#96282: An Introduction to Infant-Preschooler Mental Health

Because infant-preschooler mental health is such a broad area of study, there are no specific, global criteria to define infant-preschooler mental health practice. Johnston and Brinamen define infant mental health as, "a set of principles, a field of practice, and a state of being" [2]. This definition, although vague, does lend itself well to the inclusive nature of infant-preschooler mental health.

In many states, including Michigan, New Mexico, and California, infant-preschooler credentialing and/or certification programs are available. The requirements for these programs vary by state and/or credentialing association. Additionally, differing funding sources, such as grants and third-party payors, may also have specific requirements regarding the qualifications of professionals providing services for children younger than 5 years of age.

This being said, there are some basic concepts associated with infant mental health that are widely accepted as core practice principles, regardless of discipline or profession. Primarily, practitioners should have an understanding of the social, emotional, and behavioral health needs of young children and their families [3]. To achieve this, practitioners should have a solid base of knowledge in early childhood development to understand both normative and atypical child development in addition to risk and resiliency factors facing this population. Additional competencies include knowledge and understanding of emotional/behavioral disorders; assessment; interventions; community resources and referrals; and organization, collaboration, and communication [4].

A mental health clinician interested in treating children 0 to 5 years of age should have a solid foundation in counseling psychology in addition to education and knowledge of attachment theory, child development, and play- and relationship-based interventions. Infant-preschooler mental health clinicians should listen carefully, be sensitive to the unique needs of families, and work collaboratively with parents on behalf of their children. In addition to the basic knowledge and experience necessary to treat young children and families, there are also personal characteristics that may make an individual a more effective infant-preschooler mental health practitioner, including warmth, empathy, caring, curiosity, and reflective capacity. Personal development is also an essential characteristic. Clinicians should have a mature capacity for self-reflection to create and maintain an awareness of personal feelings, experiences, motivations, and reactivity. Personal development should also be sought to increase openness to engagement and collaboration with families, to maintain professional boundaries while balancing the complex needs of families, and to know when and how to refer to services and supports outside the practitioner's scope of practice [5].

Most importantly, infant-preschooler mental health clinicians should also have support and supervision from those experienced and educated in the field [5]. Clinicians should actively seek consultation, reflective practice supervision, and quality clinical supervision. Even clinicians experienced in the field of therapy, counseling, or mental health services should seek specialized support and training to serve the infant-preschooler population.

Interdisciplinary/multidisciplinary collaboration is also an essential part of providing mental health services to this population. Practitioners should have a clear understanding of scope of practice and define a plan for referral or linkage if and when necessary. A "warm hand-off" is the most successful when connecting parents to other agencies and services when needed. Parents left to make their own connections or to follow-up on suggested referrals are often unsuccessful. The more relationships cultivated by the practitioner, the better for children, families, and the community.

One of the most important relationships in life is that between a child and parent. When infants enter the world, they are completely reliant on others for survival. D.W. Winnecott, developmental theorist and pioneer of attachment-theory, once wrote, "There is no such thing as an infant," meaning that infants do not exist in and of themselves [8]. Conversely, there is no such thing as just a parent. In order to be either of these things, one must be in relationship to the other. Infant-preschooler mental health supports the parent-child dyad as the most influential relationship on the lifelong development of the child. This relationship should be valued and supported in order to impact change. The infant-preschooler mental health practitioner, regardless of discipline, should be attuned to the importance of relationships.

Understanding the importance and complex nature of the attachment bond and the intricate dance of the attachment and bonding process is of utmost importance for infant-preschooler mental health practitioners. Bonding is the term for the tie from parent to infant and is one of the strongest and most important human relationships. Attachment applies to the tie from the infant to parent. Attachment patterns develop in infancy and can be carried throughout the lifespan (as will be discussed in detail later in this course).

Both of these processes are complex and intricate. Small moments of attunement, connection, and availability are the building blocks of these connections. It happens between two distinct people, each bringing his/her own temperament and personality to the interaction and experiences of bonding.

The bonding process consists of interactions and experiences that occur over time. Bonding often starts for parents, especially mothers, during pregnancy. However, bonding has its roots in parents' own relationship and attachment history.

