Infant Mental Health Guide for Parents and Healthcare Providers

Infant mental health is measured by how a child develops socially and emotionally from birth to age three. Identifying potential mental health issues in infants helps families and their healthcare providers encourage the development of healthy social and emotional behavior in children.

From birth to three years old, a child’s brain develops rapidly. The child begins to learn how to relate to others and express and manage emotions. By identifying the potential for poor mental health at an early age, interventions can be started that will have a more powerful and lasting impact than interventions at later ages, as the Manhattan Psychology Group explains.

It is important for parents to be aware of an infant’s developmental benchmarks so they can accurately monitor their mental development. The resources in this guide explain the concepts underlying infant mental health, factors that impact infant mental health, common issues in infant mental health, and how parents and healthcare providers can intervene effectively to promote a young child’s mental health.

What Is Infant Mental Health?

The mental health of infants, toddlers and young children is as important as their physical health. In the nurturing and protective actions of parents and other caring adults, infants form the basis for other special relationships that are the foundation for development of cognitive, emotional and social skills.

Key Concepts Behind Infant Mental Health

Newborn babies have very little ability to self-regulate: their emotional expressions reflect their biological processes, as explained in the Handbook of Infant Mental Health.

• Caring for an infant’s mental health begins before birth, as Mental Health America reports. Researchers are investigating techniques to identify signs of autism spectrum disorder (ASD) and other disabilities in infants. Some researchers believe such disorders may be related to “over-blooming,” or abnormally high growth of the brain during infancy.
• Factors that affect an infant’s mental health include the mother’s physical and mental health during pregnancy, her use of alcohol or other intoxicants during pregnancy, and her exposure during pregnancy to toxins such as lead, mercury or organophosphates.
• Exposure to intimate partner violence during pregnancy has been linked to a doubling of the risk of preterm birth and low birth weight. Both of these conditions are believed to increase the incidence of attentional, behavioral and psychological disorders in children.

How Infant Mental Health Develops

In their first three years, children learn these three important skills:

• How to manage and express emotions
• How to establish close, secure relationships with people
• How to explore and gain knowledge about their environment, including their family, community and culture

Children rely on adults to help them experience, process and express emotions. The Manhattan Psychology Group points out that infants and children learn how to share and communicate their feelings within the context of family and community.

How Infant Mental Health Development Differs from Physical Health Development

Differences between a child’s physical development and mental development are due primarily to the unique way the child’s brain develops. The family activity site Red Tricycle explains that physical development includes the child’s gross motor skills, fine motor skills and hand-eye coordination as the body grows and the child becomes more active.

Conversely, a child’s social, emotional and intellectual development relate to how the child’s brain develops. Development milestones for physical and mental development vary considerably from child to child. While both physical and mental development relies on nutrition, a child’s physical growth requires exercise and the opportunity to explore and interact with the physical world. A child’s social, emotional, and intellectual development depends on a loving environment that promotes self-awareness, social awareness, problem-solving, intellectual curiosity, and the ability to focus attention.

Brain development is affected by the child’s environment, relationships, and experiences. Disruptions to a child’s home and family circumstances can hinder the child’s ability to learn and relate to others. This can have lifelong consequences, according to Harvard University’s Center on the Developing Child.

• Children exhibit signs of anxiety disorders, attention-deficit/hyperactivity disorder (AD/HD), depression, post-traumatic stress disorder (PTSD) and other mental conditions at a very early age. However, children don’t react to traumatic events the way adults do, which can make diagnosing these conditions difficult.
• A child’s genetic predispositions can interact with stress-inducing experiences over a sustained period to increase the likelihood of mental health problems enduring into adulthood.
• Toxic stress hinders the brain’s development and impacts a child’s other organs, which in turn impacts both the physical and mental health of the child. It also impairs the child’s ability to learn. Persistent poverty is a primary cause of toxic stress in children. Other causes include abuse, chronic neglect, domestic violence and parental mental illness.

