Fostering Healthy Minds: Exploring Occupational Therapy's Role in Supporting Infant and Early Childhood Mental Health

Editor’s note: This text-based course is a transcript of the webinar, Fostering Healthy Minds: Exploring Occupational Therapy's Role in Supporting Infant and Early Childhood Mental Health, presented by Jessica McMurdie, OTR/L.

Learning Outcomes​

• After this course, participants will be able to identify the 4 types of infant-parent attachment.
• After this course, participants will be able to recognize the specific behaviors that warrant concern in infants, toddlers, and preschoolers.
• After this course, participants will be able to list 3 ways occupational therapists can strengthen the social-emotional development of infants and young children.

Introduction

I'm thrilled to be here. I'm Jessica McMurdie, a pediatric occupational therapist, and I'm excited to discuss a topic close to my heart: working with children, especially in their early developmental stages.

Welcome to the World of IECMH!

• Overview of Topics
  • What is Infant and Early Childhood Mental Health?
  • Early Brain Development 
  • Attachment Theory
  • Early warning signs for mental health concerns
  • OTPs Role in Supporting Infant and Early Childhood Mental Health

Welcome to the world of infant and early childhood mental health. This course is designed to provide you with insights into several crucial aspects of this field. 

Firstly, we'll define and understand the concept of infant and early childhood mental health. It's important to grasp the significance of mental health in these early developmental stages.

Next, we'll delve into the fascinating realm of early brain development and why it holds such importance in a child's life.

Attachment theory is another topic we'll be exploring. We'll unravel what attachment theory means in the context of young children and their relationships with their primary caregivers.

Recognizing early warning signs of mental health concerns is a critical skill. We'll discuss what signs to look out for in infants, toddlers, and preschoolers.

Lastly, we'll focus on the role of occupational therapy providers in supporting infant and early childhood mental health. Occupational therapists play a vital role in this field, and we'll uncover how they can contribute.

Please note that while this course will provide you with valuable insights, it's just the beginning of your journey into the extensive domain of infant and early childhood mental health. This course is just the tip of the iceberg, as seen in Figure 1.

Figure 1. Image of an iceberg.

There is so much more to learn and apply to your practice, not only when it comes to pediatrics but especially within this unique framework of infant and early childhood mental health.

Prevalence of Mental Health Problems Children Ages 0-5 Years

• Approximately 9.5%–14.2% of children from birth to 5 years old experience emotional, relational, or behavioral disturbance. (Zerotothree Briefing Paper, 2017)

Determining the prevalence of mental health issues in very young children, from birth to five years, is a critical aspect of understanding the scope of this challenge. Research indicates that approximately 9.5% to 14.2% of children within this age group encounter emotional, relational, or behavioral disturbances. To put this into perspective, in a hypothetical scenario with three childcare classrooms, each consisting of 100 children, there could be between 10 to 15 children who are grappling with such challenges. Recognizing and addressing these issues at such an early stage is of paramount importance, as it can significantly impact a child's future development and well-being.

Practice Settings

• Opportunities for identification, evaluation, and intervention
  • NICU
  • Birth to Three
  • Early Intervention Center
  • Schools
  • Outpatient Clinic
  • Hospital
  • Community (e.g. Childcare)

Infants and young children who may benefit from early identification and intervention for mental health-related concerns can be found in various settings. Occupational therapists should keep a watchful eye in these different contexts to identify opportunities for intervention. These settings include neonatal intensive care units (NICUs), birth-to-three centers, schools, outpatient clinics, hospitals, and the community. 

It's essential to remember that occupational therapy has its roots in psychiatry, emphasizing the importance of mental health considerations in the profession's history and practice. This foundation equips occupational therapists to contribute significantly to the mental health and well-being of infants and young children.

AJOT

• The roots of occupational therapy are grounded in psychiatry (AJOT, 2017).

The roots of occupational therapy are firmly grounded in psychiatry, as reiterated in the American Journal of Occupational Therapy (AJOT) in 2017. This historical connection highlights the unique position of occupational therapists in addressing mental health issues and underscores the profession's capacity to contribute significantly to the well-being of individuals, including infants and young children, in various healthcare and educational settings.

Mental Health Opportunities (WHO)

• “Occupational therapy practitioners contribute to the promotion of mental health, which is understood as a state of well-being in which a person realizes his or her abilities, copes with challenges and is able to work and contribute to the community.”

(World Health Organization, 2013)

According to the World Health Organization (WHO), occupational therapy practitioners play a crucial role in promoting mental health, which is defined as a state of well-being where individuals recognize their abilities, effectively handle life's challenges, and actively participate in their communities. The convergence of social-emotional development, mental health, and the caregiver-child relationship creates a fertile ground for occupational therapy practitioners to make a meaningful impact on the well-being of young children.

OT Role in Early Intervention Team (AOTA)

• In the early intervention setting, occupational therapy practitioners can fulfill a variety of roles to support infants and toddlers and their caregivers...
• Along with being a collaborative team member on the EI team, an occupational therapist has opportunities to help not only as a direct service provider but may also fulfill the role of educator and trainer, resource consultant, advocate, leader, and/or researcher! (AOTA, 2017)

In the early intervention setting, occupational therapy practitioners wear multiple hats to support infants, toddlers, and their caregivers. They serve as collaborative team members on the early intervention team and can fulfill various roles, including direct service providers, educators, trainers, resource consultants, advocates, leaders, and even researchers. These versatile roles allow OTs to contribute significantly to the well-being and development of young children in various ways.

A Winning Combination

• OT in Mental Health + OT in Early Intervention = Enhanced Service Delivery

Combining the frameworks of occupational therapy, mental health, and early intervention creates a powerful opportunity to provide enhanced services. This combination elevates the quality of care and allows practitioners to excel in their field. Additional training, especially in areas like mental health, early intervention, and telehealth, can be valuable for clinicians to become well-rounded in their practice. Personal experiences and upbringing can also influence one's passion for this work, as it did for me. I had a father in psychiatry and a mother who was a preschool teacher, so I naturally pursued a career in occupational therapy.

