Infant Psychiatry: Looking Backwards and Forwards
My own journey to infant psychiatry was through the intensive care nursery. As an intern in pediatrics, I found the ethical dilemmas of what to do for very sick babies especially wrenching. Too often, it seemed, crucial decisions were being made based on powerful feelings stirred up in attendings, residents, nurses and families. After I became a psychiatry resident (then at another institution), I wanted to return to the ICN to try to make sense of the place and my own reactions to it, as well as to determine what I might have to offer.
In this work, I became especially curious about development: What was the likely future development of these babies? What were the factors that led very sick babies to recover or to remain compromised? What I read surprised me greatly. Setting aside a few extreme conditions like prolonged perinatal hypoxia, the best predictor of outcome for preterm infants was not any characteristic of the baby or even the illness, but rather, the social class of the family. Stunning! Family characteristics were more important than infant or illness characteristics. Now, I was really curious about development.
I still am, nearly 25 years later. And for someone interested in development, there is no period more fascinating than the first few years of life. The miracle of the fertilized egg becoming a human infant in only 9 months is followed by another astonishing miracle. In a mere 36 months, completely dependent human newborns become remarkably complex creatures who understand that they can share thoughts, feelings, and intentions with others, who come and go as they please, who express themselves abstractly using symbols, who empathize with others, and who read and understand subtle social signals from others. Brain development in the early years is so extraordinary that the rapidity and profundity of behavioral development in first 3 years of life is unprecedented in human life cycle.
Increasingly, we have learned how the nature of early experiences during those first few years of life impacts and shapes current and later development. Although development continues throughout the life cycle, and change is always possible, the appeal of trying to make changes early, at a time when the central nervous system is still so enormously plastic, is obvious. That is the business of infant psychiatry.
Although it appears unlikely that the same kinds of neurobiological critical periods will be discovered for social and emotional development that exist for some forms of perceptual development, it is likely that interventions in the early years will have more profound effects on developmental trajectories than interventions at later ages. There is no longer any question that experience sculpts brain development—that is neurochemistry and circuitry--the remaining questions are details of how, under what circumstances, and to what degree. The most exciting developments in psychiatry that I see as I look ahead towards the next 25 years will be in detailing the processes of gene environment interactions. Infant psychiatry stands to gain enormously from our increased understanding of these processes, as they will have enormous implications for the design of more meaningful and more powerful preventive interventions.
Infant mental health, which is actually a more accurate term than infant psychiatry, is the field that has emerged to study and treat young children and their families. The World Association for Infant Mental Health has a multidisciplinary membership on every developed continent, and the Infant Mental Health Journal has been publishing articles for more than 20 years.
A national professional advocacy organization, Zero to Three, has defined infant mental health as “the young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn. All of these capacities will be best accomplished within the context of the caregiving environment that includes family, community, and cultural expectations for young children” (Zero to Three, 2002). This means that the field of infant mental health encompasses multidisciplinary approaches to enhancing the social and emotional competence of infants through their biological, relationship, and cultural contexts. Infant-caregiver relationships are the primary focus of assessment and intervention efforts, not only because infants are so dependent upon their caregiving contexts but also because infant competence may vary widely in different relationships. Assessments in infancy always are considered a form of intervention, as they may have important impacts on both infant and family. Moreover, intervention efforts always involve prevention because the young child is constantly developing, and the developmental trajectory must be attended to in addition to the child’s here and now adaptation (Zeanah and Zeanah, 2001).
Infant mental health is multidisciplinary because the complex, interrelated nature of human development and its deviations requires expertise and conceptualizations beyond the capabilities of any particular discipline. The complexity of the clinical problems of infants and toddlers invite multidisciplinary collaboration to minimize suffering, and to enhance development and promote competence. For the same reason, it is likely that the field of infant mental health will remain pluralistic, a subspecialty within a number of different disciplines rather than an integrated and distinct discipline itself. Child and adolescent psychiatrists have been vital contributors to this effort from its earliest beginnings, and their role will remain powerful in the future.
How does one become an infant psychiatrist? Infant psychiatrists are child and adolescent psychiatrists who have special interest and expertise in the early years. Many infant psychiatrists have completed postdoctoral fellowships in infant mental health under the mentorship of established investigators and clinicians. There are several established training programs in which these interests can be pursued, and the AACAP Infancy Committee maintains a list of such programs.
What does one do as an infant psychiatrist? First and foremost, one sees an array of troubled young children and families: young children who have been traumatized, infants who are failing to thrive or have other feeding disturbances, toddlers who are overly aggressive or impulsive and self-endangering, maltreated young children and their maltreated parents, infants with sleep disturbances, and many others. At our program, infant psychiatrists provide direct clinical services to young children and families, consult to community and state agencies, consult to juvenile courts, consult to pediatrics, train mental health professionals in a variety of disciplines, conduct research on early experiences and brain and behavioral development, evaluate the efficacy and effectiveness of early interventions, and work collaboratively with state government officials on policy initiatives.
Prevention is the great uncharted territory in child psychiatry. If the idea of using relationships to effect powerful changes in the brain that have lasting impacts on children appeals to you, then you should consider infant mental health as an area of focus. I have been privileged to watch it grow from an exciting but obscure area to one that has grabbed the attention of the Surgeon General (1999), the Institute of Medicine (Shonkoff and Phillips, 2001), and the authors of Healthy People 2010 (DHHS, 1997), the nation’s blueprint for public health in the first decade of this century. What we need now is to grab the attention of you, the future leaders of child and adolescent psychiatry.
Institute of Medicine (2000). From neurons to neighborhoods: The science of early childhood development. Institute of Medicine, National Research Council, Board of Children, Youth and families, Committee on Integrating the Science of Early Childhood Development. J. Shonkoff and D. Phillips (Eds.).
Task Force on Infant mental Health (2002). Definition of infant mental health. Zero to Three, Arlington, VA, www.zerotothree.org.
U.S. Department of Health and Human Services (1997). Developing objectives for healthy people 2010. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion.
U.S. Department of Health and Human Services (1999). Mental health: A report of the surgeon general, Rockville, MD: US Department of Health and Human Services, Substance Abuse, Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health, National Institute of Mental Health.
Zeanah, C.H. & Zeanah, P.D. (2001). Towards a definition of infant mental health. Zero to Three, 22, 13-20.
Charles H. Zeanah, M.D.
Professor of Psychiatry and Pediatrics and Director of Child and Adolescent Psychiatry at Tulane University Health Sciences Center.