Prevalence of Depression in Infants

Child and Adolescent Psychiatric Clinics of North America published a survey of the clinical research on the incidence of depression and anxiety in preschoolers and determined the prevalence rate of mental illness in very young children to be about 2 percent. However, the researchers concluded that insufficient evidence is available to link the incidence of preschool depression with depression later in life.

WebMD cites figures compiled by the Federal Center for Mental Health Services that found that one in every 33 children and one in eight adolescents experience depression. Kathy HoganBruen of the National Mental Health Association (NMHA) states that while childhood depression is a real and common problem, it is also very treatable. Kathleen P. Hockey, a licensed social worker and author on childhood depression, notes that failure to treat childhood depression increases the risk of relapses and successively severe incidents.

Resources for Infant Mental Health

• Center of Excellence for Infant and Early Childhood Mental Health Consultation, Resources — Helpful sites for mental health consultants, program managers and policy makers.
• Michigan Association for Infant Mental Health, What Is Infant and Early Childhood Mental Health? — Information for parents and healthcare professionals on applying infant mental health principles and practices to prevent and treat developmental problems in very young children.
• Zero to Three, Resources — Infant mental health guides for parents, early childhood professionals, and policymakers.

Factors That Influence Infant Mental Health

In their first few months, infants progress rapidly in their ability to express complex emotions such as sadness and anger. Toddlers begin to show empathy for others as they become increasingly self-aware, exhibiting self-conscious emotions that include shame, embarrassment and guilt, as explained in the Handbook of Infant Mental Health. As the child becomes more emotionally competent, feelings of self-efficacy, security and trust increase.

Among the aspects that may impact an infant’s mental health development are parental responses to the child’s emotions, socialization to promote emotional regulation and social development milestones in the first three years. While attachment theory remains the predominant model of infant mental health, other factors include parenting behavior, verbal engagement with the infant, parents’ mental representation of their past relationships with their parents and parents’ current relationship with their child.

Role of Caregiver Attachment in Infant Mental Health Development

As the Encyclopedia of Children’s Health explains, attachment theory states that the bond between infants and their primary caregivers has the greatest influence on many aspects of infant development, including:

• Coping skills
• The ability to establish relationships
• The development of the infant’s personality

According to attachment theory, infants organize their behavior around caregivers, who serve as the basis for physiological, emotional, cognitive and social growth. In their first year, infants reach many milestones in their emotional and psychological development:

• First two months: Kind, sensitive and reliable responses of the caregiver to the child lay the foundation for attachment.
• Two months to seven months: Infants interact differently with caregivers than with strangers, but still don’t indicate a strong preference.
• Four to six months: Infants begin to anticipate how caregivers will respond to them when they are upset or unhappy.
• Seven months to one year: Infants indicate a clear preference for their caregivers, wariness of strangers and the onset of separation anxiety.

Temperament Differences Between “Easy” and “Difficult” Babies

Some children have a more challenging temperament than others, as Parents magazine points out. A Harvard University researcher determined that 40 percent of babies respond calmly to such stimuli as light and noise, while 15 percent to 20 percent of infants have a “more reactive temperament,” causing them to become upset by such stimuli and more difficult to soothe.

However, while parenting may not be effective in changing a baby’s temperament, thoughtful and consistent parenting does impact the temperament of older children. Parents can devise strategies to minimize the impact of a temperamental baby on families. Most importantly, parents and other family members can recognize that the cause of an infant’s behavior is beyond the child’s control.

How an Infant’s Temperament Matches Their Environment

A study reported in PLoS One found that children who exhibit high emotionality in their earliest years may need early intervention to avoid potential “adverse developmental pathways.” The study highlights the connection between an infant’s environment and their emotional and behavioral problems in childhood and later in life.

