March 15, 2004

As you may know, the Infant Toddler Mental Health Coalition of Arizona ("Coalition") is a voluntary organization that was established in 1995. Its mission is the promotion of optimum mental health as a component of all family service systems and the definition of a system which provides access to comprehensive infant mental health services from trained and qualified practitionersin community based settings.

I am writing now to introduce to you the Coalition's Position Statement on the Health Assessment of Children Birth Through Five, particularly those coming into the Child Protective Services' system after removal from parental custody. Given the recent mandate for a 24 hour assessment of all children entering foster care, the Coalition believes it is critical that assessment personnel assess infants and toddlers according to established guidelines.

The enclosed Statement addresses the following significant issues:

• The need for assessment of all children removed from parental custody by CPS

• Assessment guidelines for infants and toddlers

• Qualifications of assessment personnel

The Coalition Board of Directors has fully endorsed this Position Statement and want to discuss the implications of it with you more fully in person after you have an opportunity to review it. If upon review you find that these guidelines for assessment are compatible with your organization's philosophy, we would encourage you to consider endorsement of this statement. We will contact you to arrange a mutually convenient time to meet. Should you have questions in the meantime, you may contact our Advocacy Committee Chair Suzanne Schunk at 602-266-5976 x 1050 or sschunk@swhd.org.

Thank you very much. We look forward to talking with you and working together to implement the guidelines we advocate.

Sincerely,

Barbara Wightman
ITMHCA Chairperson

Infant Toddler Mental Health Coalition of Arizona
Position Statement
February 6, 2004

The experience of abuse or neglect sufficiently serious to warrant a child's removal from his/her primary caregiver by Child Protective Services poses a significant risk to that child's behavioral health and overall adaptive functioning and development in all domains. All such children should be referred for developmentally appropriate behavioral health and developmental assessments.

I. Assessment Guidelines

Behavioral health assessments of children ages birth through five years should be consistent with the Practice Parameter for the Psychiatric Assessment of Infants and Toddlers (0-36 Months) established by the American Academy of Child and Adolescent Psychiatry [1], the assessment guidelines for use of the Diagnostic Classification of Mental Disorders of Infancy and Early Childhood established by Zero to Three [2], and the guidelines established by Zero to Three in New Visions for Developmental Assessments of Infants and Toddlers [3]. These guidelines include:

• Infants and toddlers must be evaluated within the context of relationships with their primary caregivers, and the child's relationship and interactions with his or her most trusted caregiver should form the cornerstone of any assessment [1,3].
  
  
• The collaboration of parents and caregivers is a prerequisite for an accurate diagnosis, and a working relationship between the assessor and the child's primary caregiver(s) is the crucial foundation for a useful assessment [2].
  
  
• Multiple assessments over time are needed because infants and toddlers change rapidly in response to internal and external stressors [1]. Diagnosis needs to be an ongoing process involving periodic re-evaluation of the child and caregivers [2]. When an initial diagnosis is required to secure appropriate multiple assessments and re-evaluation, the following are appropriate designations to consider and use as indicated: Parent-Child Relational Problem, Physical Abuse of Child, Sexual Abuse of Child, Neglect of Child (See DSM-IV for appropriate coding).
  
  
• Information from multiple sources including primary caregivers, caseworkers, and other professional caregivers is essential [1].
  
  
• Standardized instruments may be used as part of a comprehensive assessment but should not constitute the sole basis for evaluation [1].
  
  
• Young children should never be challenged during assessment by separation from their parents or familiar caregivers and should never be assessed by a strange examiner [3].
  
  
• Evaluation of infants and young children should utilize the DC 0-3 classification system in conjunction with the DSM IV classification system [1,4].
  
  

• A full diagnostic evaluation includes attention to the following
  - Presenting symptoms and behaviors
  - Developmental history - past and current affective, language, cognitive, motor, sensory, family, and interactive functioning;
  - Family functioning and cultural community patterns
  - Parents as individuals
  - Caregiver-infant (child) relationship and interactive patterns
  - The infant's constitutional-maturational characteristics [2].
  * An assessment will usually require a minimum of three to five sessions of 45 or more minutes each after the initial intake [2].
  * An assessment will usually involve:
  - Taking a medical and developmental history
  - Direct observation of functioning in multiple contexts in all developmental domains, including the caregiver- infant relationship and interaction patterns
  - Hands-on interactive assessment of the infant
  - Standardized developmental assessments as indicated

II. Practices to Avoid in the Assessment of Children Ages Birth Through Four Years

• Young children should never be challenged during assessment by separation from their parents of familiar caregiver [3].
  
  
• Assessments that are limited to areas that are easily measurable, such as certain motor or cognitive skills, should not be considered complete [3].
  
  
• Formal tests or tools should not be the cornerstone of the assessment of a young child [3].

III. Qualifications of Assessment Personnel

Changes in social-emotional development and adaptive functioning during infancy and early childhood are rapid and significant, involving bio- behavioral shifts that are both driven by and dramatically impact the structure and function of the child's central nervous system. The nature and pace of these changes present clinicians with uniquely complex challenges when conducting behavioral health evaluations for very young children and their families. Mental health evaluations for these children should be conducted by behavioral health professionals with the following qualifications:

• A minimum of a master's degree in a behavioral health discipline (clinical psychology, counseling, psychology, social work, psychiatry)
  
  
• Specialized training in infant mental health.

References

1 American Academy of Child and Adolescent Psychiatry. (1997). Practice parameters for the psychiatric assessment of infants and toddlers (0-36 months). Journal of the American Academy of Child and Adolescent Psychiatry 36, 21-36. 

2 Zero to Three. (1994). Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Arlington, VA: Zero to Three/National Center for Clinical Infant Programs.

3 Meisels, S.J. & Fenichel, E. (Eds.). (1996). New Visions for the Developmental Assessment of Infants and Young Children. Washington, D.C.: Zero to Three/National Center for Clinical Infant Programs.

4 Lieberman, A.F., Wieder, S., & Fenichel, E. (Eds.). (1997). The DC 0-3 Casebook. Washington, D.C.: Zero to Three/National Center for Clinical Infant Programs.

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