Principal author: Jean M. Thomas, M.D., M.S.W. This summary was developed by the Work Group on Quality Issues: John E. Dunne, M.D., Chair; Valerie Arnold, M.D., R. Scott Benson, M.D., William Bernet, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., and Jon McClellan, M.D., and additional authors: Anne L. Benham, M.d., Margaret Gean, M.D., Joan Luby, M.D., Klaus Minde, M.D., Sylvia Turner, M.D., and Harry H. Wirght, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The full text of the Practice Parameters for the Psychiatric Assessment of Infants and Toddlers (0 - 36 months) is available to Academy members on the World Wide Web (www.aacap.org) and appears in the October 1997 supplement to the JAACAP. The full text of these parameters was reviewed at the 1996 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council on June 2, 1997. Â© 1997 by the American Academy of Child and Adolescent Psychiatry. ABSTRACT This summary describes the psychiatric assessment of infants and toddlers (0-36 months) and supports the growth of infant and toddler psychiatry, a rapidly developing field. Infants and toddlers are brought to clinical attention because of concerns about emotional, behavioral, relational, or developmental difficulties. It is axiomatic that the infant or toddler must be understood, evaluated, and treated within the context of the family. A perspective that is developmental, relational, and multidimensional and that borrows from the knowledge of multiple disciplines is essential. Collaborative efforts support the urgent need and incomparable opportunity to understand and to intervene early and preventively with young children and their families. Key words: infant psychiatry, infant, toddler, interdisciplinary assessment, practice parameters, guidelines. These parameters give the clinician direction in the psychiatric assessment of infants and toddlers (0 - 36 months). Recommendations are based on extensive review of the scientific literature and consensus among clinical experts in the field. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1997). The field of infant and toddler psychiatry is young and rapidly developing. Collaborative, intertheoretical, interdisciplinary, interinstitutional, and international efforts support the urgent need and incomparable opportunity to understand and to intervene early and preventively with young children and their families. The practice parameters summarized here are intended as a vehicle for sharing with clinicians the expertise of child and adolescent psychiatrists and other clinicians who specialize in clinical work with infants, toddlers, and their families. These parameters suggest structure and content for the family interview; guide observations of interactions and relationships; present the Infant and Toddler Mental Status Exam (ITMSE); describe the Diagnostic Classification: 0 to 3 (Difficult Child:0-3) (Zero to Three, 1994); discuss adjunctive, helpful standardized instruments; suggest interdisciplinary team and referral strategies for integrating complex multidimensional information; and guide the diagnostic formulation process and development of a treatment plan. Challenges encountered in developing these parameters included: the bringing together of experts in an emerging field for which knowledge is still largely clinical, rapidly developing, and minimally represented in the literature; and concisely but thoroughly presenting knowledge and clinical strategies to practitioners for whom work with very young children is new or who are in solo practice and do not have access to specialized professionals or assessment facilities. CONSIDERATIONS IN THE ASSESSMENT OF INFANTS AND TODDLERS By design, assessment and intervention with infants and toddlers is a unified process oriented toward prevention. Since infancy and toddlerhood are a time of rapid change and lay the foundation for future development, the clinician's primary effort is aimed at facilitating the child's rapid change toward healthy development and strengthening parental and extended environmental support systems. Parents are primary in the treatment team because infants and toddlers are maximally dependent on parents. Facilitation of change, therefore, must be accomplished primarily through the parents. A multidimensional perspective that borrows from pediatrics, developmental psychology, speech and language therapy, occupational therapy, physical therapy, and other disciplines is essential to effective work with very young children, who are able to provide only limited behavioral and verbal clues to help the clinician understand complex mutually influencing etiologic factors. In assessing infants and toddlers, a developmental perspective is essential to differentiate normality from risk and pathology. In addition, a relationship perspective is essential to understand the power of relationships both in the child's development and in collaborative assessment, intervention, and treatment planning with the parents. Multiple assessments over time often are needed because infants and toddlers change rapidly in response to internal and external stressors. For infants, the most frequent referral concerns are: dysregulation of physiologic function, including fussiness or colicky behavior; feeding and sleeping problems; and failure to thrive. For toddlers, the most frequent referral concerns are: behavioral disturbances, including aggression, defiance, impulsivity, and over activity. In addition, constitutional factors, including developmental delays and subtle physiologic, sensory, and motor-processing problems often derail expected developmental progress and bring young children to clinical attention. Problems with "goodness of fit" between the child's constitutional attributes and temperament and the parents' expectations create relationship difficulties that also may lead to referral. Infants and toddlers must always be understood, evaluated, and treated in the context of the family or primary caregiving unit and within additional significant contexts, including relationships with other important caregivers and extended family; school; day care center; and the larger culture. The family's alliance with the evaluating clinician provides a context for the assessment and intervention process. Through this relationship, the clinician and parents together observe and facilitate the family's behavioral, affective, and psychological responses to each other, clarify concerns about the child, and mutually develop a treatment plan. It is helpful to keep in mind that the parents of infants and toddlers often feel anxious or guilty because they think that problems existing in a young child may imply that their parenting skills are inadequate. The purposes of the psychiatric assessment of infants and toddlers include developing a shared understanding of the core concerns and other factors leading to the referral; determining whether psychopathology or conditions that lead to risk or vulnerability are present; establishing a developmentally based differential diagnosis and an ongoing mutual process of formulation that helps organize the parents' understanding of their experience with the child; and developing a treatment plan that addresses the parents' explicit and implicit expectations and facilitates parent--child relationships that support the child's healthy development. To accomplish these purposes, the aims of the diagnostic assessment are: to establish with the parents an ongoing therapeutic relationship built on respect for the parents' knowing their child, being a central influence in their child's life, wanting to make a better life for their child, and having unique values, preferences, and cultural ideals; to assess the nature, severity, and developmental impact of the child's behavioral difficulties, functional impairment, or subjective distress on the child and on the family; and to identify transactional, mutually influencing, biopsychosocial, individual, family, and sociocultural risk and protective factors that may, in the process of development, contribute to or ameliorate the presenting concerns.