Infant psychiatry mainly covers disorders in the relationship between infant and parent, focusing on children from the perinatal period to approximately 3 years of age. In addition to psychiatry, many domains are involved in the conduct of collaborative research and clinical practice. There are cases in which the child, the parent, or both, constitute the primary cause. However, in most cases, the parent and child are influencing each other in forming the patient's condition. In situations where adaptation of the DSM-5 or ICD-10 is difficult in rendering a diagnosis, other instruments such as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Child-hood-Revised edition (DC: 0-3R) are used in conjunction. Projection of a mother's own up-bringing onto her child, and an infant's attachment formation and patterns therein can be identified as primary factors influencing disorders in the parent-child relationship. Psychotherapy for infants includes short-term crisis intervention, developmental guidance, and parent-infant psychotherapy, in accordance with the situation. In addition to child psychiatric care, the clinical care of infants is being provided through settings such as psychological consultation offices, perinatal care, and the mother-and-child health administration services.
Recently, early intervention for infants at high risk of autism spectrum disorder (ASD) has shifted towards adjusting patterns of interaction between infant and environment, to foster more typical development of neural circuitry associated with social cognition to bring about reduction in autistic symptoms. In this report, the author presents a method of psychiatric support for infants displaying abnormality in interpersonal reactivity at high risk for ASD and their parents. Joining the parents in playing with the infants alongside the infants' attention or interest, and paying sympathetic attention to the parents' anxieties and distress associated with child care were effective for enhancing the infants' sense of security and interest in social stimuli, leading to parental confidence and improved parent-child interaction. Further study on early intervention, and establishment of systematic regional support for infants at high risk of ASD and their families are needed to provide children with comprehensive support, regardless of the region they are born into.
The purpose of this article was to examine what might constitute a clinically valid construct of “neurosis” among infants and toddlers, working on the assumption that such a state can exist, alongside demonstration of the difficulties of capturing psychopathology in early childhood. Starting with a short review of the concept of neurosis per se, and that in infants and toddlers, the concept of a “neurotic state” was proposed. The state would include both mental disorders and risk states during infancy as well as psychopathologies that could become manifest in later stages of development. Three inclusive conditions for subsistence of the state were defined as: 1) relatively low severity of pathology, 2) presence of psychogenic and/or extrinsic/environmental conditions as primary etiological factors, and 3) allowance for relationship specificities. Lastly, a number of candidates for this theoretical “neurotic state” were listed and discussed.
Recently, increase in the prevalence of Autistic Spectrum Disorder (ASD) has become a focus of wide-spread attention, prompting many studies on the etiology, early diagnosis and early intervention for ASD throughout the world. Discussed here will be the current state and issues surrounding the Health Check-up for 5-year-old children in Japan. Browsing through literature on early detection and diagnosis worldwide, it is seen that while studies abroad report intensively on epidemiological research and biomarkers to detect ASD on one hand, problems such as the presence of an endophenotype that fails to meet diagnostic criteria for ASD in the later stages of development have been revealed. In our country, health checks for pregnant women and infants based on the 1965 Maternal and Child Health Act are being conducted as standard practice. However, it is as yet difficult to pick up developmental disabilities, such as Attention Deficit-Hyperactivity Disorder (ADHD) and Specific Learning Disorder (SLD), and ASD without Intellectual Disabilities. To this end, efforts aimed at the early detection and early intervention for developmental disorders have been incorporated into national policy, recommending implementation of Health Check-ups for 5-year-old children by local government. However, many problems exist regarding this check-up for 5-year-olds. For example, implementation has not been unifrom across all regions as it is not a legal requirement like the medical checkups for 18-month-olds and 3-year-olds. Additionally, even where implemented, assessments have not been standardized, calling for further scientific validation. Scientific clarification should bring about needed change in the recognition and concrete aid for developmental disorders including ASD. Just as infant health checkups were instrumental in reducing infant mortality rates historically, it is hoped they will similarly contribute to the early diagnosis and support of developmental disorders in future.