The concept of "ghosts in the nursery," originally developed by Selma Fraiberg and colleagues, speaks to the impact of intergenerational parenting practices, experiences, and events [1]:

Fraiberg and colleagues introduced this concept to discuss the ease with which parents re-enact their own early relational experiences with their children, potentially unwittingly transmitting child maltreatment from one generation to the next. Counter to "ghosts in the nursery" is the concept that attuned and sensitive caregiving ("angels in the nursery") has an equal impact. These positive experiences can be protective factors in shaping parent-child interactions in a positive manner.

Alicia Lieberman and colleagues expanded on the concept of intergeneration impact on parenting in their article Angels in the Nursery: The Intergenerational Transmission of Benevolent Parental Influences [9]:

Practitioners should understand and respect the significant impact of early parental care on the long-term emotional health of infants and children. This is done partly by offering developmental guidance, assisting parents in finding joy in their relationship with their child, and supporting parental capacity [7].

As discussed, the infant-preschooler mental health practitioner should always remain attuned and attentive to the individual strengths and needs of each parent. The family's cultural beliefs and expectations should be acknowledged with respect, and the practitioner should follow the lead of the parents, responding with empathy and curiosity.

Biologic and psychosocial factors have a huge impact on the healthy development of children and families. Family units that struggle with issues such as poverty, community violence, and mental illness are at greater risk for child abuse, neglect, and parental substance use/abuse. Quality, effective interventions can assist in supporting families to be resilient. In some cases, factors such as prematurity, congenital abnormalities, and developmental delays can contribute to parents experiencing symptoms of grief, loss, and depression. These parents often experience the loss of the fantasy of the "perfect child" when a child is born with a defect, illness, or delay. Infants born to adolescent mothers or women in relationships with domestic violence also have unique needs.

Additionally, there may be factors at play that are not at first obvious to the parent or practitioner. Issues such as sensory processing disorders may not be apparent when a child is first referred for treatment; a child could go years without another professional identifying this specific issue. However, the symptoms of undiagnosed disorders can be a primary stressor in a parent-child relationship. Careful consideration should always be made on the best type of interventions and supports offered to families struggling with biologic or psychosocial stressors.

There are many types of violence that can occur in a family, such as spousal abuse, child abuse and neglect, elder abuse, and caregiver abuse, and many families struggle with one or more types of violence and abuse. Witnessing or experiencing violence is scary and confusing. Children who are exposed to this type of violence may learn that the family unit is a source of harm instead of a source of safety and security [10]. This may lead children to mistrust those responsible for their care and to manifest symptoms of fear, anger, aggression, and poor affect regulation. Because infants and toddlers spend most of their waking hours with adult caregivers, these relationships are essential in shaping the infant's or toddler's view of the world and themselves. In 2022, the U.S. Department of Health and Human Services Administration for Children and Families published their annual report, Child Maltreatment2020, which indicated that the largest cohort of children experiencing childhood maltreatment (in the form of abuse and neglect) were younger than 3 years of age, with infants (younger than 1 year of age) at the greatest risk [11]. In total, 26% of children are exposed to family violence during their lifetimes [43].

Concerns regarding the use of substances by parents start prior to gestation. Use of and addiction to substances including alcohol, tobacco, and prescription and illicit drugs could have an impact on parental capacity even prior to conception. Many parents with substance use problems became addicted prior to parenthood and may turn to alcohol and/or drugs as a means to address low self-esteem and poor self-image [12]. Maternal substance use can have a direct and permanent impact on a developing fetus. As an example, the most commonly known and well understood impact of substance use on the fetus is that of alcohol use. Fetal alcohol spectrum disorders (FASDs) occur when the fetus is exposed to alcohol in utero, as alcohol travels in the mother's blood through the umbilical cord and to the fetus. Infants born with FASD may exhibit a host of symptoms, including but not limited to heart, kidney, or bone problems; problems with emotion regulation, attention, and sleep; low birth weight; and facial abnormalities. These types of symptoms also make a child vulnerable to physical and mental health concerns later in life.

