Jean M. Thomas, a Washington, D.C., psychiatrist, recently saw a patient who was struggling with her emotions. She was agitated and couldn't stop crying. She was recovering from an eating problem and had trouble forming relationships.
She was 11 months old.
Therapists are increasingly moving their treatments from the couch to the crib. While the field of infant mental health -- which encompasses the study of children from birth through age three -- has been around for decades, new research on everything from brain development to maternal depression is giving it a boost. A widely used mental health and development diagnostic manual for infants was revised last year for the first time since 1994 to include two new subsets of depression, five new subsets of anxiety disorders (including separation anxiety and social anxiety disorders) and six new subsets of feeding behavior disorders (including sensory food aversions and infantile anorexia).
By starting treatment as soon as possible -- even before their patients are out of diapers -- doctors feel they are helping kids become better adjusted. But the field is also getting a push from anxious parents, who are increasingly eager to catch serious problems, such as autism or anxiety disorders, in their children as early as possible. Indeed, doctors are finding that they can recognize the signs of some of these problems earlier -- sometimes in infants as young as one.
"Early intervention can make a difference," says Dr. Thomas, who practices at Children's National Medical Center in Washington, D.C.
The growing understanding of the baby's mind is leading to new therapies that address a variety of issues, including sleep and eating problems and excessive crying. What they all have in common is that they focus on the relationship between the baby and the primary caregiver -- usually the mother, but sometimes also the father and even the nanny. "It's very important to meet with who the baby is in love with," says Christine Anzieu-Premmereur, a psychiatrist and director of the Parent-Infant Program at Columbia University College of Physicians and Surgeons.
While many of these therapies were initially designed to help kids with early signs of emotional problems, more and more they're being utilized by parents of healthy babies seeking assistance with common parent-infant issues, such as toilet training and separation anxiety.
Psychologists at the Marycliff Institute in Spokane, Wash., and the University of Virginia have developed a specific course of group therapy called "Circle of Security," to help new parents understand their attachment to their own parents and how it affects their developing relationship with their baby. Parents and their babies meet once a week for 20 weeks, and each family is videotaped interacting for a half hour, with the parent periodically leaving the child and returning. The group watches the videotape from a different family each week, studying how the child expresses its needs and how the parents react.
"If parents can reflect on where the struggles are, they will do a better job of parenting," says Kent Hoffman, one of the therapy's creators. Currently, Circle of Security -- which is practiced at approximately 10 universities in the U.S., as well as an additional six abroad -- has been used by a variety of clients, from doctors and their families to mothers in prison.
The growing demand from parents for infant mental-health services is, in turn, driving a rapid expansion in the field. While no one tracks the number of infant mental health professionals, the World Association for Infant Mental Health, an organization that seeks to educate early-childhood professionals, currently has 44 affiliate organizations around the world, more than double the number it had in 1996. This year alone, new groups formed in Nebraska, New Zealand, Portugal and Latvia.
In the U.S., there are new graduate programs that aim to train professionals in the field -- including one that started last month at Seton Hall University, in South Orange, N.J. -- and new academic journals, such as the Journal of Early Childhood and Infant Psychology and the Journal of Developmental Processes. Two years ago, the Michigan Association for Infant Mental Health created a system to give accreditation to professionals who have completed specific coursework in the field and passed other requirements. Currently, the system is in the process of being adopted by four other state infant mental-health associations: Texas, New Mexico, Oklahoma and Arizona.
The growth in the field comes as experts increasingly demonstrate that the emotional and social development of young children is every bit as important as their motor and cognitive development. "Those first few years are unprecedented in the life cycle for how rapidly the changes occur, as well as for the complexity of the changes," says Charles Zeanah, a professor of psychiatry at Tulane University, and author of the "Handbook of Infant Mental Health." "The experiences that young children have are very important."