A child’s temperament can be affected by their family and social environment:

• Parental separation and single parenthood have been associated with children’s temperament, emotional regulation and well-being.
• Children who have difficult temperaments are more likely to suffer adjustment problems if their parents experience marital problems.
• Children whose families are disadvantaged or who live in low-income neighborhoods are more likely to have difficult temperaments.

Signs of Disruption to Typical Mental Health Development in Infants

Diagnosing potential mental illness in infants is challenging because symptoms must be viewed in the context of their personal history, caregiving team and other unique circumstances. The Child Mind Institute lists 11 warning signs that parents should watch for when assessing their child’s mental health. These are the signs that apply to infants:

• Periods of sadness or withdrawal that last for more than two weeks
• Doing serious harm to themselves
• Overwhelming feelings of fear that arise suddenly and unexpectedly
• Wanting to hurt others and getting into fights
• Out-of-control behavior that may harm the child or others
• Loss of appetite or unwarranted concern about their appearance
• Intense fear and worrying that impedes normal activities
• Difficulty concentrating or inability to stay still
• Drastic mood swings and changes in behavior or personality

What Are Potential Infant Mental Health Issues?

Early intervention in potential mental health problems in infants can have a significant impact on preventing mental illness later in life. That’s why monitoring an infant’s mental health status carefully for signs that the child may be struggling with a mental health issue is so important. These are among the behaviors that may indicate a burgeoning mental health problem in an infant.

Attachment: Separation Anxiety and Parental Withdrawal

The HelpGuide describes separation anxiety as crying, tantrums and clinging behavior that occurs when an infant is separated from a parent or caregiver. While these are common reactions in young children, separation anxiety may cause intense responses in some infants and may last until the parent or caregiver returns.

Separation anxiety disorder is defined as a serious emotional problem that causes infants to become extremely distressed when parents or caregivers leave. It is distinguished from normal childhood separation anxiety by the intensity and persistence of the infant’s response to the separation. The child may become anxious at the possibility of separation, and the condition may prevent the child from participating in normal activities.

Language Development and Mental Health

The Conversation describes developmental language disorder as an “invisible disorder” because it is frequently misidentified or mislabeled. While some researchers believe the inability to express themselves verbally is the cause of some children’s mental illness, a recent study conducted by the University of Bristol identified a genetic link that affects a child’s language ability and mental health.

The researchers posit that the genes responsible for language development may also be the source of mental health problems in children. The results suggest that while some language development delays may improve over time, early intervention in young children’s language development difficulties may reduce their chances of being affected by mental illness later in life.

Spotting Behavioral Regression

Some infants experience a loss of language skills and other social capabilities between the ages of 15 months and 24 months, as the American Academy of Pediatrics explains. Behavioral regression is one of the early signs of autism spectrum disorder (ASD), along with differences in the way infants develop body gestures and pretend play.

Children with ASD also exhibit other communication differences:

• They don’t point at things they want or share items with others.
• They aren’t able to say single words by 16 months.
• They “parrot” or “echo” what they hear others say without understanding what it means.
• They don’t respond to their name but do respond to other sounds, such as a car horn.
• They mix up pronouns, such as referring to themselves as “you” and to others as “I.”
• They don’t enjoy communicating and may avoid conversations.
• They don’t use toys or other items to represent people while they play.

Extended Periods of Difficulty or Stress

Babies are not immune from the high levels of stress created by the COVID-19 pandemic, as PublicSource reports. Infants need to develop at least four secure relationships, according to a licensed professional counselor cited in the article. The pandemic has made it more difficult for infants to enter into those relationships, and this can cause a baby to experience “toxic stress,” which differs from “healthy stress” related to learning to walk, talk or toilet train.

Toxic stress is caused by caregivers failing to give a child sufficient attention, and because an infant’s mood often mirrors that of their caregiver, increased depression in a caregiver can lead to depression in infants. The stress may also impact the child’s brain development because the stress causes hormones to overwhelm the child’s neural system. This may prevent the infant from crawling, exploring and doing other activities that spur development.