Parental substance use also increases the likelihood of childhood maltreatment, even more so after the birth of a child with special needs, colic, or emotional regulation difficulties. In 2017, 30.8% of child victims of maltreatment, or 112,319 children, were identified with a parental drug abuse risk factor [11]. It is important to remember that these numbers are only the reported and substantiated claims of abuse and are therefore likely an underestimation. Not all parents who use substances abuse their children, but parental substance use has been shown to have a negative impact on the nature and quality of the parent-child relationship, often resulting in poor parenting outcomes and unfortunate and negative consequences for the infant-parent relationship.

Pregnancy and impending parenthood are naturally stressful and exciting times for many individuals and parent dyads. The experiences of mothers before, during, and after pregnancy have an impact on child development and relational outcomes. Approximately 50% to 75% of new mothers experience feelings of anxiety, fatigue, fear, and sadness [13]. These transient depressive symptoms, often referred to as the "baby blues," are considered relatively normal if they are not excessive and if they resolve in one to two weeks. In Touchpoints, T. Berry Brazelton, MD, states [14]:

Approximately 15% to 20% of new mothers will develop postpartum depression [15]. The symptoms of postpartum depression are similar to the symptoms of any major depressive disorder. However, due to the unique issues regarding the mother-infant relationship, the adaptation to parenthood following the delivery of a baby, and the impact of the mother's depression on the infant, it is considered a unique mood disorder suffered by postpartum women. A more severe form of postpartum mental disturbance, postpartum psychosis, occurs in 1 to 2 of every 1,000 new mothers [44]. Although postpartum depression has become the most well-known mental illness associated with pregnancy and birth, there are many other illnesses that are directly related to pregnancy, birth, and delivery.

Women who have difficult or degrading birth experiences may also manifest symptoms of post-traumatic stress disorder (PTSD). Delivery or post-delivery trauma can include an unplanned cesarean delivery, long-term separation of infant and mother after birth, medical interventions due to emergency or illness, and lack of caring by medical staff. The reported prevalence of birth trauma is 32%, with up to 6% of woman developing symptoms associated with PTSD [16]. Infant-preschooler mental health professionals can be a support for families who are struggling with maternal mental illness.

When pregnant or expecting a child, parents often fantasize about what their baby will be like, what he or she will look like, and what temperament he or she may have. For a typical pregnancy, this fantasy does not include congenital abnormalities, developmental delay, or serious health problems. When a child is born with such a problem, parents may experience grief at the loss of their fantasy. Adjustment in expectations and the creation of a new vision of the future, including new ways of caring, are necessary [17].

Not all parents struggle with adjustment to an infant with special needs; every parent and family has a unique experience that should be honored and respected. When parents are supported in nurturing and caring for a child with special needs, it enhances the parents' confidence and the child's lifelong view of him- or herself and others. Child psychologist Bruno Bettleheim wrote: "Children can learn to live with a disability. But they cannot live well without the conviction that their parents find them utterly lovable…If the parents, knowing about [the infant's] defect, love him now, he can believe that others will love him in the future" [18].

Children with special needs are at greater risk for abuse, and 13.3% of child victims of maltreatment have a disability [9]. Because children born with developmental or physical disabilities are especially vulnerable to maltreatment, their families may benefit from added support and intervention.

In the 1940s, René Spitz, an Austrian-born psychoanalyst, focused his research on the negative impact of maternal deprivation on child development, which he termed anaclitic depression or "hospitalism." In his research with abandoned or surrendered children, Spitz found that although children had basic needs met in "foundling hospitals," many had significant maladaptive responses to the lack of a secure attachment figure [19]. Some of these children appeared to die as a result of the separation from their attachment figures. Although these studies were conducted 80 years ago, their findings are still relevant today.

Infants and toddlers are impacted greatly by a disruption in their attachment relationships, regardless of the quality of those relationships. Children separated from their attachment figures often appear to slow developmentally and to regress in social-emotional skills and affect regulation.