Doctors, of course, have been studying the cognitive development of children for many decades. In the late 1960s, Selma Fraiberg, a researcher at the University of Michigan, began examining the infant-caregiver relationship. She coined the phrase "ghosts in the nursery" to denote emotional patterns that parents bring with them from their own childhood, and created services for vulnerable babies and their families as well as one of the first training programs for professionals in the field.
Since then, research has shown that a baby's environment affects both its psychology and its neurobiology. If a mother is depressed, for example, her baby may become listless and nonresponsive. Additionally, studies show that negative experiences during infancy can alter brain chemistry. Experts understand that many adult disorders -- such as depression, anxiety or attention-deficit hyperactivity disorder -- start in childhood, and increasingly can recognize them as early as late infanthood or early toddlerhood.
Doctors have developed an integrated roadmap of what an infant's healthy emotional, social and cognitive development should look like. "By understanding the building blocks of healthy development, we can see when a baby is going off the healthy pathway," says Stanley Greenspan, a clinical professor of psychiatry, behavioral sciences and pediatrics at George Washington University's medical school and author of "Infant and Early Childhood Mental Health," which lays out risk factors for specific disorders as well as explicit interventions for each one.
Next month, the Interdisciplinary Council on Developmental and Learning Disorders, a nonprofit organization of which Dr. Greenspan is the chairman, will release a report in conjunction with the U.S. Centers for Disease Control that will offer guidance on early identification and preventive therapies.
Many babies who show up at a therapist's office have no serious issues. "The parents got the message that these are the critical years, and it's caused a lot of anxiety," says Claire Lerner, director of parenting resources at Zero to Three, a Washington-based infancy educational group that published the newly revised diagnostic manual. "They're watching for every marker." She says that good therapy can still help a healthy child: "It's an opportunity for parents to tune into their child, understand what makes him tick and to develop strategies to help him thrive."
In Washington, Dr. Thomas sees babies who have physical or psychological problems as well as babies with parents whose expectations are out of sync with the child's abilities. "What if the parent expects the child to sit at six months and the child is not sitting?" she says. "The parent might worry that the child is delayed or retarded. They might pressure the child and then the child gets frustrated."
Dr. Thomas practices "early childhood family-based therapy" in which she observes the parents with their baby -- both while she is in the room as well as through a one-way mirror -- and points out what pleases and what frustrates the child. Often, she gives the parents a daily homework assignment, such as setting a timer for every 20 minutes while the baby is awake and then, when it rings, finding some small activity that both baby and parent can enjoy, such as following the child's lead in play. "This is about helping the parent and the child have good experiences together that are going to be driving healthy development," says Dr. Thomas.
The cost of infant mental-health therapy varies, but generally runs between about $85 to $250 per session. Typically, insurance will not cover it unless one of the participants -- either parent or child -- is given a diagnosis. But some therapists say they are reluctant to give the baby a diagnosis.
For Elizabeth Thomason, the price was worth it. After her son Peter was born, she had trouble bonding with him -- the labor had been difficult, he had an intestinal problem that required surgery and refused to sleep, and the overwhelmed new mom fell into a post-partum depression. "He was not getting a lot from me -- I just fed him, changed his diaper, put him to bed," says Ms. Thomason, 32, who worried that her depression would permanently affect her baby. "There was no joy."
When her therapist suggested she see a clinical social worker who specializes in infant mental health, she quickly agreed. Once a week for about five months, the infant specialist came to Ms. Thomason's home and the two women discussed the baby's issues, how Ms. Thomason was feeling about her baby and different techniques to soothe him. "She helped us get the dialogue going between us," says Ms. Thomason. "Just having someone there to listen was huge."
Bringing Up Baby
Where to find information on early childhood development:
Zero to Three (www. zerotothree.org), a nonprofit group that offers resources for parents and professionals.
The Interdisciplinary Council on Developmental and Learning Disorders (www.icdl.com), a group of experts who published a comprehensive diagnostic manual last year.
Floortime.org (www.floortime. org), a nonprofit that provides information on infant and early childhood emotional and developmental challenges.