Introduction to Infant and Early Childhood Mental Health

Next is an introduction to infant and early childhood mental health. Before I get started, I have a poll for you.

Poll 1:

• Who is the client in the IECHMH service delivery model?
• Choose the best answer below:

A.) The focus is on direct treatment with the child only.

B.) The focus is training the parents and caregivers so they know what to do at home.

C.) It’s essential to focus on the needs and occupational therapy performance areas of both the child and his/her caregivers.

The best answer is that it's essential to focus on the needs and occupational therapy performance areas of both the child and the caregivers. This approach is unique compared to traditional models in healthcare, which often focus on one person as the client or patient.

What is IECMH?

• Infant and early childhood mental health (IECMH) is the developing capacity of the child from birth to 5 years old to...
  • Form close and secure adult and peer relationships;
  • Experience, manage, and express a full range of emotions
  • Explore the environment and learn—all in the context of family, community, and culture.

Source: Zero to Three Briefing Paper (2023)

What is infant and early childhood mental health? During this critical period of development, children learn to establish secure and nurturing relationships with both adults and peers. They acquire the skills to understand, manage, and effectively express their emotions across a broad spectrum. Additionally, they explore their surroundings, gaining knowledge and adapting to their environment. All of these facets of development occur within the encompassing contexts of family, community, and culture, shaping the child's mental health and emotional well-being.

IECMH Framework

• Multi-disciplinary field 
• Focus on enhancing the social-emotional competence of children ages 0-5 years
• Focus on establishing and maintaining healthy relationships 
• Focus on clinicians using a family-centered and diversity-informed approach

In this framework, infant and early childhood mental health is a multidisciplinary field where occupational therapists collaborate closely with various professionals such as pediatric therapists, social workers, family resource coordinators, psychologists, educators, and, most importantly, parents and caregivers. The primary focus is to enhance the social and emotional competence of children aged zero to five, extending beyond the traditional areas of pediatric occupational therapy, like ADLs and fine motor skills. 

This framework emphasizes establishing and nurturing healthy relationships, guiding clinicians to adopt a family-centered and diversity-informed approach. In early intervention settings, this approach naturally aligns with creating Individualized Family Service Plans (IFSPs), which set goals not only for the child but also for the entire family unit. This holistic perspective recognizes the interconnectedness of the child's development with their family's well-being and diversity of cultural backgrounds.

Diversity-Informed Practice

Diversity-informed practice in the context of infant and early childhood mental health encompasses several fundamental principles that guide clinicians in providing culturally sensitive and effective care. These principles are essential for fostering understanding and collaboration within diverse family and community contexts.

Firstly, clinicians should approach their work with a mindset of curiosity. This means actively seeking to understand and appreciate the unique cultural backgrounds and experiences of the children and families they serve. Instead of making assumptions, clinicians should ask questions, explore differences, and gather information to gain a deeper insight into each family's cultural context.

Secondly, cultural connection is a vital aspect of diversity-informed practice. It involves recognizing and establishing meaningful connections with the cultural norms, values, and traditions of the families and communities being served. By acknowledging and respecting these cultural factors, clinicians can build trust and rapport with families, facilitating more effective interventions.

Another crucial element of diversity-informed practice is the concept of collective responsibility. This approach emphasizes that everyone involved in the child's development, including clinicians, parents, caregivers, and other service providers, shares responsibility for the child's well-being. Collaboration and communication among all stakeholders are key to ensuring that the child's needs are met comprehensively and holistically.

Furthermore, clinicians should be mindful not to filter the experiences and perspectives of children and families through their own singular lens. It's essential to avoid imposing one's own cultural biases or assumptions onto others. Instead, clinicians should begin their interactions with an open and nonjudgmental stance, starting with the lens of curiosity and a commitment to diversity-informed practice. This approach promotes respectful and culturally sensitive care that can positively impact the social-emotional development of infants and young children.

Poll 2:

• Have you had any formal clinical training to use The Infant and Early Childhood Mental Health framework?

a.) Yes, I learned about it in school.

b.) Yes, I have taken additional CEU courses on the topic.

c.)  No, I have not had any additional training.

d.)  No, I’ve never heard of the IECMH framework

Thank you for sharing your responses to the poll. It's clear that there's a significant portion of occupational therapy practitioners who haven't received formal training or are unfamiliar with the infant and early childhood mental health framework. This highlights the potential need for increased education and awareness in this area, as it can significantly impact the quality of care provided to infants and young children, especially in the early intervention setting. Expanding knowledge and training opportunities related to infant and early childhood mental health could benefit both clinicians and the families they serve.

Skill Areas that are Associated with IECMH

• Two Primary Skill Areas

1. Social-Emotional Development

2. Executive Functioning

Infant and early childhood mental health, as highlighted in this presentation, centers around two primary skill areas: social-emotional development and executive functioning. These areas are distinct from the traditional focus on motor development, sensory processing, and fine motor skills often associated with pediatric occupational therapy. Emphasizing social-emotional development and executive functioning in early intervention can significantly impact a child's overall development and well-being.

Social-Emotional Development

• The child's ability to: 
  • Identify and understand their own feelings;
  • Accurately read and comprehend emotional states in others
  • Manage strong emotions and their expression in a constructive manner
  • Regulate their own behavior
  • Develop empathy for others
  • Establish and maintain relationships.

Social-emotional development in children encompasses various aspects. Firstly, it involves their ability to identify and understand their own emotions, such as feeling happy, sad, or angry. Additionally, it includes their capacity to accurately perceive and comprehend the emotional states of others, fostering empathy and emotional intelligence.