In the United States in 2020, approximately 170,000 children younger than 6 years of age were in foster care [20]. The stress of foster placement alone is a significant event in the life of child, not to mention the circumstances that warranted removal in the first place. Young children with a history of poor parent-child relations struggle with initiating, accepting, and maintaining quality relationships with substitute care providers. This, particularly in cases of chronic placement changes, can impact the quality and pattern of children's attachments not only in early childhood, but for life. Nationwide, about one-third of foster children experience two or more placement changes each year [52].

Research indicates that adults who were once foster children have a rate of diagnosed PTSD that is twice that of Vietnam veterans [21]. Children in foster care tend to have poor outcomes in regard to health and education as well. Without support and intervention from trauma-informed, relationship-focused professionals, infants and young children impacted by attachment disruptions in any form, especially those exposed to institutionalized care, are at risk for medical, behavioral, and emotional problems.

One of the most common reasons parents seek services is behavioral or affective dysregulation by a child. This occurs most often in toddlers or preschool-aged children, but it can occur in infants as well. Parents may have their own concerns or may receive feedback from family members, daycare providers, or early education teachers regarding the behavior or presentation of their child. Behavioral issues common to this age group include frequent or intense tantrums, violent reactions (e.g., hitting, biting), excessive shyness/fear, poor peer interactions, and attention problems.

On some level, many of these behavioral concerns may actually be on the high end of age-appropriate behaviors, and parents seeking services may be unaware of normative child development. It is the practitioner's role to assess and address this issue, if necessary. It is common for parents to have little to no exposure to young children prior to becoming parents, and they may have a misunderstanding of or unrealistic expectations for their young children. In these cases, education may be the only necessary intervention.

Alternatively, parents may have an overly permissive approach to parenting that could be contributing to behavioral issues or a child's behavioral issues may be an indication of psychopathology. Either situation requires careful navigation by the practitioner working in collaboration with the family to best meet their needs while offering developmental guidance.

In the United States, preschoolers are expelled at more than three times the rate of their school-aged peers, often due to common behavioral issues [22]. However, with quality mental health consultation in the preschool setting, expulsion rates decrease significantly [22]. It is essential that children receive early intervention to assist with mediating poor social and academic behaviors, as a pattern of poor school functioning can have a significant impact on family stress, self-esteem, peer relations, and academic achievement.

Eating and sleeping issues are also common concerns for parents and caregivers of children younger than 5 years of age and often motivate help-seeking. It is easy to see why, as a child with sleeping difficulties can be a disruption to an entire household and eating problems could easily trigger fear and anxiety that a child's nutritional needs are not being met. When there is not a medical reason for eating or sleeping issues, intervention may be provided by an infant-preschooler mental health professional. This is another opportunity to provide developmental guidance, if needed, but also to explore the role of household and family dynamics on infants and young children. Often, children will manifest symptoms of sleeping and eating difficulties as a result of an underlying issue.

The senses are the body's way to gather information both internally and externally. The most commonly known senses are those of sight, smell, taste, touch, and sound. But, there are also lesser known senses, such as vestibular senses, proprioception, and interoception [23]. Infants and children with hypo- or hypersensitivity to one or more senses may manifest behavioral or regulatory symptoms. Young children with sensory processing disorders may:

Infant-preschooler mental health practitioners should have a basic knowledge of sensory processing disorders and should make connections with professionals, such as occupational therapists, who can support children and families struggling with sensory processing disorders.

Much of the accepted research on infant attachment comes from the work of Mary Ainsworth. Using the Strange Situation Procedure, Ainsworth's team was able to examine the behaviors of young children during a structured observation with a primary caregiver, with the ultimate goal of identifying attachment patterns. From this work, both healthy (secure) and unhealthy (insecure) attachment patterns were defined.

Healthy, secure attachment is the ideal pattern of attachment, and it is the most commonly observed type. Healthy, secure attachment is created when parents are available and attuned to the needs of their child, providing consistent care and maintaining a sense of safety and comfort for the child. When secure attachment is observed in a young child, the child may reference his/her parent for reassurance in new situations, take comfort from his/her parent, exhibit reciprocal interactions and joint attention with his/her parent, show emotional involvement, and visibly relax when with the parent. Of course, when observing for attachment, it is important to take into consideration variables that may impact the attachment style, such as developmental delay, attention deficit hyperactivity disorder (ADHD), autism, or brain injury/trauma.

