Educator Argues for Integrating Infant MH in Child Psychiatry Training

For many American child psychiatrists, the study of infant mental health and development, although a thriving field of research and clinical endeavor going back to the late 1970s, is a sidelight to their core training—an elective and still slightly exotic area of interest.

But in a commentary posted August 25 in Academic Psychiatry, Joy Osofsky, Ph.D., argues that child psychiatry fellowship programs should integrate infant mental health into the regular training curriculum. As a model, she offered the comprehensive training program in the Department of Psychiatry Harris Center for Infant Mental Health at the Louisiana State University Health Sciences Center (LSUHSC).

Osofsky, director of the Harris Center, argues that with an increasing focus throughout American health care on prevention and integration of behavioral health and general medicine—including pediatrics and obstetrics/gynecology—incorporation of infant mental health into the regular training curriculum of child psychiatrists is vital.

“As there is greater recognition of the importance of prevention, which is aided by addressing problems early in young children, child psychiatry needs to respond with an enhanced focus on ages 0–3 with more comprehensive training,” Osofsky wrote. “Through the increased understanding and application of key concepts provided in infant mental health training, child psychiatry fellows will become competent in a repertoire of skills that can be used to assess, comprehend, and treat a varied patient population in a more thoughtful and helpful manner.”

Joy Osofsky, Ph.D.

Her coauthors were Martin J. Drell, M.D., Howard J. Osofsky, M.D., Ph.D., Tonya Cross Hansel, Ph.D., M.S.W., and Andrew Williams, M.D.

In the article, she noted that neither requirements of the Accreditation Council for Graduate Medical Education nor the Milestones Project for residency programs make specific reference to infant mental health. Osofsky told Psychiatric News that though there are notable exceptions, including some training programs that have been pioneers in the field, most child psychiatrists receive only occasional instruction in infant emotional and behavioral development.

“It’s not really on the radar of training programs,” she said. “You might have a lecture here or there or a course offered as an elective, but the idea of incorporating it into a program so that it is regular part of the training of every child psychiatrist has not generally been accepted.”

There’s support for the idea among academic child psychiatrists. In a statement about infant psychiatry on the website of the American Academy of Child and Adolescent Psychiatry, Charles Zeanah, M.D., vice chair for child and adolescent psychiatry at Tulane University School of Medicine, wrote this:

“Prevention is the great uncharted territory in child psychiatry. If the idea of using relationships to effect powerful changes in the brain that have lasting impacts on children appeals to you, then you should consider infant mental health as an area of focus. I have been privileged to watch it grow from an exciting but obscure area to one that has grabbed the attention of the Surgeon General, the Institute of Medicine, and the authors of Healthy People 2010, the nation’s blueprint for public health in the first decade of this century. What we need now is to grab the attention of you, the future leaders of child and adolescent psychiatry.”

The Harris Center for Infant Mental Health, established in 2006, offers multidisciplinary training to child psychiatry fellows, psychologists, and social workers. Since then, the child psychiatry rotation has evolved into a mandatory 12-month course that begins in the second year of training. During the rotation, child psychiatry fellows learn methods for conducting infant mental health assessments, evaluations, and treatment for young children and their parents or caregivers using evidence-based practices. The training program includes four components: weekly didactics, infant observation, clinical experience, and reflective supervision.

“We meet once a week for a year,” Osofsky told Psychiatric News. “We have a two-hour didactic class where a lot of information is shared. We also meet for an hour and a half of group supervision in which trainees present cases.”

The group supervision is intended to help residents gain an understanding of the emotions and feelings that may emerge when providing treatment for very young children and their caregivers who may be at high psychosocial risk.

During the course of their rotation, trainees assess and provide treatment for at least two young children, aged 0 to 3 years, with their parents or caregivers. Videotaping is encouraged and is used by trainees when they present their cases for group supervision.

Faculty and trainees have sometimes been known to bring their own infants in for observation. “It’s important to have the perspective of normal development,” Osofsky said.

What has been the response of trainees and faculty? “They think it’s excellent,” she said. “At first there was some skepticism, but our child psychiatry fellows really enjoy it. They like the didactics because they are learning new material that isn’t covered in any other course. There’s also a focus on normal as well as abnormal development that trainees like.

“I have found that adult psychiatrists are becoming more interested in early life development because of what they see in their patients,” she added. “We have both child and adult psychiatrists who are very positive about our program.”

Osofsky tells other institutions that the key to integrating infant mental health into their training curriculum is having a champion to push that goal. At LSUHSC, Osofsky credits Martin Drell, M.D., director of Infant, Child, and Adolescent Psychiatry, as that champion.

“You need someone who says not only ‘I think it should be done,’ but who says, ‘I will do it,’” she said. ■