Another essential aspect is the management of emotions. While temper tantrums can be common among toddlers, it's crucial to help them learn how to manage and express their feelings in a more constructive manner. This involves teaching children how to cope with strong emotions effectively.

Furthermore, social-emotional development involves regulating behavior. Children should be capable of consistently practicing self-control and making choices that align with appropriate social norms. This skill is essential for their interactions with others and functioning in various social settings.

Empathy is a fundamental component of social-emotional development. Children need to develop an understanding of and care for the feelings and perspectives of others. This capacity for empathy is essential for building positive and meaningful relationships.

Lastly, establishing and maintaining relationships is a key aspect. Children should acquire the skills needed to initiate, nurture, and sustain relationships with family members, peers, and individuals in their community. These early relationship-building experiences significantly impact their future social interactions and emotional well-being.

Focusing on social-emotional development during early childhood is vital because it lays the foundation for healthy emotional intelligence and interpersonal skills that children will carry with them throughout their lives.

• “Healthy social and emotional development for infants and toddlers unfolds in the context of positive, ongoing relationships with nurturing parents and caregivers.”

The significance of healthy social and emotional development, especially in toddlers, is underscored by its reliance on positive and enduring relationships with nurturing parents and caregivers. These relationships extend beyond the immediate family and can encompass childcare providers, teachers, grandparents, and other individuals involved in the child's care. Therefore, fostering social and emotional growth involves a rich tapestry of social interactions across a diverse range of caregivers and individuals within the child's network. These interactions lay the foundation for the child's emotional well-being and future social interactions.

Cognitive Development

• The process of growth and change in intellectual and mental abilities (to think, reason & understand).

Cognitive development encompasses the progression and evolution of a child's intellectual and mental capabilities. It involves the maturation of their thinking processes, reasoning abilities, and overall understanding of the world around them.

• Starts at birth.
• Natural drive to learn
• Intense curiosity helps develop critical thinking
• Acquisition and consolidation of knowledge
• Skills necessary for success in school and life

Cognitive development begins right from birth, and infants are born with an innate drive to learn. Their natural curiosity and eagerness to explore the world around them play a crucial role in developing essential thinking skills. From an early age, they start grasping concepts such as cause and effect, which lays the foundation for more advanced cognitive abilities needed for success in school and life.

Executive Functioning Development

• The child’s ability to:
  • Control impulses
  • Filter out distractions
  • Focus his/her attention
  • Organize information and put a plan into action
  • Problem-solve alternative solutions

When we discuss cognitive development, our focus is not on academic achievements but on executive functioning. Executive functioning encompasses various skills that allow a child to control impulses, filter out distractions, focus their attention, organize information, create plans, and problem-solve. While executive functioning challenges are often seen in older children, it's crucial to recognize that these difficulties may have started during early childhood. Identifying executive functioning issues in toddlers and preschoolers can help set the stage for improved performance in school and life as they grow older. The key is understanding how executive functioning skills manifest in children at different ages, from one-year-olds to four-year-olds.

Old Enough: Ultimate Executive Functioning Errand Challenge

• Young children ages 2-5 years old are tasked with running errands without their parents while a camera crew follows along (Netflix).

A fascinating example of young children's executive functioning abilities can be observed in the Netflix show "Old Enough." In this show, children as young as two to five years old are given the task of running errands without parental guidance while being followed by a camera crew. It's remarkable to witness how these young children can navigate multiple shops, locate specific items, remember their shopping lists, and even understand the concept of paying for their purchases. These abilities stem from the observational learning and modeling they receive from their caregivers. Children are constantly watching and learning from their surroundings, demonstrating their impressive executive functioning skills from a very early age.

3 Reasons Why the IECMH Framework is Important for You to Incorporate Into Practice

Reason #1: Birth to age 5 is a critical window of time in brain development.

The first reason is that the period from birth to age five represents a critical window for brain development. During the prenatal stage and the first three years of life, the rate of brain growth surpasses any other period, as it is when the foundational architecture for brain development is being established. We will explore early brain development in more detail shortly, but it's crucial to understand that early intervention is significant because it offers optimal chances to establish healthy brain connections and nurture the earliest relationships. Additionally, early identification of mental health issues is achievable through awareness and education.

Reason #2: Early identification of mental health problems is possible through awareness and education.

The second reason is supported by research, which has shown that mental disorders can manifest in infancy. Sometimes, when working with preschoolers who have experienced difficulties, looking back into their history and talking to parents reveals clear red flags or signs that were present earlier. Recognizing these challenges and increasing awareness of what to look for is essential. Some examples include regulatory problems, such as sleep difficulties, the inability to soothe very young children, avoidance of eye contact, or consistently atypical responses to stimuli. Identifying these red flags is crucial. We also need more standardized criteria for diagnosis, and I will share resources later on regarding how to better determine whether a social-emotional or mental health issue is occurring in a young child. We will also delve into screening and assessment criteria used in developing a diagnostic manual for identifying mental health disorders in children from birth to age five.

Reason #3: The social-emotional development of young children impacts future mental health.

The third reason is that the social-emotional development of young children has a significant impact on their future mental health. We know that mental disorders in children and adolescents have a profound global impact on their overall development and potential for leading fulfilling lives. Unfortunately, the costs associated with mental disorders in children from birth to three years have received limited attention. However, research consistently demonstrates that early intervention can help prevent problems later in life.

Studies show that children who develop healthy, secure, and attached relationships with primary caregivers are more likely to have positive outcomes in terms of future mental health. They tend to exhibit heightened optimism, stronger self-esteem, and enhanced problem-solving abilities. Regulatory problems observed in infancy can be associated with potential issues in childhood, adolescence, and even adulthood, leading to conditions such as anxiety, depression, and behavioral problems. As a result, there is often a wish that these issues had been identified and addressed earlier, especially when working with older children or teenagers.