When a child has a secure attachment with an adult caregiver, he/she will develop a mental representation (internal working model) of him/herself as lovable and psychologically coherent [24]. This process is essential for children to develop appropriate affect regulation and empathy. Additionally, secure attachment assists in developing self-esteem and confidence in oneself as a social being.

Insecure styles of attachment are often created when caregivers are unavailable, hostile, unpredictable, or dismissive. Insecure attachments have a variety of subtypes, including avoidant, ambivalent, and disorganized [24]. Children with these attachment patterns may learn to reject parents/caregivers, have difficulties with self-regulation, exhibit compulsive self-reliance, be aggressive, and be easily dysregulated.

Attachment patterns are not concrete; they can be impacted by intervention and support, and unhealthy, insecure attachment styles often require intervention or support to repair. This can be done by supporting the parent-child dyad, by parents receiving treatment for any previous loss, grief, or trauma, and by supporting parents in receiving substance abuse treatment. This can also be accomplished by children moving into homes with securely attached parents and/or caregivers.

An essential part of the assessment process is observation of the child and primary care provider(s). The information obtained during observation can guide the selection of the most applicable and appropriate services to support families and young children. Gaining first-hand knowledge of the parent and child dyad can shape the course of treatment and help identify strengths that parents may not be aware they have. Additionally, direct observation can provide a baseline for attachment relationships, assisting the professional in identifying the areas for interventions and support.

According to the American Academy of Child and Adolescent Psychiatry, when assessing the mental health of infants and toddlers, the parents may be interviewed with or without the infant or toddler present. The assessment format should be responsive to the needs of the family and should allow the clinician to explore the parents' explicit and implicit concerns (including the reason for the referral), the child's current difficulties, and the impact of the child and his or her symptoms on each parent, the parental couple, and the family as a whole.

( https://www.jaacap.org/article/S0890-8567(09)62592-2/pdf Last Accessed: August 16, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Understanding what and who the child represents within the context of the family provides invaluable information to a professional. This can shape how and when interventions are used as well as how to offer developmental guidance and support to families with young children.

When assessing an infant or child for mental health services, it is important to complete a comprehensive biopsychosocial evaluation. This process will take into account age-appropriate screening tools, collateral interviews, and observations in addition to collecting a variety of information on a child's environment and history.

Obtaining the family history of a child is essential for the assessment process. Understanding a family's unique culture and make-up helps the professional conceptualize the child's needs and strengths within the context of his/her family. Gathering information on the cultural background of the family, including immigration and acculturation, is important for conceptualizing needs and strengths. Information about the parents' functioning and attachment history will also assist with case conceptualization and identification of needs. Understanding any intergenerational transmission of abuse, neglect, or other unhealthy parenting styles or beliefs can shape the treatment process.

An assessment should also focus on the child's prenatal experience. Attention should be given to the mother's pregnancy experience, including physical or emotional stressors during pregnancy, as maternal stress can have a negative impact on fetal development. How did the parents feel about the pregnancy? Was there any trauma related to the conception? Was there a long history of problems with conception or miscarriage prior to the pregnancy? Stressed new mothers are also at risk for postpartum depression, which can lead to child maltreatment and negatively impact the child's attachment style. Fetal exposure to drugs, alcohol, and domestic violence are also important factors.

A child's first days in the world can also impact his/her well-being. Gaining information on birth and birth trauma for both the infant and mother are important. How long did the child stay in the hospital after birth? Were the parents able to hold their infant immediately after birth? Were there any physical, developmental, or neurologic concerns at birth?

Carefully gathering information on trauma history within the family and specifically for the infant will also help formulate an approach to working with a family. Gathering information on parents' maltreatment history will help a professional identify familial patterns or intergenerational concerns. Understanding the role of violence, aggression, gender roles, and expectations of childhood within a family will assist the professional with navigating the needs, strengths, and concerns of the family.