Several decades of research has proved the considerable power of the mother-infant relationship on infant development. In keeping with those findings, the mother-infant relationship is emerging as the main target of intervention and prevention efforts in infant mental health.
In recent years, findings from translational research on the parental brain has revealed that mothers undergo neurobiological changes in the perinatal period that support development of mother-infant relationships regardless of great individual differences. In addition to demonstration of neural plasticity of the mother's brain through pregnancy, childbirth, and child-rearing based on functional magnetic resonance imaging (fMRI) studies, abnormal changes in the maternal brain associated with psychopathology (e.g., postpartum depression, posttraumatic stress disorder, substance abuse) are being clarified, as are the potentials of brain remodeling through the course of mother-child interventions.
In clinical assessment and formulation of infant mental health care, most clinical disturbances in the first 3 years of life, are more usefully conceptualized as relationship disturbances when manifested as problems in child behavior. Updated infant diagnostic criteria (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised: DC: 0-3R) now include relationship disorders (Relationship Problems Checklist: RPCL) and an assessment scale of dyadic functional impairment (Parent-Infant Relationship Global Assessment Scale: PIR-GAS) as axes in the multi-axial diagnostic system.
To address problems in the parent-infant relationship—impaired bonding in mothers with psychopathologies such as perinatal depression or PTSD, and infants with high risk for neurodevelopmental disorders, and problems such as excessive crying or sleeping/ eating difficulties—numerous forms of psychotherapeutic interventions focusing on both mother-infant interaction and attachment representation have been developed. Nonetheless, parent-child psychotherapy for this age group is still in need of validation by efficacy and longitudinal studies, towards which findings are being accumulated through the various modes of child-rearing support in practice today.
In crisis situations, younger children typically seek to achieve a sense of security by approaching an attachment figure. In instances of child abuse by a principal caregiver, however, a child is doubly impacted by both the trauma and the loss of an attachment figure who should have protected the child.
Abused children who have difficulty developing attachments tend to be less capable of appropriate expression and control of their emotions, with a tendency to exhibit increased incidence of violent behavior and social withdrawal. Moreover, abused children often come to manifest problems with interpersonal relationships in general-loss of the sense of security and trust as the result of abuse often hampering subsequent re-establishment of attachments.
Recent studies indicate that interventions to increase the sensitivity of caregivers are the most effective in repairing attachments. According to the studies, effective interventions are focused, with clear goals, and specified limited time. As diagnosis of PTSD in abused infants and toddlers is not easy, familiarity with the manifestations of trauma-related symptoms in younger children is essential for providing adequate care and support to abused children and their families from the dual perspectives of attachment and trauma.
Introduction: This paper presents the impact of a large scale natural disaster on the mental health of preschool children. On March 11, 2011, Japan was struck by the Great East Japan Earthquake, of magnitude 9 with an ensuing tsunami, causing unprecedented damage. There were over 18,000 fatalities, and more than 380,000 victims were forced to live in temporary housing for a long time. As for children, there were over 700 deaths, and many others lost their parents—250 were orphaned, and over 1,500 children lost one parent. Japan is one of the countries most frequently stricken by natural disasters. But even so, the Great East Japan Earthquake left us with much to learn in terms of disaster preparedness.
Subjects & methods: Our subjects were 71 preschool children encountering the quake at a day care center, and severely affected by the series of traumatic events which ensued. The authors have been following and providing the children with mental health support in collaboration with the day care center, and subsequently, the elementary schools they entered. Further investigation was conducted on 32 of the children from whom parental consent was obtained, through direct observation and interview of the children, parents, and teachers, regarding the children's clinical features and course of PTSD.
Results: The rate of PTSD was very high, and traumatized children exhibited various symptoms associated with the event. Numbing and dissociation were more commonly recognized over other symptoms, such as re-experiencing the traumatic event and increased arousal. Children without immediate parental presence after the disaster, and children of parents with problems exhibited higher incidence of PTSD. The presence of such parental issues was also suggested as one of the factors in the deterioration and protraction of the course of PTSD.