Early Brain Development
The Science of Early Childhood Development

Part of our responsibility is to recognize the importance of bringing awareness early on. In this image, you can see a giant neuron, symbolizing early brain development and the science of early childhood development.

Quick Neuro Development Review

• Central Nervous System
• Peripheral Nervous System
• Transient Exuberance
• Synaptic Formation
• Synaptic Pruning
• Sequential Development and Foundation

Early brain development is a critical aspect to understand. The central nervous system consists of the brain and spinal cord, while the peripheral nervous system gathers sensory information. During this period, transient exuberance is at its peak, signifying exuberant growth, but it doesn't all persist as synaptic pruning takes place, shaping which neural pathways remain and which are discarded. Sequential formation and developmental foundation are essential concepts, as this early growth lays the blueprint for the brain's future architecture, making early experiences and interactions pivotal in shaping a child's brain.

Brain and Growth Development

• Sleep is prime time for development.
• Key Factors
  • Genes
  • Nutrition
  • Exposure to toxic substances
  • Sleep
  • Disease or disorders
  • Role of relationships and attachment

What are the key factors that are contributing to this amazing burst of growth? Sleep is a prime time for early brain development. There are recommendations on the number of hours of sleep that certain children should be getting in terms of how old they are.

Genes play a significant role as well. There's an interplay of genes and experiences that shapes the circuitry of the developing brain. Early life experiences and environments not only influence the brain architecture but also impact gene expression, determining how the genes are turned on or off. This interaction between the genetic code and environmental influences is known as epigenetics.

Nutrition is another critical factor, starting prenatally and continuing postnatally. Severe malnutrition can slow brain growth, thin the cerebral cortex, reduce neuronal growth connections, and hinder myelination. Poor nutrition can significantly affect a child's future learning.

Exposure to toxic substances, whether through substance abuse or environmental factors like heavy metals (e.g., lead, manganese, mercury), can also impact brain development. Diseases and disorders, including sleep-related issues, can affect a child's brain development.

Finally, the role of relationships, especially attachment theory, plays a crucial role. Secure attachment occurs when an infant has a sensitive and responsive caregiver who makes them feel safe and ensures their needs are met. This security allows children to explore their world confidently, which is an essential aspect of healthy brain development.

Adverse Environment

• Lack of nutrition
• Exposure to toxins
• Deprivation of sensory, emotional, and social experiences disrupt foundational capacities.
• Detrimental effects: A weak foundation in early development hinders further brain development, despite subsequent improvements.

We've discussed adverse environmental factors that can hinder future brain development. It's also crucial for pregnant women to consider factors like folic acid intake and nutritional supplements. A full environmental experience, including typical sensory input and nurturing love and affection, is vital for healthy brain development. Without these experiences, foundational capacities can be disrupted.

For instance, research has examined children who have been institutionalized with insufficient caregiver-to-baby ratios, leading to inadequate interaction for the babies. Such situations can impact their future social interactions and overall brain growth and development. While some children may bounce back, it can be more challenging, and we'll explore this further in the future.

Science Breakthroughs

• Advances in understanding
• The Importance of Early Intervention

Advancements in our understanding of infant mental health, as well as the significance of early intervention, have been greatly influenced by decades of research and discoveries in fields such as neuroscience, molecular biology, and epigenetics. As occupational therapists, we can draw knowledge and insights from these disciplines to gain a deeper understanding of healthy brain development, risk factors, and potential interventions.

One notable aspect of this framework is its multidisciplinary nature, and it underscores the critical importance of early intervention. While the brain retains its capacity for adaptation, known as brain plasticity, this ability diminishes with age. This underscores why early intervention is a central focus.

Windows of Opportunity

• Early years have a strong influence on brain architecture, offering great opportunity and vulnerability for development. 
  • Brain development begins about 2 weeks after conception.
  • Critical Periods
  • Sensitive Periods

The early years play a pivotal role in shaping brain architecture, offering both significant opportunities and vulnerabilities for development. Brain development initiates approximately two weeks after conception and involves critical and sensitive periods. These periods are vital for laying the foundation of a child's future cognitive, social, and emotional development.

• Critical Period
  • A time period when specific regions of the brain have distinct windows of time when learning or development starts or stops before that window of opportunity closes. 
  • A restricted developmental period during which the nervous system is particularly sensitive to the effects of experience:
    • Example:  Language Acquisition and Fluency
  • When parents use “baby talk” or “parentese,” this type of speech actually emphasizes the phonetic distinctions as compared to normal speech among adults. 
  • The relative fluency of English grammar and vocabulary declines from approximately age 7 onward. (Purves et al., 2001)

A critical period refers to a specific timeframe during which certain brain regions are particularly responsive to the effects of experiences. An example of this is language acquisition and fluency, where early exposure to speech sounds and language patterns, such as through parentese or baby talk, can significantly influence a child's phonetic distinctions and language development. These critical periods are essential for acquiring language skills, and missing them can make it more challenging to learn languages or acquire specific accents later in life.

• Sensitive Period
  • When specific regions of the brain are the most open to learning or refining a particular skill or brain function. The window of opportunity stays open longer as compared to critical periods of development. 
    • Example:  Motor milestone acquisition
  • A sensitive period for movement is from birth to 2 ½ years of age for developing foundational gross and fine motor skills.
  • Skills can still be acquired later, although it may be more difficult.

The next concept to explore is the sensitive period, which refers to a timeframe when specific brain regions are highly receptive to learning or refining particular skills or functions. Unlike critical periods, sensitive periods offer a more extended window of opportunity for skill acquisition or development. A practical example of a sensitive period is observed in motor milestones, which typically occur from birth to around two and a half years of age. During this time, children develop foundational gross and fine motor skills like sitting, standing, walking, and running. While these skills can still be acquired later in life, the sensitive period provides a more flexible timeframe for achieving these milestones. Typically, children are expected to learn to walk by around 12 months, but variations within a few months are still considered within the typical range. This illustrates the concept of a sensitive period.

