How a child plays, says Clinic Director Joyce Harrison, reveals motor skills and behavior traits that spill into life.

The first time Ron appeared at Joyce Harrison’s clinic, he was 31/2 years old and sleeping only three hours a night. Born addicted to heroin, he displayed impulsive behaviors, and was hyperactive, aggressive and about to be tossed out of his Head Start school.
“He was a jumping jack, passing out and throwing tantrums,” says his Aunt Sally (not her real name). “Now he’s a lot calmer and thinks before he acts.”

Ron is a patient in the Zero to Five Clinic, one of several preschool clinical outpatient programs that Harrison, a psychiatrist and School of Medicine assistant professor, directs at Hopkins Bayview’s department of community psychiatry.

For too long, she observes, this population has been largely ignored. “There’s a lack of awareness that children this young can already experience severe behavioral problems,” she says. These include aggression, depression, disruptive behavior disorder, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, anxiety, hyperactivity, and sleeping, eating and other developmental abnormalities.

Since starting the program in 2005, Harrison has evaluated about 100 youngsters in the Zero to Five Clinic, which is staffed with four psychiatric social workers. Until her appointment two years ago, the field of early childhood mental health was never an organized subspecialty here, and Harrison is still the only psychiatrist at Hopkins specializing in this population.

Indeed, like most of her colleagues, Harrison spent her psychiatric training diagnosing and treating patients no younger than age 6. Yet Harrison brings rare expertise to her job: For five years, she worked closely with internationally renowned psychiatrists Jean Thomas and Irene Chatoor, who work with the very young at Children’s National Medical Center in Washington, D.C. Thomas wrote the authoritative text on infant feeding problems; Chatoor is chair of the Infant Committee at the American Academy of Child and Adolescent Psychiatry.

Although this field has been studied for decades, new understandings about the brain and a baby’s development have catapulted early childhood mental health to prominence. “Early intervention,” explains Harrison, “prevents more serious problems down the road.”
 Assessment and diagnosis, she adds, primarily involve observation “You don’t have to do a whole lot, other than watch how the kid and mom behave.”

The trick is knowing what to look for. Harrison observes the patient’s appearance, motor and cognitive skills, mood, play, level of physical activity and reactions. She speaks to the mom about the child to understand parental attitudes and relationships.

In about 50 percent of the cases, the caregiver needs help with parenting or may be depressed, abused or chemically dependent. In such circumstances, one of the therapist’s goals is to assist the parent in obtaining treatment.

About 10 percent of Harrison’s under-5 patients are treated with drugs, but only as a last resort. The majority of the medicines target ADHD, anxiety and severe mood disorders.
Because weekly therapy sessions are sometimes insufficient, this month Harrison is opening an intensive outpatient program at Bayview that offers patients and caretakers three-hour sessions for up to five days a week. The new clinic for 3- to 5-year-olds will be the only one locally housed within a psychiatric department that offers on-site physical, occupational and speech therapy.

Ron, meanwhile, shows steady progress. After dumping Legos into a toybox, he sits still as Harrison checks his blood pressure. A year ago, Ron tore off the blood pressure cuff and—scrambling onto Harrison’s desk—hurled down her telephone.
                                                                                   
–LydiaLevis Bloch

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