Intervention Strategies and Infant Mental Health

When potential mental health issues can be identified at an early age, interventions designed to prevent and treat the problems tend to be more effective. Strategies for responding to indications of mental illness early include discouraging negative behaviors and promoting healthy social environments for young children.

How Intervention Strategies Affect an Infant’s Developing Brain

At birth, infants are about 6 percent of their adult body weight, but a newborn’s brain is 25 percent of its adult weight. Two-year-olds on average are 20 percent of their adult body weight, while their brains are 77 percent of their adult weight, according to a study cited in the book Child and Adolescent Health and Development. An infant’s environment impacts the development of the brain during this crucial early period.

Researchers have determined that postnatal interventions to support mothers improved the development of infants’ brains in the region associated with memory and stress modulation. Conversely, prenatal maternal stress led to decreased development in a region of the infant’s brain associated with emotional regulation.

How Infant Intervention Strategies Differ from Those for Other Developmental Stages

Infants and young children reach developmental milestones at different rates. Early intervention strategies are intended to assist infants and toddlers who experience developmental delays, as explained on the disabilities services site Understood. The Individuals with Disabilities Education Act (IDEA) ensures that families are able to access the services their young children need in five areas:

1. Physical skills include an infant’s ability to reach for items, crawl, walk and build things.
2. Cognitive skills include the ability to think, learn, solve problems and reason.
3. Communication skills include the ability to talk, listen and understand what others are saying or communicating nonverbally.
4. Self-help and adaptive skills include the ability to eat and dress.
5. Social and emotional skills include knowing how to play, share with and otherwise interact with others.

Impact of Positive Environmental Factors in Intervention Strategies

Studies have shown a link between good mental health and positive physical and social environments for infants and their mothers from prenatal development through early childhood. Mental Health Colorado offers an Early Childhood Mental Health Toolkit that identifies six steps to change.

1. Identify: Find a person who can be a vocal advocate for infant mental health in your community.
2. Assess: Create a directory of organizations, agencies and early-learning programs that are working on early childhood mental health issues.
3. Promote: Determine which practices will best meet the community’s needs for the mental health of young children.
4. Share: Make sure information about infant mental health is disseminated throughout the community.
5. Support: Contribute to the community’s effort to promote early childhood mental health.
6. Follow up: Continue to assess best practices and funding opportunities to ensure the success of local programs in support of infant mental health.

Importance of Removing Negative Environmental Factors

In addition to ensuring a positive environment for mothers, infants and their families, identifying and addressing negative aspects of a young child’s environment is also important. Mental Health America describes the factors that impact an infant’s brain development during this crucial period.

• Healthcare: Despite the added funding for prenatal and infant care through the Affordable Care Act (ACA), many pregnant women and new mothers do not receive the healthcare they and their babies need. Mothers who don’t receive healthcare during pregnancy are three times more likely to deliver a baby with a low birth weight, and their infant mortality rate is five times higher than mothers who received prenatal healthcare.
• Housing: Young women experiencing homelessness are five times more likely than average to become pregnant, and when pregnant they are less likely to receive medical care.
• Nutrition: Pregnant women need good nutrition to ensure their baby develops normally. Studies have shown that babies born to malnourished women have a higher likelihood of developing depression, schizophrenia and mania.

Resources for Intervention Strategies and Infant Mental Health

• American Academy of Child and Adolescent Psychiatry, “Diversity and Culture in Child Mental Health Care” — A discussion of the importance for families of working with mental health care providers who are culturally competent when caring for infants and young children facing mental health challenges.
• S. Substance Abuse and Mental Health Services Administration (SAMHSA), Understanding Child Trauma — Infographics available for download in English and Spanish that provide information on the mental health impact of child trauma.
• Verywell Mind, “An Overview of Baby Depression” — The symptoms, causes, diagnosis and treatment of depression in infants.

