Mental Health Assessment of the Toddler

1
Mental Health Screening, Assessment and Diagnosis
of Toddlers
Kristina Hindert, MD Nick Tsandes, LCSW The
Childrens Center
2
Overview

• Remember the toddlers perspective
• Interagency Coordinating Council of
  Babywatch--State Practice Model for
  Mental Health of Children ages zero to five
• www.utahbabywatch.org/ICC
• Utah Association of Infant Mental Health
  
• www.hope.usu.edu

3
Screening

• Who needs a mental health assessment and why?
• Some symptoms cause such impairment, intervention
  is critical
• Some problems are common and treatable, so
  intervention is very successful

4
Symptom vs. Disorder

• Symptoms in an infant may develop into a
  disorder
• Negative initial response to stimuli at 4 months
  predicts inhibited behavior at 2 years and
  increased likelihood of an anxiety disorder

5
Intensity of a Symptom

• Tantrums are common
• Prolonged Destructive Tantrums predict later
  disruptive disorders and mood disorders
• Persistent irritability predicts disruptive
  disorders and mood disorders

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So What Do We Screen For?

• Problems can exist within the child, be secondary
  to the caregiver AND/OR be a function of the
  caregiver-child relationship
• There is no such thing as a baby
• DSM V due in 2010 will likely focus on disorders
  residing in the infant/toddler BUT there is great
  debate in progress over how to recognize the
  importance of relationship

7
Dont Miss Critical Concerns

• For young infants, post-partum depression in the
  mother impacts development, can be identified and
  is treatable. See handout/Edinburgh Postnatal
  Screening
• By age 2, symptoms of autism can be identified.
  See handout/MCHAT
• The BABES reveals parental concerns
• Dept of Health using Ages and Stages

8
Whenever a caregiver is worried

• There is a problem if a caregiver feels
  unable to help their baby/toddler with
  sleep, eating, self-soothing, or communicating
• It may be the baby or the caregiver or the
  fit
• Refer to Healthy Minds and Brain Wonders handouts
  from www.zerotothree.org
• Infant developmental history/observation guide

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Developmental/Emotional Challenges of Toddlerhood

• Toddlerhood18-36 months
• Simultaneous onset of increased mobility and
  language
• Capacity for symbolic representation evolves-can
  now imagine outcomes and anticipate consequences
• Sudden acquisition of new emotions emotions
  differentiating at rapid pace

Lieberman, 1992
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Challenges of Toddlerhood

• Onset of elation, pride, anxiety,
  self-consciousness, shame, intentional hurting,
  guilt
• Quick transitions between carefree marching away
  and frantic clinging behavior
• Internal struggle with can I do it by myself, or
  do I still need help?

Lieberman, 1992
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Toddler-Parent Relationship

• Restructuring of the relationship between
  attachment exploration
• Secure Base Behavior (Balance)
• Parent struggles with Protective Behaviors, and
  Letting Go (parental signals)
• Social Referencing

Lieberman, 1992
12
Toddler-Parent Relationship

• Toddler seeks to explore, learn, and individuate
• Parent strives to protect and to socialize
• Given these different goals, struggles are
  inevitable

Lieberman, 1992
13
Goal Corrected Partnership

• Where parent and child learn when and how to
  compromise and rearrange their individual goals
  for the sake of the relationship, or to
  accommodate the more urgent priorities of the
  other
• Toddler internalizes parental emotional support
  and standards of behavior

Lieberman, 1992
14
Toddler Referral Concerns

• Aggression
• Defiance (temper tantrums)
• Impulsivity
• Overactivity
• Anxiety (separation and fears)

JAACAP, 1998
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Other Referral Concerns

• Developmental Delays
• Parent-Child relationship problems
• Eating and Sleeping Problems
• Elimination Difficulties-Toilet Training

JAACAP, 1998
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Assessment is Relationship-Based

• What does the toddler bring to the relationship?
• What do caregivers and other family members bring
  to the caregiver-child relationship?
• How do the contexts of biology, social
  factors/environment, and cultural factors affect
  these relationships?

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Goal of Clinical Interview

• Establish a therapeutic alliance
• Develop a complete, comprehensive view of the
  child in context
• Facilitate a shared understanding of the parents
  perspective of the childs problem
• Develop a plan for treatment
• 
  

Hirshberg, 1996
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Assessment as a Collaborative Process

• Is the first intervention, and invites the
  family to tell their story
• Is ongoing, never stops
• Can form the beginning of understanding and hope
• Parents as primary in treatment team
• Clinicians are hopefully interested in assessing
  their own impact, continually

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Primary Referral Concerns

• The therapist follows the clients lead, in
  deciding what is important about this initial
  assessment
• Tell me about your concerns.
• Each critical area is carefully explored with the
  parent using open-ended questions
• Throughout, both strengths and concerns are
  discussed

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Areas for Assessment

• Family Social History
• Early Developmental History
• Parent-Child Relationship/Attachment
• Relationship to Sibling(s)
• Family/Environmental Stressors (risk and
  protective factors)
• Parent-Time Concerns
• Abuse/Neglect/Domestic Violence
• Trauma and Loss

21
Areas for Assessment

• Behavioral Concerns
• Emotional Concerns
• Preschool/Peer Relationships
• Sensory Integration
• Regulatory Issues
• Daily Routine and Schedule
• Development and Self Help
• Medical
• Legal

22
Areas for Assessment

• Caregivers Attempt to cope with presenting
  problems
• Family Psychiatric History
• Prior Treatment / Current Involvement with other
  community agencies

23
Behavioral Measures

• Parenting Stress Index - Summarizes sources of
  parental stress, arising from attributes of both
  the parent and child. (Normed only for
  biological parents).
• Child Behavior Checklist (1.5 - 5 years)
  Summarizes normative data for various areas of
  pathology.
• ITSEA BITSEA

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Infant/Toddler Mental Status Exam

• Observational Tool with following categories
• Appearance
• Reaction to Situation
• Self-Regulation
• Motor
• Speech and Language
• Thought
• Affect and Mood
• Play
• Cognition
• Relatedness

JAACAP, 1998
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Diagnosis

• Research Diagnostic Criteria-Preschool Age
  (RDC-PA)
• Developed for research, but demonstrate
  modifications when necessary to utilize DSM IV
  criteria for children under age 6
• Unclear how the Classification System for Zero to
  Three will be used in DSM V

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Treatment PlanningSo much to Choose From

• Summarize the symptoms of the infant/toddler
  developmental skills, temperamental
  characteristics, coping styles(ie helpless,
  overstimulated, avoidant), range and intensity of
  moods and behaviors alone, with caregivers, with
  siblings, with other adults and with children
• Summarize the caregiver capacities

27
Treatment Planning

• Summarize social supports, cultural strengths,
  whats working, and where there are deficits
• If not SURE, refer for hearing, vision,
  development screening, including motor skills and
  language .
• Consider Occupational Therapy eval. for sensory
  sensitivities

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Treatment planning

• Refer for genetic or neurological evaluations if
  needed
• Determine interventions for the family, the
  parent-child relationship and for the child,
  which is often accomplished through the parent

29
Treatment Interventions

• Provide practical help for families
• Take advantage of strengths
• Provide information, advice, translate infant
  signals, provide emotional support for families,
  help with behavioral techniques

30
Treatment Interventions

• Provide play interventions when needed for the
  child
• Provide corrective attachment experiences
• Open windows when helpful to the parents own
  past and issues