Brain Plasticity

• The brain retains the capacity to adapt and change throughout life.
• Change beyond early childhood: Change is possible beyond early childhood, but it becomes harder and more costly in terms of effort, both at the societal and individual levels.
• Importance of early intervention: Optimal outcomes are more likely when things are done well in the beginning, emphasizing the significance of early intervention efforts.

Brain plasticity refers to the brain's ability to adapt and change throughout a person's life. While it's true that the brain can continue to change beyond childhood, these changes become more challenging and resource-intensive, both at the individual and societal levels. This is why early intervention is crucial. When interventions are initiated during critical and sensitive periods, the likelihood of achieving optimal outcomes significantly increases. In the context of mental health, identifying and addressing issues early, such as symptoms of depression, anxiety, or personality disorders in children, is far more beneficial than allowing these challenges to persist into adulthood. Early intervention is key to facilitating positive developmental trajectories and mental well-being.

The Influence of Relationships on Brain Architecture

• “The influence of relationships and the experiences between young children and the people consistently present in their lives significantly influences their brain structure and function.”

There are three factors.

Consistency

• The impact of consistent relationships: Children's experiences with the people consistently present in their lives significantly influence their brain structure and function.

One of the critical factors is the impact of consistency in relationships. Children's experiences with individuals who are consistently present in their lives have a profound influence on their brain structure and function. These individuals can include caregivers, educators, and family members in various settings such as home, school, or daycare. The stability and continuity of these relationships play a crucial role in shaping a child's brain development.

Reciprocity

• Serve and return interactions between children and their caregivers.
• Children naturally reach out for interaction, and responsive adults engage in vocalizing, gesturing, and emotional engagement.

Reciprocity is another key factor in early brain development. Think of it like playing tennis, where you serve and return the ball. Similarly, in interactions between children and caregivers, there's a constant back-and-forth exchange. Children naturally seek interaction and engagement, reaching out for responsive adults to communicate with them. This includes vocalizing, gesturing, and emotionally engaging with the child. These reciprocal interactions have a significant impact on a child's brain development.

Dynamic Interactions

• Dynamic interactions actively shape the architecture of the developing brain.
• Reciprocal and dynamic interactions are essential for healthy development.
• Individualized experiences: These interactions provide unique experiences tailored to the child's unique personality style, interests, capabilities, and initiative.

Dynamic interactions are the third crucial factor in early brain development. These interactions actively shape brain architecture and are essential for healthy development. They involve a back-and-forth exchange and are dynamic, meaning they are individualized to each child. These experiences are tailored to the child's unique personality, style, interests, capabilities, and initiative. Just as with older children, where you might engage them based on their interests, early interactions should also be customized to a child's unique interests and needs. This personalization enhances their engagement and learning experience.

Relationship Dysfunction

• Disruption and impairment:
  • Unreliable, inappropriate, or absent responses from adults can disrupt the architecture of the child's developing brain, potentially impairing later learning, behavior, and health.

When relationship dysfunction occurs, it can lead to disruption and impairment in a child's development. This dysfunction often manifests as unreliable, inappropriate, or absent responses from adults, particularly primary caregivers. Such experiences can disrupt the child's developing brain, impair later learning, and have a negative impact on their behavior, as well as their overall mental health and well-being, if they are consistently exposed to dysfunctional relationships.

Resilience and Protective Factors

It's crucial to identify factors within a child's ecosystem, community, environment, and family nucleus that can protect them from adverse experiences and support healthy development.

Influential Protective Factors for Infants

• Growth-promoting environment: Nurturing setting with adequate nutrients, toxin-free surroundings
• Strong relationships:  Secure attachment relationship with primary caregivers.
• Rich social interactions with other responsive caregivers

Living in a growth-promoting environment, which encompasses nurturing surroundings, adequate nutrition, toxin-free spaces, strong relationships with primary caregivers, and rich social interactions with responsive caregivers, serves as a protective factor for children's healthy development. On the contrary, children exposed to trauma or displacement face environmental risk factors that increase their vulnerability to future mental health issues.

• Individual characteristics: Personality,  temperament, and intelligence
• Parental knowledge of child-rearing, child development, and how to support social-emotional competence
• Parent’s own levels of resilience
• Families access to concrete support

Another set of characteristics to consider are individual factors related to the child, such as their personality, temperament, and intelligence. These traits can vary, and what triggers one child may not affect another in the same way.

Parental knowledge of childbearing and child development is crucial, as it enables parents to support their child's social-emotional competence by modeling, teaching, and demonstrating these skills. Additionally, a parent's level of resilience and the family's access to concrete support play essential roles. Families facing challenges related to basic needs like food, formula, and diapers may prioritize addressing these needs over other developmental goals. In such cases, connecting families with community resources and financial assistance can be invaluable.

Attachment Theory Overview

Attachment theory is a fascinating area of study that helps us understand the various types of attachments that develop between infants and their caregivers. These attachment patterns have a significant impact on a child's social-emotional development and future relationships.

Attachment Theory

• Attachment theory is a widely recognized and supported theory related to parenting.
• It emphasizes the importance of the parent-child bond in ensuring the child's safety, security, and protection.
• Attachment is distinct from other parenting aspects like discipline, entertainment, and teaching (Benoit, 2004).

Attachment theory is a well-established and widely recognized framework for understanding parenting and the parent-child bond. It highlights the critical role of parents in ensuring their child's safety, security, and protection. It's important to note that attachment is a distinct aspect of parenting and differs from other roles such as discipline, entertainment, and teaching.