When assessing a family, obtaining reports from key collateral sources is also informative. Connecting with daycare providers, preschool teachers, grandparents, and/or significant support persons in the life of a family can shed light on areas for intervention and parental strengths. This may also assist in understanding a family's community and social environment, which can have a significant impact on functioning and overall well-being.

When considering an assessment form for use with the infant-preschooler population, it is important to keep in mind that the form should include:

The idea of psychopathology in infants, toddlers, and preschoolers can be disagreeable to some, as it is disturbing to think of mental illness in young children. Psychopathology is about identifying children who fall out of the normal range of childhood behavior within the context of development and environment. With many diagnoses, early identification is the key to successful intervention and treatment, mitigating long-lasting or severe psychopathology.

There is not yet a consensus on the classification of psychopathology in early childhood [29]. There continues to be concern that diagnosing mental health disorders in early childhood "overpathologizes" normal variations and individual differences of childhood [29]. However, a valid and reliable classification system for early childhood disorders could assist children and families in obtaining the services and treatments needed.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association) and the International Classification of Disease (ICD) (World Health Organization) systems are the most widely used psychiatric classifications systems used around the world. These systems can be applied to infants and young children but were created without significant consideration of the unique behavioral and emotional problems associated with these developmental stages.

Because of the limitations of classification systems like the DSM and the ICD as they apply to infants and toddlers, a task force, Zero to Three, was created by the National Center for Infants, Toddlers, and Families in 1987. This task force, consisting of professionals in the fields of infant development and mental health, created the Diagnostic Classification of Mental Health and Development of Infancy and Early Childhood (DC: 0–3) in 1994 as a multiaxial system for disorder classification of young children [30]. In 2005, the revised version was published to reflect advances in disorder classification and increased emphasis on the effects of relationship characteristics, psychosocial stressors, and contextual factors on infant-toddler mental health and development [30]. In 2016, the Diagnostic Classification of Mental Health and Development of Infancy and Early Childhood was revised and expanded to include children up to 5 years of age [30]. The DC: 0–5 guides professionals to use diagnostic criteria for effective assessment and treatment planning for existing and newly introduced disorders. This manual has grown in popularity and is now a common tool for classification of early childhood mental health and developmental disorders.

The Attachment and Biobehavioral Catch-Up (ABC) Model was developed by Dr. Mary Dozier and associates to address and improve the regulatory capabilities and caregiver-child relationships of infant and toddlers who have experienced early childhood maltreatment and/or disruptions in care [31]. The ABC Model helps caregivers reframe how they view a child's behaviors, assisting them in approaching parenting with a trauma-informed paradigm. The goal is to assist caregivers in providing consistent, responsive care to young children to help them regulate their emotions, affect, and behavior.

The ABC Model is a structured, evidence-based approach whereby weekly one-hour sessions are provided for 10 weeks in the caregiver's home. Support and guidance is provided in the moment by the trained professional to focus on target behaviors. This intervention uses video feedback.

The ABC Model is rated a 1 on the California Evidence-Based Clearinghouse for Child Welfare scientific rating scale. The California Clearinghouse independently reviews evidence-based treatments for child welfare, and a rating of 1 indicates that the program has the strongest research evidence among those interventions rated [32].

Play therapy is based on the theory that a child's language is play. It is a common intervention for children older than 3 years of age who are dealing with grief/loss, depression, anxiety, attachment issues, behavioral and emotional regulation issues, and divorce, among other issues. The toys in the playroom (therapy room) are considered the words of the child's language, used to express inner experiences and perceptions. A comprehensive definition of non-directive play therapy is provided by Dr. Gary Landreth [33]:

Non-directive play therapy can be used for a variety of different mental health or behavioral concerns. Research has supported this approach to treat concerns such as trauma, sadness, worry, fear, grief, and adjustment.

The toys in the playroom are carefully chosen, with special attention to including items that can be used in a multitude of ways. Items for creative expression (e.g., crayons, paints, construction paper), real-life toys (e.g., dolls, play money, medical kit), and aggression-release toys (e.g., soldiers, wild animals, clay) should be among the toys chosen for a playroom. (See the Appendix for a more complete list of toys and objects to include in a play therapy room.)