How Parents and Nurse Practitioners Work Together to Improve Infant Mental Health

Intervention strategies allow parents and healthcare providers such as nurse practitioners to work together to mitigate the potential effects of mental health issues in infants. In recent years, the new position of infant and early childhood mental health consultant (IECMHC) has gained popularity. The Substance Abuse and Mental Health Services Administration describes the position’s qualifications:

• A master’s degree or higher in a mental health field
• A license in the person’s specific field of study
• Three or more years of experience working with infants and young children in a mental health capacity
• Knowledge of the culture and healthcare system of the community in which they will serve

Parent Strategies to Find the Right Professional Partner

Infant and early childhood mental health consultation has been shown to promote positive emotional and social development in young children. SAMHSA has identified national competencies that parents can use to determine the qualifications of healthcare professionals offering IECMHC services.

• An understanding of the specialized role of IECMH consultants in supporting the emotional, social and relational health of children and families
• Foundational knowledge of the mental healthcare needs of children and families
• Equity and cultural sensitivity
• Reflective and collaborative practice
• Systematic and contextual assessments

How Nurse Practitioners Help Parents Address Infant Mental Health

Nurse practitioners use their specialized skills and experience to provide parents and caregivers with the help they need to identify and address potential mental health issues in young children. The Arizona Healthcare Cost Containment System lists the interpersonal skills that practitioners require to assess and treat infant mental health.

• Listen carefully.
• Demonstrate concern and empathy.
• Promote reflection.
• Pay close attention to the relationship between the infant and parent or caregiver.
• Respond thoughtfully when interactions become emotionally intense.
• Understand and regulate your own feelings and use them to help families.

Importance of Building an Infant’s Developmental Profile

Children reach specific developmental milestones at stages throughout their infancy and into adolescence. The Centers for Disease Control and Prevention explains that a child’s developmental profile charts the developmental milestones the child has reached at ages from two months to five years old. MedlinePlus presents the normal growth and development periods for children from birth through age 15. For example, a four-month-old baby’s sensory and cognitive skills typically include the following:

• Well-established close vision
• Increased eye contact with parents and others
• Early hand-eye coordination
• The ability to coo and laugh out loud
• Anticipation of feeding
• Early memory and recognition of a parent’s voice and touch
• Ability to demand attention by fussing

Tracking Improvements in Relation to Regular Development

By tracking a child’s developmental milestones and comparing them to the statistical norms outlined in the CDC’s timeline, parents and healthcare professionals can identify potential delays in a child’s progress. If a child misses a milestone, a doctor, nurse or other professional may conduct a developmental screening that includes a brief test and questionnaire to determine whether a developmental evaluation is required. The evaluation is conducted by a trained specialist in child development who can diagnose a developmental delay and take steps to prepare the child for social and educational settings.

Resources for Parents and Nurse Practitioners Partnering in Infant Mental Health Efforts

• National Association of Pediatric Nurse Practitioners, “Behavioral and Mental Health Services” — The directory lists facts for families and resources for patients and parents.
• S. Centers for Disease Control and Prevention, “Important Milestones: Your Child by One Year” — The site examines the activities and cognitive skills that children typically exhibit by their first birthday.
• National Center on Early Childhood Health and Wellness — Tools and resources from the Department of Health and Human Services covering subjects such as emergency preparedness for early childhood education programs and health and safety standards in Head Start and child care programs.
• Psych-Mental Health NP, “Infant Mental Health” — Ten facts about infant mental health, including treatment approaches for young children experiencing emotional problems.

The Role of Nurse Practitioners in Promoting Infant Mental Health

Everyone benefits if infants and young children receive the care they need when facing potential mental health problems. As more attention is given to monitoring infant mental health and devising successful treatment strategies, the prospect of preventing future serious mental health problems increases. Parents and nurse practitioners trained in diagnosing and treating infant mental health issues form a partnership with the goal of ensuring all children have a chance to grow and bloom in positive environments.