Attachment Theory Concepts

• #1. Infancy is a critical period for attachment relationships, and disruptions in these relationships can further contribute to disorders in infancy and future development.
• #2. The relationship between the infant and their primary caregivers has an important influence on the development of the child’s capacity for emotional and behavioral regulation.

Attachment theory encompasses several key concepts. Infancy is a critical period for attachment relationships, and disruptions in these relationships can have lasting effects on a child's development, potentially contributing to disorders both in infancy and later in life. The relationship between an infant and their primary caregivers significantly shapes the child's ability to regulate their emotions and behaviors. This early relationship lays the foundation for the child's emotional development and ability to manage stress and distressing situations.

Unique Mental Health Intervention

• Early dependence on caregivers requires mental health interventions that involve both the infant and the caregiver.
• The caregiver's presence and attentiveness are critical for the infant's development.

Supporting the caregiver is an integral part of promoting healthy attachment and infant mental health. Caregivers play a vital role in an infant's development, and their mental health and emotional well-being can significantly impact the child. Occupational therapy practitioners can be instrumental in recognizing signs of caregiver stress, depression, or other mental health issues and connecting caregivers with appropriate support services. By addressing both the needs of the infant and the caregiver, OTs can contribute to the overall well-being and development of the child and foster a positive parent-child attachment relationship.

Treatment Focus

• Treatment should focus on the caregiving relationship because the quality of the relationship has widespread effects on...
  • Gene expression
  • Brain growth
  • Stress system function

Focusing on the caregiving relationship is paramount in the treatment of infant and early childhood mental health. The quality of this relationship can have profound effects on various aspects of the child's development, from gene expression to stress regulation. By addressing and enhancing the caregiving relationship, occupational therapy practitioners can play a vital role in promoting the child's mental health and overall well-being. This approach recognizes the interplay between the child and caregiver and aims to create a nurturing and supportive environment for optimal development.

Infant-Parent Attachment Types

• Each type of attachment has its own antecedents and consequences, shaping the child's socio-emotional development.
  • The quality of Caregiving
  • The infant’s strategy to deal with distress
  • Special emphasis is given to disorganized attachment due to its correlation with emotional and behavioral difficulties, especially in high-risk groups.

The quality of caregiving is indeed a critical factor in shaping infant-parent attachment types. How caregivers respond to an infant's distress plays a significant role in determining the attachment style that develops. Disorganized attachment styles, in particular, are associated with emotional and behavioral difficulties, especially in high-risk groups. Recognizing and addressing these attachment styles early on is essential for promoting healthy socio-emotional development in infants and children.

Secure Attachment Style.

• One type
• Children feel safe and explore confidently, knowing the parent is available for support.

A secure attachment style is characterized by children who feel safe to explore their environment confidently, knowing that their parent is available for support when needed. In this attachment style, the child's needs are consistently met, and they receive ample love, affection, and attention from their caregivers. This secure base allows them to develop a sense of trust and security, which forms a strong foundation for their socio-emotional development.

Insecure Attachment Styles.

1. Insecure-avoidant attachment: Children show little distress when separated from the parent and may avoid contact upon reunion.
2. Insecure-resistant attachment: Children become highly distressed upon separation, and their attempts to seek comfort are met with mixed responses from the parent.
3. Insecure-disorganized attachment: Children display inconsistent and disorganized behaviors, often associated with significant emotional and behavioral problems.

Insecure attachment styles encompass three distinct patterns, the first of which is known as insecure-avoidant attachment. In this attachment style, children exhibit minimal distress when separated from their parent or caregiver. Upon reunion, they tend to avoid physical contact or emotional closeness, demonstrating self-reliance and a preference for self-soothing mechanisms.

The second style, insecure-resistant attachment, contrasts with the avoidant style. Children with this attachment type become highly distressed during separations from their caregivers. However, their attempts to seek comfort and reassurance upon reunion are met with inconsistent responses from the parents. This inconsistency in caregiving can leave these children uncertain about the availability of emotional support.

The third and final insecure attachment style is insecure disorganized attachment. Children displaying this style exhibit inconsistent and disorganized behaviors during interactions with their caregivers. This attachment pattern is often linked to significant emotional and behavioral challenges in children, making it a complex area of study.

OT: Special Considerations

• Combination of OT frameworks in EI and MH
• Infants developing brain is shaped by the quality of the caregiving environment and relationship with primary caregivers
• Effective treatments should involve both the infant and the caregiver.

Occupational therapy plays a crucial role in the context of early intervention and mental health, particularly when it comes to understanding the child's developing brain, the caregiving environment, and the caregiver-child relationship. Effective treatments often involve both the child and the caregiver. So, you might be wondering, how do you identify areas to focus on in your role as an occupational therapist?

Early Signs of Mental Health Concerns

Identifying early signs of mental health concerns in infants and toddlers, particularly from birth to three years old, is important. It's crucial to recognize that some degree of sadness or separation anxiety is a normal part of a child's development. However, the key is to differentiate between typical developmental phases and serious emotional problems based on the intensity and persistence of behaviors that cause extreme distress or upset in children.

Red Flags

• Infants and Toddlers (Birth to 3 Years Old)
• Specific behaviors that warrant concern
  • Inconsolable “fussiness” or irritability
  • Incessant crying with little ability to be consoled
  • Extreme upset when left with another adult
  • Inability to adapt to new situations
  • Easily startled or alarmed by routine events
  • Inability to establish relationships with other children or adults
  • Excessive hitting, biting, and pushing of other children or very withdrawn behavior

  • Flat affect (shows little to no emotion at all)

When identifying potential red flags for mental health concerns in infants and toddlers, it's crucial to consider the persistence and intensity of these behaviors and whether they interfere with the child's participation in normal activities. Some behaviors that may raise concerns include inconsolable crying, extreme fussiness, difficulty adapting to new situations, excessive startle reactions to routine events, an inability to form relationships with others, and aggressive behaviors like hitting, biting, or pushing other children. Additionally, if a child displays a very withdrawn behavior with flat affect, showing little or no emotion, it's essential to take note of these atypical signs and monitor them over time.

