Infants placed in foster care are at high risk for emotional and behavioral problems. Assessment of their mental health must account for their often-adverse life experiences prior to placement and the involvement of multiple systems that shape their lives in lieu of parents' authority. This article presents practice guidelines for infant mental health evaluations with consideration of legal requirements and the unique issues conferred by foster care.
Early childhood presents an unparalleled opportunity to improve the mental health and developmental outcomes of high-risk infants1 (Shonkoff & Phillips, 2000). Much of what is published on early childhood assessment has focused on childcare settings or early intervention programs for infants with developmental delays and disabilities (Knitzer, 2000; Shonkoff & Meisels, 2000). The vast majority of these children reside with their parents. However, infants who experience maltreatment and placement in foster care2 face the greatest risk for emotional and behavioral problems.
This paper is intended to inform the professional practice of those involved in the mental health assessment of infants in foster care. It briefly summarizes existing guidelines for infant mental health assessment and recommends practice modifications based on legal requirements and other distinctive issues associated with foster care. Mental health evaluations of these infants must address the complexity contributed by their atypical life experiences and the involvement of multiple systems that shape children's lives in lieu of parents' authority. In 2003, the Child Welfare League of America and the American Academy of Child and Adolescent Psychiatry (AACAP) collaborated to develop guidelines addressing the mental health needs of children in foster care. The authors, a clinical child psychologist and a child welfare/disability attorney participated in and developed recommendations for assessment based on work with court-involved infants (Dicker & Gordon, 2004; Silver, DiLorenzo, Zukoski, Ross, Amster, & Schlegel, 1999a).
Why Assess Infants?
Infants in foster care experience longer placements, higher rates of reentry into foster care (experiencing recurrent maltreatment and disruption of family bonds), and high rates of behavior problems, developmental delays, and health problems (Blatt, Saletsky, Meguid, Church, O'Hara, & Haller-Peck, 1997; Goerge & Wulczyn, 1999; National Survey of Child and Adolescent Weil-Being, 2005; Silver et al., 1999a). Because of these risk factors, mental health assessment is critical.
Infants are exquisitely sensitive to the emotional tone of their environments. When confronted with episodes of abuse, domestic violence, and volatile adults, their brains respond by secreting atypical levels of stress hormones (Dozier, Manni, Gordon, Peloso, Gunar, & Stovall-McClough, 2006; Gunnar & Barr, 1998). Similarly, severe neglect, which leaves the infant isolated, hungry, and in pain and discomfort, also results in high levels of stress (Dozier et al., 2006; Gunnar & Barr, 1998). Infants experience heightened physiological arousal, manifested in symptoms of intense anxiety, such as exaggerated startle responses, sleep and feeding disorders, fearfulness, and irritability (Scheeringa & Gaensbauer, 2000). Infants also experience grief and depression in response to losing beloved family members due to foster placement, a parent's incarceration, death, or child abandonment (Zero to Three, 2005).
Infants express emotional distress in several ways. They may demonstrate physiological dysregulation (for example, intense irritability, heightened arousal, limited ability to self-soothe, feeding and sleep disorders). Often, toddlers also present with behavioral disturbances (for example, aggression, defiance, impulsivity, overactivity, or sexualized behavior). Toddlers may exhibit intense fears and anxiety related to situations associated with past trauma (for example, bathing, being left alone in a room, diaper changes) (Heller, Smyke, & Boris, 2002). …