Non-directive, child-centered play therapy is based on the following eight principles [34]:

One of the main goals of non-directive play therapy is to support and allow the child to communicate his or her inner thoughts and feelings. Within a play session, and over the course of sessions, themes emerge in the child's play, giving the therapist insight into the child's experiences, thoughts, feelings, and interpretations of his/her world.

Child-parent psychotherapy (CPP) is a relationship-based intervention for trauma-exposed children 0 to 6 years of age. CPP is a culturally informed treatment, focused on strengthening the parent-child dyad to restore and protect the mental health of children. The goals of CPP are to improve the emotional attunement of the parent-child dyad and enhance interactional patterns [37]:

Over the course of CPP treatment, the parent and child are guided and supported in creating a joint narrative of the traumatic events experienced by the child. Additionally, the parent and child are guided to identify and address traumatic triggers that contribute to dysregulated behaviors and affect [10]. More can be found on CPP by reading Don't Hit My Mommy! A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence [10].

DIRFloortime is a treatment approach developed by Dr. Stanley Greenspan as a relationship-focused play intervention that promotes growth in a child's social, emotional, and developmental abilities by following the child's lead and challenging the child's capabilities. The definition of DIR is [51]:

The DIRFloortime model is often used with children who have an ASD or who have other developmental disabilities. This comprehensive framework lends itself to a multidisciplinary approach by including team members such as occupational or speech therapists in the intervention.

Touch is an essential component in relationships and attachments. Infant massage can be used as a nurturing and attachment-promoting technique to improve relationships. It can be particularly helpful for foster and adoptive parents trying to build or repair a child's ability to attach. Additionally, infant massage also offers physiologic benefits for infants struggling with colic, gas, and sleeping issues.

Dr. Tiffany Field, founder of the Touch Research Institute at the University of Miami Medical Center, has completed many research projects on the value of touch and infant massage. In one research study, 20 preterm infants were massaged in the hospital, three times per day, for at least 15 minutes per massage. These infants gained 47% more weight and left the hospital on average six days earlier than their non-massaged counterparts. Additionally, the infants who received massages were noted to be more alert, more active, and showed significantly more mature neurologic development [39].

Vimala McClure, the founder of the International Association of Infant Massage, writes [40]:

Infant massage can also lead to increased parental confidence and capacity. Parents who massage their infants report an increased ability to read the infant's cues and to feel a sense of increased nonverbal communication. This intervention can be especially important for fathers, mothers with depression, and caregivers who have been away from the infant for an extended period of time.

Theraplay is a treatment method developed by Ann Jernberg and Phyllis Booth in the late 1960s. Theraplay is an attachment- and relationship-focused, play-based therapy intervention designed to increase a healthy emotional connection between child and parent. The MIM is used as an assessment tool prior to the use of Theraplay; the CBC and PSI are also often given prior to initiation of the intervention. In the text Theraplay, Jernberg and Booth state, "Our model for treatment is based on attachment research that demonstrates that sensitive, responsive caregiving and playful interaction nourish a child's brain, form positive internal representations of self and others, and have a lifelong impact on behavior and feelings" [25]. Theraplay focuses on four essential qualities within the parent-child relationship: structure, engagement, nurture, and challenge [25].

The core characteristics of Theraplay are [25]:

In terms of structure, it begins with parents providing a safe and secure environment for their children. During the intervention, the parent is supported in organizing a predictable experience for the child. The parents should be seen as a source of safety and be trustworthy and reliable. The parents should provide attuned, playful experiences to increase joyful, shared emotional involvement. This occurs when parents are able to accurately read and respond to a child's signals, modifying activities to gain engagement and positive responsiveness from a child.

The parents should respond empathetically to a child's needs, providing a warm, open, and comforting experience for the child. The parent should be reassuring and gentle; this quality promotes positive attachment behaviors.

The parents should encourage the child to challenge themselves and to strive for mastery. The parent should act as a secure base while encouraging the child to take developmentally appropriate risks.

Because this intervention is attachment informed, it is useful with children in foster care and adopted children. It is also useful for children with difficult temperaments, parents who have been separated from their children, parents who experienced a lack of quality parenting, and parents and families living in stressful environments.

Reflective practice facilitation is the development of one's awareness of thoughts, feelings, and responses and the impact of these thoughts, feelings, and responses on young children and families. This approach speaks to the practitioner's ability to be present and mindful of the relationships at play in the life of a young child.

Reflective practice is about contemplating issues both internally and within a family, without judgment. The ability for a practitioner to be reflective often comes from the support and encouragement of a mentor. This support and encouragement often comes in the form of reflective practice facilitation/supervision/consultation.

The working definition of reflective practice facilitation from the California Center for Infant-Family and Early Childhood Mental Health is [41]:

Administrative and/or clinical supervision differs from reflective practice supervision in that these types of supervision have a specific focus on reviewing and enforcing policies and procedures, monitoring productivity, evaluation, and documentation review. This is not to say that administrative and/or clinical supervision cannot be reflective in nature. In reflective practice facilitation, however, the focus is on the emotional exploration of the work with infants and toddlers. Additionally, reflective practice facilitation focuses on the parallel process and exploration of relationships (e.g., parent-child, practitioner-supervisor, practitioner-parent).

Quality reflective supervision is a consistently scheduled relationship-oriented practice that invites the sharing of emotional content and attends to the feelings, observations, and experiences of the supervisee. Reflective supervision supports and strengthens the process of integrating emotion and reason in the work with infants, toddlers, and families.

The Michigan Association for Infant Mental Health outlines the following points as paramount to reflective practice supervision [38]:

Bowlby J. A Secure Base: Parent Child Attachment and Healthy Human Development. London: Routledge; 1988.

Brazelton TB. Touchpoints: Your Child's Emotional and Behavioral Development, Birth to 3. 2nd ed. Cambridge, MA: Da Capo Press; 2006.

Gray DD. Nurturing Adoptions: Creating Resilience After Neglect and Trauma. London: Perspectives Press; 2007.

Greenspan SI, Wieder S. Infant and Early Childhood Mental Health: A Comprehensive, Developmental Approach to Assessment and Intervention. Washington, DC: American Psychiatric Association; 2005.

Hughes D. Building the Bonds of Attachment: Awakening Love in Deeply Troubled Children. 2nd ed. New York, NY: Jason Aronson, Inc.; 2006.

Hughes DA. Attachment-Focused Parenting: Effective Strategies to Care for Children. New York, NY: W. W. Norton & Company; 2009.

James B. Handbook for Treatment of Attachment-Trauma Problems in Children. New York, NY: The Free Press; 1994.

Karr-Morse R, Wiley MS. Scared Sick: The Role of Childhood Trauma in Adult Disease. New York, NY: Basic Books; 2012.

Klaus MH, Klaus P. Your Amazing Newborn. New York, NY: Perseus Books; 1998.

Klaus MH, Kennell JH, Klaus PH. Bonding: Building the Foundations of Secure Attachment and Independence. New York, NY: Da Capo Press; 1996.

Kranowitz CS. The Out-of-Sync Child Has Fun: Activities for Kids with Sensory Processing Disorder. New York, NY: Penguin Group, Inc.; 2010.

Kranowitz CS. The Out-of-Sync Child. New York, NY: Berkley Publishing Group; 2005.

Lieberman AF. The Emotional Life of the Toddler. New York, NY: The Free Press; 2018.

Lieberman AF, Van Horn P. Psychotherapy with Infants and Young Children. New York, NY: Guilford Press; 2008.

Perry B, Szalavitz M. Born for Love. New York, NY: William Morrow; 2010.

Perry B, Szalavitz M. The Boy Who Was Raised as a Dog. New York, NY: Basic Books; 2017.

Sears W, Sears M, Sears R, Sears J. The Baby Book, Revised Edition: Everything You Need to Know About Your Baby from Birth to Age Two. New York, NY: Little, Brown and Co.; 2013.

Siegal DJ, Hartzell M. Parenting from the Inside Out. New York, NY: Penguin Group Inc.; 2014.

Siegel D. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. 2nd ed. New York, NY: The Guilford Press; 2012.