Implications: Personnel involved with the provision of post-disaster mental health should be aware that rates of PTSD are not low in preschool children, and that symptoms of numbing and dissociation are readily overlooked by first responders and caregivers. Furthermore, as parental influence factors largely in both the traumatization and care of children with PTSD, the possibility of perspectives such as Complex PTSD should be kept in mind in cases involving the deterioration of PTSD.
Skin is recognized as the boundary between an individual and society. Skin is also known to impact social and psychiatric conditions. The social aspect of skin characteristics has been gaining attention especially when it comes to hair-pulling or skin-picking disorders. These disorders, which target skin, hair or nails, have been investigated and described in the revised version of DSM-5 as “body-focused repetitive behaviors”(BFRB).
Most patients with BFRB have psychiatric problems. However, most will visit a dermatologist, and not a psychiatrist, although the psychiatric symptoms and recurrent BFRBs are difficult to manage for dermatologists who do not typically have psychiatric knowledge. The untreated psychiatric symptoms, including targeting of the skin, will eventually result in skin damage such as lesions, infection, and scars.
DSM-5-revised describes a new categorization of obsessive-compulsive and related disorders (OCRDs). Hair-pulling disorder known as trichotillomania is now categorized as an OCRD, whereas it was previously recognized as an impulse-control disorder under DSM-IV. Additionally, excoriation (skin-picking) disorder and body-focused repetitive behavior disorder, recognized as a new unit in diagnosis, have also been categorized as OCRDs. These revisions in diagnostic criteria reflect significance of the close relationships between BFRB and OCRDs, as well as the importance of psychosomatic dermatology and psychodermatology, which examine the clinical relationships between dermatology and psychiatry.
This study reviews literature that is relevant to hair-pulling and skin-picking disorders, as well as scratching behavior, especially that which occurs in patients with atopic dermatitis (AD). The paper also investigates the clinical characteristics and treatment of a patient with hair-pulling disorder and AD treated in a child psychiatry clinic, demonstrating the benefits of placing greater focus on psychodermatology, and the importance of collaboration between child psychiatrists and dermatologists.
The Strengths and Difficulties Questionnaire (SDQ) is a widely used measure of states of adjustment and mental health in children employed worldwide. However, few studies exist on the application of the SDQ by teachers in Japan, relative to the association of results with clinical assessments.
The subjects of this study were 307 first-graders at an elementary school, whose parents and teachers were asked to respond to the SDQ. The teachers were then interviewed by an experienced child psychiatrist or clinical psychologist regarding children for whom parental consent had been obtained regarding participation in the survey. Data from the interview were subsequently applied for clinical evaluation of the psychological and social functioning of the children using the Children's Global Assessment Scale (CGAS), and the results were used to investigate the association between results of the CGAS and the teacher- and parent-rated SDQs.
The results from 276 children were included in the study. The results from the SDQ showed moderate correlation between parent and teacher ratings regarding total difficulties and hyperactivity/inattention. However, variance in the mean and distribution of scores between teachers and parentsnecessitated establishment of a separate set of standards for these groups of raters.
The results of the CGAS evaluation revealed 8.0% of children as having adjustment difficulties. A relatively strong correlation was found between CGAS results and those of teacher-rated SDQs regarding total difficulties score, conduct problems, and hyperactivity/ inattention, indicating close association between the behavioral and hyperactivity/ inattention problems exhibited by children in the classroom and adjustment difficulties detected by the CGAS.
The identification of children with adjustment difficulties from teacher-rated SDQ scores was examined in light of clinical evaluation using the CGAS. Setting the cutoff at 12 points yielded a sensitivity of 0.86 and specificity of 0.87, suggesting utility of the teacher-rated SDQ to assist teachers in the identification of children with possible adjustment difficulties.