Introduction to special section doing the “right” thing: Ethical issues in infant and early childhood mental health

Over the past several decades, the field of infant and early childhood mental (IECMH) has experienced rapid growth in clinical knowledge, awareness, and services. The importance of safe, nurturing, responsive care to the well-being of infants and young children is generally accepted as the most fundamental principle of infant and early childhood mental health, and the emphasis on infant-caregiver relationships is the hallmark of the field. Infant-caregiver relationships are affected by the health and well-being of the infant and the caregiver; the bi-directional relationships occur within the contexts of family, social, cultural, and historical factors that shape the dyad's interpersonal perceptions, expectations, experiences, and caregiving practices. Research demonstrating how experience—and in particular, caregiving relationship experiences—affects the rapidly developing brain and the short- and long-term development of infants and young children underscores the urgency to ensure that young children are cared for within an environment of caring, consistent, and protective relationships.

Clinical practice in IECMH spans promotion, prevention, early identification and intervention, and psychotherapeutic services. Identifying and addressing the individual, interpersonal, and social contexts that impact the relationships of caregivers and infants across this spectrum presents unique challenges. First, the relational focus of IECMH demands attention to the needs of both the caregiver and the infant, which can present difficulties when these needs do not align. Second, IECMH practice includes clinicians from varied professional groups, each with specific professional knowledge and skills, orientation, and priorities; these perspectives enrich our understanding of IECMH, but also may create discrepancies in how problems are identified, defined, and addressed. Third, IECMH practice occurs in myriad settings beyond “the office,” where most professionals are trained and interventions are developed, and working within these environments can lead to feelings of being untethered from the practitioner's professional signifiers and support. Fourth, infant-caregiver relationships occur within social, cultural, and historical contexts that may be unfamiliar to the provider and/or may not be accounted for in service provision models or theories. Finally, working with infants and caregivers can be motivated by and often tap into the personal experiences and values of the provider; teasing out professional and personal boundaries is an ongoing challenge. While the field has developed many approaches to help manage the complex clinical issues that arise (e.g., provider and public education, specialized training tracks, reflective supervision, IECMH consultation), there has been relatively little explicit attention given to how ethical frameworks might inform clinical practice and decision-making.

Although there are different definitions of ethics, the core feature is succinctly summed up in the Merriam-Webster dictionary definition of ethics as “the discipline dealing with what is good and bad and with moral duty and obligation” (https://www.merriam-webster.com/dictionary/ethic). Professional ethical codes articulate what the profession stands for, provide standards for which ethical and unethical behavior can be judged, and provide professional as well as public accountability, which supports the public's confidence in the profession. Our field, one that is continuing to grow and evolve, and one that is relationship-centric and values the family, social, and cultural contexts of infant health and development, can expect for ethical dilemmas to occur not infrequently. By ethical dilemma, we mean situations in which a decision must be made between two different courses of action and in which some cost or injury likely occurs as a result. Our thesis is that considering these dilemmas within an ethical framework is helpful if not essential.

In this three-paper series, our goal is to lay the groundwork to stimulate deeper and fuller discussion of ethics in infant and early childhood mental health. In the first paper, Lim et al. assert that attending to the ethical dimension of clinical decision-making is central to reflective and patient-centered mental health care, and some unique ethical considerations that arise in IECMH practice are described. Ethical decision-making is distinguished from legal and clinical decision-making and ethical components of clinical decision-making, as well as ethical skills are described.

Zeanah, C. et al. use case examples from different areas of the service spectrum representing familiar clinical situations with underlying ethical conundrums. The first case describes a young infant whose mother experiences substance abuse, and child protection is involved. The mother receives treatment, but her progress is sporadic, and the child's development and behaviors begin to deteriorate. The second case, based in a parent support home visiting context, exemplifies the ethical considerations related to providing complex services when more expertise or resources are needed—what are the ethical underpinnings of determining the provision of necessary and sufficient care or services? The third case grapples with the ethical dilemmas that arise in a hospital setting when parents seem to abdicate their responsibilities and the providers must make decisions about their role. The cases are powerful examples of ethical dilemmas when the best interests of the infant and parent do not align.

In the final paper, Zeanah, P.  et al. examine some of the major approaches currently available in the field for grappling with complex clinical dilemmas, including workforce development and reflective supervision and more recently, the Diversity-Informed Tenets for Work with Infant, Children and Families (Ghosh Ippen et al., 2012) and World Association for Infant Mental Health's [WAIMH] Position Paper on the Rights of Infants (WAIMH, 2016) As the authors point out, many, but not all, professions have ethical codes to which they must adhere, though these codes tend not to address directly some of the most salient issues facing IECMH clinicians involved in dyadic and interdisciplinary work. Ethical values statements for infant mental health are beginning to emerge (e.g., Michigan Association of Infant Mental Health, 2021; Zero to Three, 2019), but they tend to be too vague and difficult to translate when determining “right” and “wrong” in infant mental health practice. The paper ends with suggested avenues for ongoing discussion and a call for the development of an ethics framework for IECMH.

The goals of this special section are to encourage the IECMH field to engage with the challenges and grapple with the complexities of defining ethical practice in a way that feels just across diverse societies, and to consider how to develop useful guidance for practitioners. Three papers by themselves do not do the work needed to address the many challenges and conditions contained within. But by raising these issues, we hope to raise robust debate and include many more voices as we consider the way forward when working with our youngest and most vulnerable populations.

The authors have no conflicts of interest to declare.