Diagnostic Criteria & Assessment

• Diagnostic Classification Manual (DC:0-5)
  • Published in 1994
  • Purpose: Helps professionals diagnose and treat mental health problems in young children. Disorders in infancy have distinct features as compared to later years.
  • Separate diagnostic descriptors have been developed to better fit the presentations of very young children.
  • Assessment example: Infant Toddler Social Emotional Assessment (ITSEA)-2006

Assessing mental health problems in young children requires specialized tools and approaches due to the distinct features of these disorders in infancy and early childhood. One valuable resource is the Diagnostic Classification Manual for Infants and Young Children, often referred to as DC:0-5. This manual is designed to assist professionals in diagnosing and treating mental health issues in young children, taking into account the unique presentation of symptoms at this developmental stage.

Another useful assessment tool is the Infant Toddler Social Emotional Assessment (ITSEA), which provides a comprehensive questionnaire for evaluating the social-emotional development of infants and toddlers. While there are various assessments available, the ITSEA is one example that can help professionals gain insights into a child's emotional and social well-being.

As an occupational therapist, understanding these assessment tools and their applications is important for providing appropriate interventions and support for young children's mental health. In the next section, we will explore how to implement these concepts and tools effectively in your practice.

Occupational Therapy Roles & Opportunities in IECMH

Goals of the IECMH Program

• To develop the capacity of the infant or young child to form close and secure relationships
• To experience, manage, and express a full range of emotions
• To feel safe and secure in order to explore the environment and learn
• To promote positive mental well-being in both parent and child

Incorporating infant and early childhood mental health into your practice involves several important roles and opportunities. These roles align with the goals of the infant and early childhood mental health framework and are essential for promoting healthy social-emotional development in young children. Here are the key roles and goals:

Your role is to support and facilitate the capacity of infants and young children to form close and secure relationships. This may involve providing guidance and interventions that promote healthy attachment and bonding between the child and their caregivers.

Help infants and young children experience, manage, and express a full range of emotions. This includes assisting them in developing emotional regulation skills and providing a safe space for emotional expression and exploration.

Create an environment where children feel safe and secure, allowing them to explore their surroundings and learn about the world. This could involve home visits or recommendations for modifying the environment to enhance safety and security.

Focus on promoting positive mental well-being not only for the child but also for their parents or caregivers. Recognize that the mental health and emotional state of caregivers can significantly impact the child's development, so your interventions should consider the well-being of both parties.

OTPs Role in Supporting Infant and Early Childhood Mental Health

• OT’s specialized training and unique skill set can support the social-emotional development of infants and toddlers by...

1. Promoting positive birth outcomes
2. Enhancing parent-child relationships
3. Addressing caregiver roles and routines
4. Improving parenting practices
5. Addressing parent mental health

Incorporating infant and early childhood mental health into your practice provides various opportunities for specialized training and utilizing your unique skillset as an occupational therapist. Here are different areas where you can support the social-emotional development of infants and toddlers:

Promoting Positive Birth Outcomes: You can work with parents during prenatal and postnatal stages, including offering support in the NICU. Assisting parents in preparing for the arrival of their baby and helping them adjust after birth are valuable roles you can play.

Enhancing Parent-Child Relationships: Utilize play-based therapies and involve parents in your sessions. Provide modeling and coaching in real-time interactions to strengthen the parent-child bond.

Addressing Caregiver Roles and Routines: Assist new parents in adjusting to their changing roles and routines. Offer guidance and support to help them transition smoothly into parenthood.

Improving Parenting Practices: Educate parents about how occupational therapy can assist in various domains, providing them with tips and strategies to enhance their parenting skills.

Addressing Parent Mental Health: Recognize the importance of supporting parents' mental health. Provide resources and assistance to help parents maintain their well-being, as this is essential for promoting a healthy environment for their children.

These opportunities allow you to use your OT expertise to promote the roles and occupational performance within the daily routines of parents and children. You can provide environmental accommodations, support self-regulation, address sleep and eating routines, and enhance self-care skills. All of these areas contribute to the social-emotional development of young children.

Summary

• Relationships with caring and responsive adults, along with early positive experiences, build brain architecture for children.
• The first three years of life can have enduring consequences due to formative periods for brain development.
• Adverse early experiences or significant stress from ongoing hardship or threat disrupts the biological foundations for learning, behavior, and health with lifelong consequences.
• Stressors on caregivers during infancy have immediate consequences for the infant's stress response systems and overall development.
• Symptoms and disorders in infancy have unique features that require separate diagnostic descriptors.
• Mental health interventions in infancy need to involve both the infant and the caregiver.
• Evidence-based intervention approaches have been successful in improving outcomes for children and families.
• Providing the right ingredients for development, including the influential protective factors, can counterbalance the effects of adversity in a young child’s life. 
• Increasing awareness, identification, assessment, intervention, and treatment for mental health problems in infants and toddlers, is key to early intervention.

Relationships with caring and responsive adults, coupled with early positive experiences, play a vital role in building a child's brain architecture. The first three years of life are formative for brain development, with enduring consequences. Adverse early experiences and ongoing stress, like trauma or neglect, can disrupt a child's biological foundations, leading to lifelong consequences. Stressors on caregivers during infancy affect the infant's stress response systems and development. Effective mental health interventions involve both the parent and the caregiver. Evidence-based approaches have successfully improved outcomes for children and families. Protective factors can counterbalance adversity in a child's life. Raising awareness and intervening early in mental health problems for infants and toddlers is crucial for better outcomes.

