realize that there was a great tension she was holding on to and which was suddenly let go. Furthermore, by reading her nonverbal cues and by active listening to her expressions of relief, it was very clear from that moment that she felt more empowered and upbeat, more motivated and more hopeful. Suddenly, sleep hygiene issues did not seem so monumental. Mother was more open to discussion about how sensory issues may contribute to his distress. In fact, much of the history about sensory issues was actually gathered during the joint clinical case formulation because she felt less burdened, less inhibited, less anxious and subsequently able to remember more detail, which directly led to an occupational therapy evaluation and initiation of treatment, to which he responded very well. In that sense, that specific positive outcome was directly due to the collaborative effort between the caregivers and the clinician. This similar approach led to the joint identification of other therapeutic modalities including PCIT to further strengthen the parental bond with the goal to decrease excessive need for control and to help the parents develop additional strategies to manage behavioral noncompliance. In summary, this case vignette incorporates the many concepts discussed in this chapter regarding construction of a joint clinical case formulation and treatment plan, specifically highlighting the clinical formulation not just as a theoretical, implicit conceptualization of etiology to be monopolized by a paternalistic provider, but as a jointly constructed exploration of all the factors that contribute to the child’s and caregivers’ distress, utilizing the information provided by the caregiver and child, 354 V. L. Tamkin et al. reflected back to them in a gentle, nonjudgmental way, in an organized structure, in their own language, addressing cultural vulnerabilities, accentuating cultural strengths, thereby including the caregivers in the healing process and empowering them to engage in goal-directed, effective therapeutic interventions.

References

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A methylphenidate, 300, 301 AACAP Workgroup on Infant and Preschool non-stimulant medications, 302 Psychiatry, 143 psychopharmacological interventions on Aberrant Behavior Checklist (ABC), 303 brain development, 299 Academy of Child and Adolescent Psychiatry psychopharmacological treatments for (AACAP), 143 preschoolers, 297, 299, 302 ADOS-2 administration, 165 psychopharmacology trials, 300 ADOS-2 coding, 166–170 risk, 293 Adult attachment interview (AAI), 83 symptom tracking for preschoolers, 299 analysis, 85 Atypical antipsychotics, 304 certification and trainings, 85 Atypical maternal behavior instrument for childhood attachment experiences, 83 assessment and classification childhood mental health, 85 (AMBIANCE), 88 classification, 84 Autism Diagnostic Observation Schedule interview questions, 84 (ADOS), 144 questions, 83 Autism Diagnostic Observation Schedule-2 scoring and classification, 84, 85 (ADOS-2), 163, 164, 171 SSP, 85, 86 Autism Spectrum Disorders (ASD), 13, 196, Ages and Stages Questionnaire (ASQ) 231, 276 ADOS-2, 163, 164, 171 atypical antipsychotics, 304 DB-DOS, 171–173 behavioral interventions, 305 parent-report developmental screening, 163 core symptoms, 303 social-emotional development and evidence-based therapies, 305 behaviors, 163 psychotropic medications, 305 American Academy of Pediatrics (AAP), 14 RCT, medications for preschoolers, 304 American Academy of Pediatrics Screening treatment for children, 303 Recommendations, 14 Autobiographical memory, 199 Anxiety disorders, 287, 305 Assessment process, 22–24, 39 Attachment and Biobehavioral Catch-up B (ABC), 341, 343 Bayley Scales of Infant and Toddler Attention deficit/hyperactivity disorder Development, 229 (ADHD), 277, 330, 342 Behavioral interventions, 310 amphetamine salts, 301, 302 Beliefs, 56 medical explanatory model, 292 Berkeley Puppet Interview, 206

Bowlby’s attachment theory, 5 reflective functioning, 77 Brazelton Neonatal Assessment Scale sensitivity, 77 (BNAS), 190 stressors, 78 toddlers, 81 trauma responses, 81 C Caregiver transference, 335 Caregiver and child behavior, 114 Caregiver traumas, 102 Caregiver–child interaction, 109, 119, 288 Caregiving environment and infant/young descriptions, 114 child adaptation, 269, 270 emotion, situations, 107 Case conceptualization, 328 factors, 114 Center for Autism and the Developing Brain sensitivity, 107 (CADB), 163 Caregiver-child relationships, 5, 21, 45, 81, Child Behavior Checklist (CBCL), 109, 185, 191, 197, 203, 205, 288 225, 279 Caregiver–infant interaction Child developmental and sensorimotor assessment, 109, 112 assessments, 22 caregiver’s mood, 111 Child directed interaction (CDI), 340 clinical questions, 117 Child Parent Psychotherapy (CPP), 287, clinic-based assessment, 116 339, 343 components, 111 Child Psychiatric Rating Scale (CPRS), 303 depression and anxiety, 108, 109 Child’s active engagement, 198 developmental level, 117 Child’s and family’s sociocultural evaluation, 114 background, 42 functioning, 110–111 Child’s functioning, 185 Japanese families, 113 Child’s perception, 189 maternal–infant attachment, 108 Childhood Autism Rating Scale (CARS), 303 medical conditions, 132 Circle of Security (COS), 342, 343 NCAST and PCI, 120 Circle of Security Interview (COSI), 90 psychological and personal factors, 108 AAI, 91 separation and reunion, 117 caregiver -child interactional traumatic events, 131 procedure, 91 treatment process, 115 child’s behaviors, 92 warmth and responsiveness, 107 clinical interview, 90 young child assessment, 133 intervention, 90, 91 Caregiver management training approaches, 287 protocol, 90 Caregiver perceptions, young child Clinical case formulation AAI, 83, 84 age-related considerations, 330, 331 anxious, 79 aggressive behaviors, 346 breed toughness, 80 behavioral formulation, 329 caregiver, 80 behavioral observations, 348, 349 caregiver–infant interactions, 82 CFI, 329 child and parenting, 78 cultural considerations, 331, 336 clinical assessments, 77 cultural features, vulnerability and clinical environment, 81 resilience, 350 culturally guided knowledge, 79 cultural formulations, 329 culture, 79 definitions, 328 depressed parent, 82 developmental history, 348 emotional states, 81 explicit and implicit formulations, 328 environmental influences and stressors, 79 five Ps (see Five P’s approach) internal working models, 78, 82 idiographic and nomothetic, 328 language, 80 joint treatment plan (see Joint treatment memories, 78, 80 plan) psychotic caregiver, 82 medical history, 348 PTSD, 82 mental health treatment, 349, 350 Index 359

product vs. process, 329 Disorder of Dysregulated Anger and psychodynamic and cognitive, 329 Aggression (DDAA) psychosocial stressors, 350 children’s aggressions, 274 social history, 347 data-driven approach, 275 Clinician assisted video-feedback exposure early childhood, 274 sessions (CAVES), 95 emotional and behavioral dysregulations, 274 protocol, 96 emotional and behavioral regulation, 274 video-feedback, 95 emotions and behaviors, 274 video review, 96 family-focused therapy, 312 Clinician-child relationship, 149, 150 impulsive dysregulation in preschoolers, 312 Clonidine, 310 irritability and aggression, 274 Cognitive behavioral therapies (CBT), 287, mood and behavioral dysregulation, 275 305, 307 pharmacotherapy, 311 Cognitive functioning, 187 preschoolers, 274 Collaborative plan for assessment, 28 problematic regulation of mood, 311 Committee on Preschool Special Education symptom tracking, 311 (CPSE), 278 Disruptive Behavior Diagnostic Observation Committee on Quality Issues (CQI), 143 Schedule (DB-DOS), 171–173 Comprehensive assessment, 315, 316 Diversity-Informed Tenets, 113 Comprehensive joint clinical formulation, Domestic violence (DV), 150 co-construction, 333, 334 DSM-5 Dysregulated Mood Disorder with Comprehensive treatment plan, 336 Dysphoria (DMDD), 313 Conduct Disorder (CD), 274 Dyad’s affective tone, 112 Conducting assessment, 27 Dyadic assessment, 133–134 Countertransference, 335 Dyadic Parent Child Interaction Coding Crowell procedure, 115, 116, 133, 134 System (DPICS), 280 Cultural and religious beliefs, 56 Dyad’s behavior, 122 Cultural formulation, 329 Cultural Formulation Interview (CFI), 329 Culture, 56, 331, 332 E Culture-based resilience, 350 Early childhood assessment Culture-based stigma, 350, 352 assessment procedures, 12 Culture-specific socialization processes, 191 behavioral evaluations, 13 behaviors, 9 bilingual homes, 12 D biology, 11 Deferred imitation, 192 caregiving relationship, 12 Department of Children and Families communication skills, 17 (DCF), 59 communicative behaviors, 9 Depression, 287, 330 complication, 9 Depressive Disorder cultural researchers, 12 pharmacotherapy, 312 ecological and environmental factors, 12 preschool, 312, 313 educational assessments, 13 symptoms, 312 environment, 11 treatment effects, 312 evaluation, 11 Developmental competence, 265 evaluator qualities, 18 Developmental Coordination Disorder, 280 language abilities, 9 Developmentally based intervention, 71 language and communication skills, 9 Diagnostic and Statistical Manual of Mental medical setting, 12 Health Disorders fifth edition motor movement, 10 (DSM-5), 228, 254 physical and cognitive development, 13 Diagnostic Classification Revision Task scores, 14 Force, 259 screening instrument, 14 Diphenhydramine, 310 social emotional development, 11 360 Index

Early childhood assessment (cont.) H social-emotional needs, 9 Health-care, 53 social-emotional skills, 10 Historical trauma, 42 standardized test scores, 15 History-taking structural recommendations, 19 artificial distinction, 27 temperament and personality, 11 child medical and developmental history, 62 test scores and performance, 15 domains, 50, 51 verbal and nonverbal communication, 11 family’s socio-cultural and historical Early Intervention (EI), 224 context, 41 Early Intervention Program (EIP), 66 goal, 24 Ecological theory, 7 guiding principles Emotional dysregulation, 312 adaptation and strengths-based Empathy, 193 framework, 48 Evidence-based interventions, 317 affect, gestures, movement, pacing and ABC, 341, 343 vocalizing, 47 COS, 342, 343 calm and self-regulation, 49 CPP, 339 context of relationship, 46, 47 IY, 341 cultivate self-awareness, introspection PCIT, 340, 344 and reflectivity, 47 TF-CBT, 340 limitations, 49 theraplay, 342, 344 observation, wondering and tolerance Evidence-based psychotherapeutic of discomfort, 48 treatments, 303 organic process and family’s lead, 49 Evidence-based therapies, 285, 305 helping systems, 59 Evidence-based treatments, 297 identifying information and description of Evidence-informed treatment approaches, 287 presenting problem, 59 Explicit comprehensive clinical formulation, 331 infant, child and family, 50 Expressive language, 160 infant mental health, 24 Eyberg Child Behavior Inventory (ECBI), initial interviews, 26 (see also Interview 244, 279 process) narrative process, 23 parenting as relationship, 50 F practitioner’s stance and interpersonal Family’s support system, 52 processes, 46 Federally Qualified Health Center presenting concerns, 60 (FQHC), 62 relational history of family members, 42, 45 Feeding situation, 124 setting up, 28 Five P’s approach social and family history, 60, 61 perpetuating factors, 330, 352 strengths-based approach, 25 precipitating factors, 330, 352 ten core skills, 25, 26 predisposing factors, 330, 351, 352 therapeutic alliance, 25 presenting concerns, 351 trauma, consideration, 27, 28 presenting problem, 330 protective/positive factors, 330, 352 Food and Drug Administration (FDA), 295 I Foster care system, 53 Impulsivity and irritability, 314 Free play situation, 124 Incredible Years (IY), 341, 343 Individuals with Disabilities Education Act (IDEA), 226 G Infant and early childhood mental health Gastroesophageal reflux disorder (IECMH) assessment, 1, 24, 25, 51, (GERD), 242 253, 255, 256, 329 Gastroschisis, 314, 315 assessment, 2 Generalized anxiety disorder (GAD), 287, 309 attachment theory, 5 Index 361

childhood cognitive processes, 4 child’s play, 201 definition, 1 children’s guidance, 204 disciplines, 5 encouragement and scaffolding, 204 dynamic process, 5 expressions, 203 field, 3 expressive modalities, 199 historical context, 2 gender and cultural differences, 200 multidisciplinary approach, 6 gender identity, 199 teachers and parents, 4 internal representations, 198 WAIMH, 2 interviewing, 203 ZTT, 3 language fluency, 198 Infant and Toddler Mental Status Exam metaphorical and fantasy-based, 200 (ITMSE), 189 modalities, 202 affect and mood, 161 physical reenactments, 203 appearance, 159, 176 play materials, 205 behavioral observations, 176 playhouses, 206 caregiver context, 159 secure base, 200 child medical and developmental history, sensory-motor and emotional 175, 176 pathways, 198 cognition, 162 sexual abuse, 206 formulation and plan, 179–181 structured play, 205 mood/affect, 179 symbolic play, 199, 200 motor, 160 symptoms and environmental motor skills, 177 triggers, 201 observational skills, 159 TOM, 199 play, 161, 162, 177 unguided play, 204 presenting concerns, 174 verbal communication, 198 rating scale information, 179 ages birth to 24 months reaction to situation, 159, 176 aggression, 197 relatedness, 162 attachment quality, 192 relatedness (to grandmother), 178 behavior and emotional responses, 190 relatedness (to mother), 178 caregivers, 190, 191 self-regulation, 159, 160, 177 child’s internal schemata, 194 social and family history, 174, 175 cognitive and memory standpoint, 192 speech, 177 cognitive and motor development, 195 speech and language cognitive and social capacities, 190 expressive language, 160 compelling structured paradigm, 196 phonologic speech, 160 crawling, 196 pragmatic language, 161 custom’s inspection, 191–192 receptive language, 160 developmental and clinical research, 190 thought, 161 developmental delay, 196 Infant-child-family profile, 51 developmental testing, 193 Infant mental health, 288 distress, 194, 195 Infant parent psychotherapy, 287 empathy, 193 Infant–Toddler Social and Emotional facial expressions, 190 Assessment (ITSEA), 224 feeding materials, 197 Inner world of young child growing capacity, 193 age grouping, 186 infants, 191, 196 ages 2 to 5 years mother and child’s play, 195 autobiographical memory, 199 physiological regulation, 191 caregivers, 201 reciprocal play, 195 child’s ability, 202 secure behaviors, 196 child’s daily life and home sensory-motor based patterning, 191 environment, 202 separation/reunion sequences, 196, 197 child’s participation, 202 sequential approach, 195 362 Index

Inner world of young child (cont.) family, cultural and religious values small structuring and scaffolding, 197 and socio-cultural context, 68 social relatedness, 190 immigration status and concerns, 67 traumas, 193 interviewer’s impressions based on biological/temperamental factors, 188 history, 70 caregiver–infant interactions, 186 legal involvement and concerns, 67 caregivers, 188 parent’s internal representation child sessions, 210, 211 of child, 68 child’s internal representations, 185 pregnancy, birth and early life, 64 child’s play, 208 protective and risk factors, 67 child’s play skills, 190 questions and responses, 68, 69 clinician’s conceptualization, 186 significant caregivers, moves, clinicians, 187 separations and trauma, 65 cognitive functioning, 187 developmental status of child, 24 data gathering, 187 domains of inquiry, 51 developmental history, 209 access to services, 53 diagnosis and treatment, 211, 212 educational and social service evaluation process, 187 agencies, 53 identifying information and description, educational, skill and employment presenting concerns, 207 history, 52 infantile amnesia, 185 family, cultural and religious beliefs, 56 infants, 188 health/dental/mental health care, 53, 54 play and expressive communication, 188 immigration status/concerns, 54 presenting concerns and background legal involvement and concerns, 54 information, 209 members of family and family’s psychiatric assessment process, 185, 186 support system, 52 reciprocity and social relationships, 189 parent’s internal representation of relational scripts, 185 infant/child, 57 self-expression, 189 pregnancy, birth and/infant/child self-reflection, 187 information, 51, 52 sessions, 189 protective and risk factors, 55, 56 time frames, 186 safety, housing, food, clothing and toddlers, 188 financial concerns, 55 Insightfulness Assessment (IA), 92 significant caregivers, losses and assessment, 92 traumas, 52 child’s behavior, 92 WMCI questions, 57 classifications, 93 practitioner reflects, 58 Intergenerational transmission, 42, 45, 95 practitioner’s stance and interpersonal Internal working models, 78, 83 processes, 46 Interview process presenting problem, 39, 40 adequacy of parent, 24 proper goodbye, 58 caregiver–family, 24–26 question-answer process, 51 case studies (Ana L and Paquito) reasons for referral, 39 access to services, 66 reflections of interviewer’s experience, 58, 59 behavioral observations, 62, 63 setting up, 28, 45, 46 collateral agencies, involvement of, 66 therapeutic frame, setting, 38, 39 concrete needs, housing, safety, food, validating experiences and meaning- financial needs, 67 making, 49, 50 current medical/dental and mental health, 66, 67 current members and household, 64 J diagnosis and formulation/plan, 70, 71 Joint clinical case formulation, construction educational skills and employment caregiver’s emotional responses, 335 history, 65 caregiver’s perspective, 333 Index 363

clinicians, 334 case studies, preschoolers with anxiety, 306 comprehensive joint clinical formulation, decisions and informed consent, 288 333, 334 mental health concerns, 291 conceptualization to treatment plan, 333 non-stimulant, 301, 302 consistent and routine invitation, OTC, 309 caregiver, 336 perceptions, 290 depression/substance abuse, 335 psychotropic, 305 development, 333 PTSD, 308 empathic and inclusive approach, 333 rapid development, 293 failure to construct, 334 RCT, 295 infant and early childhood mental treatment decisions, 291 health, 332 Melatonin, 310 nonjudgmental language, 353 Mental health disorders patience, thoughtfulness, time and approaches and assessment, 254 commitment, 334 caseness, 255 provider’s management, 335 classification, 255 psychoeducation, 334 comprehensive assessment, 266 soft start up, 334–336 data collection, 266 subsequent soft formulation, 335 DC Joint treatment plan assessing symptoms, 260 assessment and mental health service classification system, 258 provision, 336 comprehensive assessment, 260 buy-in, 337 cultural context, 261 caregiver strengths and challenges, 337 cultural domains, 259 chief complaint, 336, 337 developmental competence, 265 clinical case formulation and cultural diagnostic assessments, 260 considerations, 336 diagnostic classification system, 259 clinician and family, 336 infant and early childhood components, 338 psychopathology, 258 construction, 338 multiaxial approach, 259 development, 337 physical conditions & considerations, 263 infant and early childhood mental health psychosocial stressors, 264, 265 clinicians, 338 reflective practice, 260 interventions, 337, 338 risks and benefits, 259 multitiered behavior, 337 self-awareness, 260 production, 338 self-reflection, 261 SMART goals, 338 Task Force recommends, 259 developmental history, 277 diagnosing mental health and L developmental disorders Level of Caregiving Environment and Infant/ child’s symptoms, 270 Young Child Adaptation, 269 clinical disorders, 271–273 Levels of Adaptive Functioning–Caregiving contextual factors, 274 Dimension, 268 cultural and contextual dimensions, 271 DC:0-5, 273 DDAA, 274 M diagnostic algorithms, 274 MacArthur Story Stem Battery (MSSB), 205 Relationship-Specific Disorder, 271 McMaster Family Assessment Device, 269 distractibility and self-regulation, 277 Medicaid services, 53 education history, 278 Medications emotional well-being, 254 anxiety disorders, 306, 307 family and social history, 278 ASD, 305 infancy and early childhood, 255 caregivers of preschoolers, 290 infant-family system, 253 364 Index

Mental health disorders (cont.) O multiaxial approach, 255 Observation tool, 121 nosology, 255 Observational assessment, 109, 115, 137 relational context Observational methods, 113 assessment tools, 268 Obsessive Compulsive Disorder (OCD), 277, caregiving characteristics, 267 278, 280, 308, 309 caregiving environment, 266, 269 Obstructive Sleep Apnea (OSA), 309 caregiving–infant /young child Oppositional Defiant Disorder (ODD), 274, 277 relationship, 268 child–caregiver relationship, 269 child-caregiving environment, 267 P child’s social and emotional Parent Child Interaction Therapy (PCIT), 242, development, 270 287, 299, 312 infant/young child, 267 Parent Directed Interaction (PDI), 340 relational context, 267 Parent Management Training (PMT) stability, predictability and emotional approaches, 311, 316 regulation, 269 Parent Stress Index, 179 school observation, 279 Parental reflective functioning, 50 self-regulation and aggression, 280 Parental trauma history, 46 symptom checklists, 279, 280 Parent–Child Early Relationship Assessment, 114 Mental health practitioners, 50 Parent-child interaction assessment, 134 Mental health treatment, 349–351 Parent-Child Interaction Therapy (PCIT), 149, Mental representations, 208 340, 344 Methylphenidate, 300, 301 Parent-child relationship, 41, 98 Minnesota Parent Rating Scale, 179 Patient Centered Medical Home (PC-MH), 54 Monotherapy, 289 Phonologic speech, 160 Mood problems, 313 Piaget’s study, 4 Motherese/infant-directed speech, 194 Play therapy, 288, 308 Motor movements, 10 Play-based assessment, 187, 207 Mullen Scales of Early Learning, 229 Play-based scaffolding techniques, 206 Multidimensional Assessment Profile of Positive predictive value (PPV), 235 Disruptive Behavior, 224 Posttraumatic Stress Disorder (PTSD), 82, 245, 276 CBT, 287 N Child Parent Psychotherapy and Infant National Institute of Mental Health, 255 Parent Psychotherapy, 287 National Scientific Council on the Developing play therapy, 308 Child, 8 preschool, 307, 308 Negative predictive value (NPV), 235 Practice parameters Nonproprietary preschool measures, 289 AACAP, 145 Non-standardized assessments, 15 caregivers, 145 Non-standardized/authentic assessment, 15 child participation, 146 Nursing Child Assessment Satellite Training child room environment, 146 (NCAST), 115, 119 clinician’s roles assessment process, 125 clinician-child relationship, 149, 150 clinical practice settings, 120 documenting observations, 152 clinicians, 121 interacting with caregivers, 151, 152 health care professional flexibility, 120 play technique and establishing rapport, infant/child’s experience, 122 148, 149 interaction procedure, 123 description, 143 national trainer, 120 developmental milestone table, 156–157 parent–child relationships, 122, 123 disruptive behavior, 145, 147 and PCI, 120 evidence base, 144 protocols, 121 factors, 144 training package, 123 ideal minimalist office set up, 147 Index 365

ITMSE (see Infant Toddler Mental Status Psychoanalytic tradition, 3 Exam (ITMSE)) Psychodynamic approaches, 329 mental health assessment, 146 Psychoeducation, 334 miscellaneous toys for developmental Psychopharmacologic intervention, 344, 345 assessment Psychopharmacologic treatment, preschool balls, 158 children behavioral disorders, 155 ADHD over medication treatments, 290 books, 158 anxiety disorders, 305 garage with cars and keys, 155, 158 ASD (see Autism Spectrum Disorders (ASD)) paper and washable thick markers, 158 caregiver–child relationship, 287 puzzles, 158 caregivers, 290 observational play, 145 clinical humility, 292 observational skills, 144 clinician beliefs, 291 parent interview room, 147 culture, race, and community, 292 semi-structured tools, 144 DDAA (see Disorder of Dysregulated structured and semi-structured assessment Anger and Aggression (DDAA)) tools, 158 infant mental health, 288 toys and materials interventions, 287 aggressive toys, 154 medication, 288–290 categories, 153 OCD, 308, 309 clinical setting, 153 play therapy, 288 ethnic and cultural factors, 153 practice guidelines, 286 expressive toys, 154 psychotherapy, 287 family/nurturing toys, 153, 154 PTSD, 307, 308 pretend/fantasy toys, 154 rapid development, 293 rules, room environment, 153 reassessment, diagnosis, 288 scary toys, 154 recommendations and decisions, 291 sensory toys, 155 regulatory factors, 295 video-conferencing applications, 147 research base guiding clinical decisions, 295 young child assessment, 144 sleep (see Sleep problems in preschoolers) young children’s behavior, 145 workforce, 296 Pragmatic language, 161 Psychosocial stressors, 264, 265 Praise, reflection, imitation, description, and Psychotherapeutic approaches, 285 enthusiasm (P.R.I.D.E.), 149 Psychotherapeutic intervention, 316 Preschool ADHD Treatment Study (PATS), 294 Psychotherapy, 86, 287, 288, 307 Preschool Anxiety Rating Scale (PARS), 306 Psychotropic medications, 305 Preschool psychopharmacology Puppet-based interviewing techniques, 206 child medical and developmental history, 314, 315 diagnosis, formulation and plan, 315–317 R principles, 317 Receptive language, 160 treatment (see Psychopharmacologic Reciprocal engagement, 189 treatment, preschool children) Reflective functioning, 50, 77 Preschoolers, 144, 151, 172, 181 Relational scripts, 185, 191 Prescribing practices Relationally-based developmental guidance, 71 caregiving status and demographics, Relationship-based assessments, 144 297, 298 Relationship-Specific Disorder, 267 child factors, 297, 298 Research Domain Criteria (RDoC), 255 insurance, 297, 298 trends, 296 workforce, 296 S Primary care providers (PCPs), 224 Scoring system, 87 Probable experience scales, 84 Screen for Anxiety and Related Emotional Proper goodbye, 58 Disorders (SCARED), 306 Protective factors, 56 Selective mutism, 287 366 Index

Selective serotonin reuptake inhibitors cultural adaptation, 237 (SSRI’s), 305 discriminant/between groups validity, 233 Self-actualization, 55 face validity, 233 Self-awareness, 47 factor structure, 233 Sensory Over Responsivity Disorder, 276 influence instrument adoption, 230 Separation/reunion situation, 124 internal consistency, 231 Sleep problems in preschoolers longitudinal developmental context, 234 behavioral interventions, 310 parent–caregiver reports, 230 clonidine, 310 predictive validity, 234 diagnosis, 309 sensitivity/specificity, 234 diphenhydramine, 310 standardization, 236 melatonin, 310 statistics and rules, 232 OTC medications, 309 test–retest reliability, 231 tracking, 309 types of, 232 SMART goals approach, 338 rating scale information, 243, 244 Social and emotional skills, 10 rating scales, 223 Social-emotional and behavioral (SEB) screening, 225 adult-report rating scales, 217 screening tools vs. comprehensive assessment goals, 223 assessment tools, 223 behavioral observations, 243 select informants caregiver, 218 caregivers, 219 child medical and developmental history, childcare providers, 220 242–243 family members and child-care clinical assessment, 217 providers, 219 clinical rating scale non-parental family members, 220 comprehensive SEB checklists, 239 parents/guardians, 220 problem-specific rating scales, 240 social and family history, 242 screeners, 238 strengths, 218 comprehensive assessments, 227 Social phobia, 287 contextual and cultural factors Socio-cultural contexts, 41, 42 influence, 221 Soft start up, 334–336, 353 interpersonal relationships, 221 Special education services, 53 language and literacy, 221 Spence Preschool Anxiety Scale (SCAS), 280 multiple settings, 222 Standardized evaluation tools, 15 neighborhood and community, 222 Still-Face Paradigm (SFP), 125 stressors, 222 infant behaviors, 126 values and norms, 221, 222 research tool, 125 domains of interest Story stem technique, 205 assessing competencies, 228 Strange Situation, 192 behavioral functioning, 227 Strange Situation Procedure (SSP), 83, 85, 126 caregiver concerns, 229 Stranger anxiety, 192 cognitive and language delays, 229 Structured clinical assessment approach, 109 disruptive behavior problems, 227, 228 Structured task situation, 124 early childhood, 227 Substance Abuse and Mental Health Services impairment, 230 Administration’s (SAMHSA), 339 trauma and stress, 228 Systemic Lupus Erythematosus (SLE), 175 formulation and plan, 244, 245 history, presenting concerns, 241, 242 identifying information and description, 241 T interpreting rating scales and sharing Theory of Mind (TOM), 199 results, families, 238–241 Theraplay, 342, 344 limitations, 219 Trauma, 330 psychometric properties historical, 41, 42, 51 content validity, 233 history-taking, 27, 28 convergent validity, 233 intergenerational, 51 Index 367

intergenerational transmission, 42 W political, 41 Working Model of the Child Interview relational, 70 (WMCI), 57, 99, 101, 315 Trauma-Focused Cognitive Behavioral AAI, 87 Therapy (TF-CBT), 294, 340, 344 AMBIANCE, 88 Treatment phases, 27 classifications, 88, 89 Treatment planning and intervention, 22 disengaged representations, 88 Treatment plans, 336 empirical research, 89 examination, 87 infant attachment classification, 90 U knowledge, 86 Unconscious projections, 80 mediation analysis, 90 questions, 87, 88 treatment planning, 87 V World Association of Infant Mental Health Video Replay Interview, 125 (WAIMH), 2, 270