OT Influence Towards Positive Outcomes in IECMH

• Occupational therapy can play an important role in not only shaping a child’s future but also in shaping the next generation.
• When children are equipped with the tools they need to thrive, they can grow up into productive citizens who actively contribute to society.

Occupational therapy plays a crucial role in infant mental health, offering numerous opportunities for making a positive contribution that has lasting effects on society. While infants may be tiny and adorable, they are our future, and helping them grow into productive and contributing adults is essential for the well-being of society. This impact on the future is a valuable aspect of our work.

• Start with awareness and mental health screening
  • Early identification and mental health intervention for both children and their caregivers from the start produce better outcomes rather than trying to fix things later.

Equipping children with the tools they need to thrive and grow into productive citizens is a vital role that occupational therapists play. It all begins with raising awareness and conducting mental health screening early in a child's life, as identifying and addressing issues at an early stage is much more effective than trying to fix them later on.

Additional Resource

• FREE Mental Health Screening Checklist  for Infants and Toddlers
• Purpose: To highlight the key red flags for social-emotional development from birth to 3 years old.
  • Available at www.playitforwardtherapy.net
  • “Screening Checklists” Section

Here is a free mental health screening checklist for infants and toddlers that can be a valuable tool for professionals and parents alike in monitoring and addressing social-emotional development in young children. 

Model of Service Delivery

• Utilize a “hybrid model” of service delivery to combine in-person sessions and telehealth sessions to support infants, toddlers, and caregiver mental health
• In Person + Telehealth Coaching Sessions
• Win-Win Set Up for both the child and caregiver(s)

Combining in-person and telehealth sessions can indeed be an effective approach to providing comprehensive support for infants, toddlers, and their caregivers. It allows for flexibility and tailored interventions that can address both the child's needs and the caregiver's mental health. This hybrid model of service delivery can create a more holistic and well-rounded approach to early intervention and mental health support.

Considerations for Implementation of IECMH Concepts Into Your Current Practice

• Incorporate telehealth into your current clinical model.
• Pursue additional training if needed for how to leverage a telehealth program that focuses on parent and caregiver education, training, and empowerment.

Incorporating telehealth into your clinical model can be a valuable addition, especially when focusing on parent and caregiver education, training, and empowerment. Additional training in telehealth can help you effectively implement this approach, and there are resources available to support you in acquiring the necessary skills and knowledge to leverage telehealth for infant and toddler mental health support. Feel free to explore these resources and consider further training to enhance your practice in this area.

Other Considerations

• Revise the treatment plan or IFSP (individual family service plan) to incorporate both in-person clinical sessions with online telehealth sessions. 
• This helps to support both the caregiver and the child keeping in alignment with the infant and early childhood mental health framework.

If you are currently working in an early intervention setting, it's important to revisit and revise the Individual Family Service Plan (IFSP) to include a combination of in-person clinical sessions and online telehealth sessions. This approach allows you to effectively support both the caregiver and the child while aligning with the principles of the infant and early childhood mental health framework.

Additional Resources

• Want to learn more? Check out these FREE Resources to further support your work with infants and toddlers

1. Mental Health Screening Checklist for Infants and Toddlers
2. Masterclass Telehealth Training for Pediatric Therapists

• Visit www.playitforwardtherapy.net for more details

Thank you for joining me in this discussion on infant and early childhood mental health. I appreciate the important work you do with children, and I hope this information has been valuable to you. If you have any questions or need further assistance, please feel free to reach out to me via email or connect with me on social media. Remember, you are making a positive impact on the lives of these children and contributing to their future. Thank you for your dedication and commitment to this field.

Questions and Answers

Have you seen an increase in mental health issues in your practice? 

With 23 years of experience as an OT, I can confirm that there has been a significant increase in mental health issues, particularly related to anxiety, depression, and emotional regulation. These issues are not always related to sensory challenges but are more focused on mental health. Stressors linked to executive functioning have also become more prevalent, especially in older children. It's not uncommon for us to work on fundamental skills that you might expect to address earlier, such as helping children identify their own feelings or teaching them how to express empathy and make friends. There's definitely been an increase in these challenges. This is why I'm committed to the idea that if we can identify and address these issues earlier, it can make a significant difference. We have a role to play in this process, and early intervention is key.

References

American Occupational Therapy Association. (in press). Guidelines for occupational therapy services in early intervention and schools. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410010. https://doi.org/10.5014/ajot.2017.716S01

American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410035. https://doi. org/10.5014/ajot.2017.716S03

Benoit D.(2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatr Child Health, 9(8):541-545. doi: 10.1093/pch/9.8.541. PMID: 19680481; PMCID: PMC2724160.

Center on the Developing Child at Harvard University (2016). From best practices to breakthrough impacts: A science-based approach to building a more promising future for young children and families. Retrieved from www.developingchild.harvard.edu.

Early Childhood Technical Assistance Center (2022). Briefing paper: Infant and early childhood mental health and early intervention (Part C): Policies and practices for supporting the social and emotional development and mental health of infants and toddlers in the context of parent-child relationships. FPG Child Development Institute, University of North Carolina https://files.eric.ed.gov/fulltext/ED626448.pdf

Lambdin-Pattavina, C., & Dart, L. (2022)  Complex trauma and neurodiversity:  What happens in childhood doesn’t always stay in childhood. SIS Quarterly Connections, 7(3)

Lyons‐Ruth, K., Todd Manly, J., Von Klitzing, K., Tamminen, T., Emde, R., Fitzgerald, H., ... & Watanabe, H. (2017). The worldwide burden of infant mental and emotional disorder: report of the task force of the World Association for Infant Mental Health. Infant Mental Health Journal, 38(6), 695-705.

Olson, J. A., & Baltman, K. (1994). Infant mental health in occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 48(6), June, Volume 48, Number 6.

Purves, D., Augustine, G. J., Fitzpatrick, D., et al. (Eds.). (2001). Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates.