THE UNIVERSITY OF AUCKLAND

Interventions for infants and pre-schoolers with mental health problems A Summary of Reviews Sally N Merry July 2009

TABLE OF CONTENTS Table of Contents

Table of Contents Abbreviations................................................................................................................................................................... 5 Executive Summary ......................................................................................................................................................... 6 Acknowledgements ......................................................................................................................................................... 7 Introduction ..................................................................................................................................................................... 8 Prevalence Data ............................................................................................................................................................... 9 Diagnosis of Mental Health Problems in Infants ......................................................................................................... 9 Epidemiological Studies of Infant Mental Health Problems ........................................................................................ 9 Literature Review .......................................................................................................................................................... 10 Search Strategy ......................................................................................................................................................... 10 Models of Intervention .................................................................................................................................................. 11 By Disorder DC: 0-3R Axis 1 ....................................................................................................................................... 11 Post-Traumatic Stress Disorder (PTSD) ................................................................................................................. 11 Deprivation/Maltreatment Disorder .................................................................................................................... 11 Reactive Attachment Disorders DSM IV ............................................................................................................... 11 Disorders of Affect (including anxiety and depression) ........................................................................................ 15 Adjustment Disorder ............................................................................................................................................. 15 Regulation Disorders of Sensory Processing ......................................................................................................... 15 Disruptive Behaviour ............................................................................................................................................ 15 Sleep Behaviour Disorder ..................................................................................................................................... 16 Feeding Behaviour Disorder.................................................................................................................................. 18 Developmental Disabilities and Behavioural Problems ........................................................................................ 20 Autistic Spectrum Disorder ................................................................................................................................... 21 DC: 0-3R Axis 2 Relationship Disorders ................................................................................................................. 23 Specific Interventions ................................................................................................................................................ 25 Parent Training Programmes ................................................................................................................................ 25 2

Behavioural Treatment ......................................................................................................................................... 29 Interventions Based on a Psychotherapeutic Framework .................................................................................... 29 Other Interventions .............................................................................................................................................. 33 Māori Models ........................................................................................................................................................ 35 Pacific Models ....................................................................................................................................................... 36 Summary ................................................................................................................................................................... 37 Appendix 1: Search Strategies ....................................................................................................................................... 38 Appendix 2: Interventions Focussing on Quality of Attachment ................................................................................... 45 Appendix 3: Interventions for Sleep Problems .............................................................................................................. 47 Table 1. Reviews By Disorder ......................................................................................................................................... 48 Table 2. Specific Interventions ....................................................................................................................................... 51 References ..................................................................................................................................................................... 54

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List of Tables Table 1. Reviews By Disorder ......................................................................................................................................... 48 Table 2. Specific Interventions ....................................................................................................................................... 51

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ABBREVIATIONS ABA = Applied Behavioural Analysis ASD = Autistic Spectrum Disorder CG = Control Group COS = Circle of Security CPP = Child Parent Psychotherapy, CS = Community Standard Intervention DC = Depressed Control Group DC 0-3R = Diagnostic Classifications: 0-3 Revised DI = Depressed Intervention Group DSM = Diagnostic and Statistical Manual of Mental Disorders GE = Graded Extinction ICD = International Statistical Classification of Diseases and Related Health Problems IG = Interaction guidance IEP = Individual Education Plans IPP = Infant Parent Psychotherapy MDD = Major Depressive Disorder MP = Mellow Parenting ND-CG = Non-depressed control group N/S = Not specified PCIT = Parent Child Interaction therapy PD = Psychodynamic Therapy PHV = Psychoeducational Home Visitation PE = Parent Education PT = Parent Training TTP = Toddler Parent Psychotherapy UE = Unmodified Extinction WWW = Watch, Wait and Wonder 5

EXECUTIVE SUMMARY This report summarises reviews of the effectiveness of psychosocial interventions for mental health problems for the 0-3 age group published by May 2008. I have largely followed the DC 0-3R Diagnostic system but have included reviews of treatments of DSM-IV TR disorders where appropriate. Reviews of the use of pharmacological interventions in this age group have not been included. It should be noted that only reviews of interventions are included in this report; this is not a review of all trials of interventions. For many disorders and many interventions there is a lack of robust evidence to guide practice. Even where there are a number of randomised controlled trials, many studies are small and methodological shortcomings are numerous. There is a lack of information about how interventions may work crossculturally. Even for interventions for which there is evidence of effectiveness there are limited data to show that these interventions will work in a New Zealand context, and across different ethnic groups in New Zealand. There is a lack of clarity around systems for diagnosis of mental health problems in this age group, and a clear need to address difficulties in the relationship between parents and young children as well as difficulties in either the parent or the child. In this review, the focus is on difficulties that manifest in the child or in the relationship. While difficulties in parents, including mental health problems, impact adversely on children, these were not included in the brief for this review. The literature on attachment disorders and attachment classification is confusing and it is important to distinguish between them. In this review, reactive attachment disorder reviews are included under Axis I disorders, reviews of interventions disorganised attachment are reviewed under Axis II relationship disorders. There is good evidence that parent management training is effective in reducing not only problem behaviour in pre-school children aged 2-5 years, but also in reducing anxiety and depression. o

o

There are a number of parent management training programmes available. Factors likely to be associated with improved outcome are: 

In vivo training involving the parents and their own children



A focus on positive interactions between parents and their children



Teaching skills related to emotional communication



Training in clear strategies for problem behaviours

There is evidence that parent training works better when it is the sole focus of therapy and including other interventions (for example marital therapy, educational or social support for children) diminishes its effectiveness.

Parent management training also appears to be effective in reducing problem behaviours in children with developmental disability and autism, although studies have been in small samples and have numerous methodological shortcomings. There is evidence of efficacy for child parent psychotherapy from a number of randomised controlled trials. It has been used in families where there are a number of risk factors including physical abuse and or neglect of children, family violence and parental mental illness. 6

There is evidence that structured behavioural programmes are effective in preventing and treating sleeping problems in infants. However, sleep problems do not equate to sleep disorders. Sleep disorders are not diagnosed below the age of 12 months in DC 0-3R. Studies may provide some guidance about promising ways forward but there will be a need for research in New Zealand to investigate the effectiveness of interventions. Ideally, services for infants should include ongoing research and evaluation. There are interventions that have been developed in New Zealand and which have good acceptance within local communities. It would be worth evaluating the effectiveness of these interventions rigorously. Some interventions developed for particular ethnic groups may also be effective across the population and could warrant wider evaluation. Given the lack of evidence for some well accepted overseas interventions, there is an argument for giving priority to investigating the effectiveness of local and well-regarded programmes. “Holding therapies” for children with attachment difficulties have widespread acceptance in some communities but there is no evidence of efficacy and several reviews have cautioned about the potential to do harm using these techniques and there are some reports where these techniques have resulted in death in the children. Their use should not be supported in New Zealand.

ACKNOWLEDGEMENTS I would like to thank the Counties District Health Board for permission to include some of the material first published in the report Kua whakawhenua te purapuraka puawai te taonga: Addressing the social and emotional needs of infants in Counties Manukau District Health Board, Dr Yolisha Singh who provided help with initial literature searches and early drafts of the report, and Dr Karolina Stasiak and Levon Wigglesworth for invaluable help with editing and formatting the document.

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INTRODUCTION There is an increasing recognition that the very early experiences in life set the scene for later adjustment. Babies and toddlers raised in warm, nurturing and responsive environments are more likely to reach their potential in terms of their social and emotional development and are also more likely to be physically healthy. However, a number of babies and toddlers face a range of stresses that might include prematurity and illness or stressful family environments where parents struggle to provide optimal parenting because of their own mental or physical health problems, because of poverty or because their own experiences as children have not given them the skills to cope well as parents. When faced with difficulties, the relationship between parents and infants (defined as aged 0-3 years) may become problematic and infants may show their distress in a range of different ways. There have been attempts to define these problems and to develop effective interventions for them. In response to perceived inadequacies in the classical Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD) classification systems of disorders, the Diagnostic Classifications: 0-3 Revised (DC 0-3R) system has been developed to complement and expand on the existing classifications. In this report, reviews of evidence for interventions for actual disorder have been summarised; this is not a review of all individual studies of all interventions for all disorders in this age group. I have included all reviews that were identified, commented on their quality and attempted to outline the extent of evidence summarised in each review. There are a number of limitations to the evidence available to date. Interventions have not always been tested at different developmental levels and reviews have not necessarily focussed on the 0-3 age group. The focus of the intervention is not always on disorders as outlined in the diagnostic systems. Outcome measurement is varied and the validity and reliability of outcomes measures is not always clear. Despite these limitations there is a great deal of information to inform the development of services for this young age group. As well as exploring approaches for problem areas, I searched specifically for two groups of interventions: 1) those with broad acceptability and/or use within New Zealand, Australia or elsewhere and 2) those specifically designed for New Zealand populations, and especially any designed for Māori and Pacific populations and have included a summary of the evidence about these interventions.

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PREVALENCE DATA DIAGNOSIS OF MENTAL HEALTH PROBLEMS IN INFANTS Infant mental health is a relatively new field. There are a number of challenges in the assessment and diagnosis of mental health problems in infants and pre-school children. The current DSM and ICD systems are generally regarded as inadequate by clinicians working in the field of infant mental health, and an alternative classification, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy (DC 0-3) is used widely to complement and expand on the DSM classification and has been used to structure this report.

EPIDEMIOLOGICAL STUDIES OF INFANT MENTAL HEALTH PROBLEMS There have been very few studies of the incidence or prevalence of infant mental health problems and none have been conducted in New Zealand. The classic Christchurch and Dunedin longitudinal studies collected data on physical development in the early years and only began collecting data on mental health from childhood onwards. One of the earliest studies of prevalence of disorder was that of Naomi Richman et al.[1] who assessed the behaviour of a 1 in 4 sample of 3-year-old children living in a North London Borough, and found that seven per cent had a behaviour problem which was moderate or severe. A further 15% had mild behaviour problems. Family and social problems were subsequently addressed [2] highlighting the interaction between a behaviour problem in a young child, maternal mental health and social factors. Follow-up at the age of eight years demonstrated persistence of moderate and severe problems [3]. Skovgaard and colleagues [4] have assessed the prevalence of mental health problems at the age of 1½ years in a random selection of 211 children from a birth cohort of all 6090 children born in the County of Copenhagen in 2000. They used a comprehensive method of assessment and found 16-18% of children met criteria for one or more diagnoses on ICD-10 or DC 0-3 criteria. Another birth cohort study was carried out in the United States. An age- and sex-stratified sample of children was randomly selected from birth records in the State of Connecticut. The 1280 participants comprised 79.8% of the eligible subjects. Using a dimensional rather than diagnostic approach, Briggs-Gowan and colleagues found 11.8% of one- and two-year olds had high scores on one or both scales on Child Behaviour Checklist. This scale is used widely in studies in child and adolescent mental health and has good test-retest reliability, strong predictive validity and moderate success in discriminating between referred and non-referred children [5]. Egger and Angold reviewed studies of the prevalence of disorder in preschoolers in four community studies. Sample sizes ranged from 100-510. Estimates of the prevalence of disorder ranged from 14-26.4%. Estimates of serious emotional disorder were available in two studies and were 9.1% and 12.1% [6]. An earlier review of studies of the prevalence of psychiatric disorders in pre-school children found a median prevalence of 8% [7]. There are a number of limitations to all the studies cited above. The most comprehensive assessment of problems was that done by Skovgaard et al with a prevalence of 16-18%. The most conservative estimate is 8%.

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LITERATURE REVIEW SEARCH STRATEGY To identify studies for this review the following databases and sources for reviews were searched: Medline, CINAHL, Cochrane Database of Systematic Reviews, New Zealand Ministry of Health publications, National Institute for Clinical Excellence website, American Academy of Child and Adolescent Psychiatry Practice Parameters, New Zealand Guidelines Group, National Child Traumatic Stress Network and the National Registry of Evidence Based Programs and Practices Substance Abuse and Mental Health Service Administration (SAMHSA). Search terms and the dates searched for the reviews are listed in Appendix 1. Studies were included if: They were reviews, systematic reviews or meta-analyses of interventions for mental health disorders in infants or preschoolers aged 0-5 years; or They reviewed interventions for risk factors linked to mental health disorders in infants or pre-schoolers; or They were guidelines for the management of mental health problems in infants or preschoolers. Note that this was an overview of reviews, a review of all studies of all interventions was beyond the scope of this piece of work. Abstracts of all articles were printed and two people (YS and SM) independently decided which studies met the inclusion criteria. Any differences were resolved by discussion. In addition, information on models of intervention used widely in infant mental health services or recommended by international experts in the field has been included where this was identified within the searches. I have not included chapters from textbooks, many of which contain a summary of available evidence and the opinion of experts in the field.

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MODELS OF INTERVENTION BY DISORDER DC: 0-3R AXIS 1 POST-TRAUMATIC STRESS DISORDER (PTSD) There are no specific reviews for PTSD but the effectiveness of child parent psychotherapy approaches and parent training have been tested in populations of children exposed to violence, some of whom fall into this diagnostic category.

DEPRIVATION/MALTREATMENT DISORDER There are no specific reviews for these DC 0-3 R disorders but the DSM-IV TR equivalent disorder is Reactive Attachment Disorder of Infancy and Early Childhood. Reactive attachment disorder is considered an unduly restrictive diagnosis by many infant mental health specialists [8] who have proposed wider criteria [8, 9]. The picture is further complicated by the classification of attachment security [10] and the development of interventions to change attachment security. In DC 0-3R the authors comment, “We removed ‘reactive attachment’ from Reactive Attachment Deprivation/Maltreatment disorders of infancy. The original label led to confusion on the part of some users of DC: 0-3, many of whom believed that the phrase referred to the qualitative features of attachment relationships, which would be recorded more appropriately on Axis II.”[pg. 9][11] The concepts of attachment classification and attachment disorders continue to cause confusion. There is an excellent recent review of the evidence and implications for clinical practice by Sir Michael Rutter [12]. In line with current thinking, I have included reviews of attachment disorders in this section and included reviews of interventions designed to impacts on disorganised patterns of attachment security under the Axis II categories (below). It is the disorganised patterns that are most clearly related to current or later psychopathology. I have included reviews of interventions targeting insecure attachment in Appendix 2 for completeness, but insecure attachment is common in the general population and cannot be considered to be necessarily problematic.

REACTIVE ATTACHMENT DISORDERS DSM IV The DSM IV outlines specific criteria for the diagnosis of reactive attachment disorder (RAD) - a clinically significant attachment disorder that manifests before the age of five. RAD may present as an Inhibited Type, in which the child fails to initiate and respond appropriately to social situations or as a Disinhibited Type, in which the child attaches non-preferentially to any available caregiver. Several papers outline the dissatisfaction with the DSM and ICD classifications of reactive attachment disorder, which is rare and is seen only with the extreme levels of deprivation, and some point to the need for a wider classifications system [13, 14] while also cautioning against confusing attachments disorders with descriptions of patterns of attachment that have arisen within a research context. The two forms of RAD have distinct differences and appear to be two different constructs [15]. The Inhibited form correlates well with the disorganised pattern of attachment that can be identified through the Strange Situation Procedure [10, 16] and has been shown to respond to care that changed from institutional care to foster care [17]. Disinhibited social behaviour is associated with the duration of deprivation and neglect and correlates with difficulty in inhibitory control [18]. There is no correlation between this disinhibited form of RAD with the patterns of attachment identified with the Strange Situation Procedure and no interventions that clearly address disinhibited behaviour successfully.

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Boris and Zeanah have developed criteria for a wider range of attachment disorders [8], and one study has shown that these can be reliably diagnosed [9] although the authors caution that there is a need for further refining before carrying out trials of interventions. In reviews conducted in 2003 and 2005, no treatments had been shown to be effective for children with attachment disorders [8, 13], but the study on the positive effect of fostering on young children in institutional care published in Science is an important step forward [17]. The reviews assessing the evidence for attachment disorders are summarised below. These include both the narrow and the wider definitions of attachment disorders.

Newman and Mares 2007 The purpose of this review was to consider recent advances in the conceptualisation and treatment of attachment disorders [19]. This does not include a systematic review of the literature on treatment but focuses on some of the current controversies in the diagnosis and management of attachment disorders. The authors summarise the difficulties with classification of attachment disorders, with Reactive Attachment Disorder narrowly defined so that the category probably does not capture all children who have attachment problems that should be the focus of intervention. Newman and Mares summarise the position of the Task Force of the American Professional Society on the Abuse of Children. More detail of this report is given below [20].They highlight the need for further research.

Chaffin et al 2006 These authors have prepared the “Report of the American Professional Society on the Abuse of Children: Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems” [20]. Like other reports on this topic, they identify the lack of clarity around concepts of attachment problems and attachment disorder but also point out the relevance of these concepts in the management of children who have been maltreated. The report arose out of concerns at the deaths that have resulted from attachment parenting which is linked to holding therapies. The aim of the authors was to present their summary and analysis of the controversial techniques to deal with attachment problems and to make recommendations about the indicated and contra-indicated methods of assessing and treating children described as having attachment disorders. The authors describe the approaches to therapy they consider uncontroversial. These include providing a supportive and stable environment for the child with care-takers who are sensitive, nurturing calm, predictable and nonintrusive. They cite the reviews from Bakermans-Kranenburg et al [21] one of which is included in Axis II reviews and the other is summarised in Appendix 2 and conclude that evidence supports interventions that increase positive parent child interactions and parental sensitivity. The most effective therapies are those that are shorter-term, focused, have specific goals and include mothers and fathers. Controversial therapies have a different theoretical underpinning. They are based on the idea that difficult behaviour in maltreated children is a result of suppressed rage (the authors of the review point out that there is little to support this theory). Proponents of this view believe that children resist attachment because of their suppressed rage and are in danger of becoming psychopaths as a result. In order to break down resistance, the child is isolated and controlled. In order to release the rage, the child is put through various techniques, such as being encouraged to release rage or to regress. One technique, which has resulted in the death of a child, involved being held down by several adults for a process of “rebirthing”. The authors outline the lack of evidence for this approach. There is little to support the notion that maltreated children become violent offenders later in life; the risk is increased but most maltreated children do not follow this course. There is evidence that expressing rage increases the aggressive behaviour. There is little to support the effectiveness of regression techniques.

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The recommendations in this report include a specific condemnation of coercive, dominating ‘attachment parenting’ techniques and approaches that identify and portray children with attachment problems in a negative way. They recommend approaches which establish stability in the environment and in the care-taker and safety for the child. Approaches which increase parental sensitivity and nurturance should be considered first line of treatment and should be short-term and focused. Treatment should involve parents and caregivers, including biological parents, if children are living with them, or likely to be re-united with them. Both fathers and mothers should be included.

Boris and Zeanah 2005 The most comprehensive and helpful review of best practice for attachment disorders in light of the current evidence (or lack of it) is found in the Practice Parameters from the American Academy of Child and Adolescent Psychiatry [8] website; however, the review was published in 2005 and does not include more recent work. The recommendations are made in light of an extensive literature review. The authors of the Parameters outline the limitations of the current diagnostic system and highlight the restrictive nature of the diagnosis of reactive attachment disorder and outline a less restrictive definition. The recommendations in the guidelines include those pertaining to assessment. These have not been included in this report. The recommendations for the treatment of RAD have been paraphrased and are listed below.

1.

Any suspicion of previously unreported or current maltreatment should be reported.

2.

There is a high risk of development delays, speech and language deficits and untreated medical conditions. Appropriate referral should be made for any of these difficulties.

3.

Treatment must focus on creating positive interactions with care-givers. a.

Dyadic work is recommended with two major models outlined i. Infant-parent psychotherapy [22] ii. Interaction guidance [23]

b.

Dyadic work should be expanded to include family.

c.

Individual work with the child is sometimes used but there is a strong recommendation for dyadic work over individual work.

4.

Adjunctive treatments should be provided for aggressive and/or oppositional behaviour.

5.

The use of non-contingent physical restraint (e.g. “therapeutic holding”, “rebirthing”) is NOT supported.

Haugard and Hazan 2004 This is a descriptive overview of reactive attachment disorder with no clear search strategy for studies on the effectiveness of interventions [24]. The authors describe the controversial “holding therapy”. This therapy has not been supported in several more rigorous reviews as it has not been shown to be effective and there have been case reports of harm and death after using this technique as discussed above. The authors also outline the importance of trying to establish a stable secure relationship for the child, teaching peer relationship skills, enhancing sensitivity and reducing stress for care-givers and providing education and support for any foster-carers. This review is of 13

limited usefulness as it includes only a few articles chosen by the authors who have not systematically reviewed and critically appraised the literature.

O’Connor and Zeanah 2003 In an article providing an overview of attachment disorders, assessment procedures and treatment approaches O’Connor and Zeanah [13] also outline the limitations of the current diagnostic category of RAD and advocate for a wider definition, while also expressing caution over the extrapolation of developmental patterns of attachment to attachment disorders. They report that “no treatment has been shown to be effective for children with attachment disorders” [13]. However, there are interventions that are attachment-based and effective in reducing risk factors. They outline a number of factors important in these established interventions: Interventions should focus on real-life interactions between parent and child: o

The aim is to enhance the parent’s sensitivity and responsiveness to the child.

o

The focus on the interaction may be complemented by individual work with the parent to help the parent recognise and respond appropriately to the child.

Most interventions involve young children, mostly infants. The interventions have not been studied with children with attachment disorders. It is not clear whether the two types of RAD, disinhibited and inhibited require different treatment approaches (but see 1 [12]). The focus on dyads assumes a lack of sensitivity on the part of the parent. This model may be less appropriate for children with attachment disorders who have been adopted or fostered, where parents may be sensitive but where the child’s past experiences and current attachment pattern may impede interaction. Parent training and support are suggested for adoptive/foster parents. The authors caution that parents may appear frustrated and detached by the time they see clinicians but this may be the result of, not the cause of, the child’s attachment difficulties. Respite care is often used but the impact on the child is unknown and is potentially problematic in the context of attachment problems. Therapy that targets social-cognitive approaches may be useful, particularly for children experiencing rejection from their peers. This is probably more relevant for older children than for the 0-3 age group specified for this review. As with the authors of the Practice Parameters, these authors caution against the use of “holding therapies” and question the rationale and safety of these approaches.

1 A recent review by Rutter (2009) shows that it is now clear that different treatment approaches are needed. 14

In summary, attachment disorders should not be confused with the attachment classification. Attachment disorders are often seen in context of maltreatment and/or deprivation. The first priority is to ensure the safety and care of the child within a stable environment with a stable caregiver. There are likely to be co-morbid conditions such as physical ill-health and speech and language delays that should be addressed. Interventions that are likely to be helpful are those that increase parental sensitivity and decrease disorganised attachment. Currently infant-parent psychotherapy and interaction guidance are recommended and “holding therapy” is contra-indicated.

DISORDERS OF AFFECT (INCLUDING ANXIETY AND DEPRESSION) No reviews of management of anxiety or depression specific to infants, toddlers or pre-schoolers were identified. Parent training programmes for very young children have been shown to have a positive effect on pre-schoolers’ anxiety and depression as well as on their disruptive behaviours. These are reviewed in more detail in the section on parent training.

ADJUSTMENT DISORDER No reviews on adjustment disorders in infants were identified.

REGULATION DISORDERS OF SENSORY PROCESSING No reviews of treatments for these disorders were identified apart from a book by Reebye and Stalker [25] describing a therapeutic approach but no evidence was presented to support this approach.

DISRUPTIVE BEHAVIOUR Tse 2006 Tse [26] has recently published a review of literature published between 1974 and 2004 on the effectiveness of clinic-based preschool programmes, for children aged 2-5 years with disruptive behaviour disorder, oppositional defiant disorder or behaviour problems. Because of the paucity of studies on clinic based interventions she also reviewed laboratory based studies and discussed how efficacious approaches identified in research settings might inform clinical practice.

Clinic based interventions Tse found only one randomized controlled trial (RCT) so widened the review to include studies that were prospective and had quantitative outcome data. Using these criteria she found a total of five studies. The RCT was small (N=17) and compared intervention with a waitlist control condition for pre-schoolers who had been maltreated. The intervention was extensive and included individual play, speech and physical therapy for the preschoolers, family therapy and education, and a 24-hour crisis hotline. The intervention resulted in significant gains in “self-concept and development”. Of the other four studies, three were case control studies and one a single cohort study and all studies had small sample sizes. Two of the four had a positive impact on the preschoolers with reduction in disruptive behaviour and “developmental gains”, but effect sizes were small.

Laboratory based interventions Tse divided the laboratory based interventions into four groups; multimodal prevention programmes, child oriented interventions, parent training interventions and teacher training interventions. 15

There were four RCTs of multimodal prevention programmes and all targeted preschoolers from low socioeconomic groups. All four were effective with reduction in various disruptive behaviours and three of the four included long term follow-up, one to 11 years (Houston Parent-Child Development Center), one to 27 years (Perry Preschool Program) and one to 26 years (Mauritius Environmental Enrichment Program). In all these programmes preschool education was supplemented with a range of support and education for the parents. There were three studies of child-oriented interventions, only two of which were RCTs. One of these “I can problem solve” was directed to children from low income families so is not strictly a treatment programme. The other was of the Incredible Years Dinosaur Curriculum (N=176 from three studies). The children were randomly allocated to the intervention or to no intervention, assessments were blind and outcomes were measured on well validated rating scales (the Child Behaviour Checklist or the Eyberg Child Behaviour Inventory). Effect sizes were moderate to large and ranged from 0.35-1.33. The third study, on the effect of play therapy on maltreated pre-schoolers compared with day treatment as usual, showed no effect. Tse identified seven different parent training intervention programmes: Living with Children; Incredible Years Parent Training; Parent-Child Interaction Therapy; enhanced family therapy; synthesis teaching; Triple P Positive Parenting Programme; and community based parenting programmes. She concluded that the effective laboratory based interventions could inform the development of day treatment programmes for preschoolers. From her review, Tse developed a list of elements likely to enhance day treatment programmes for pre-schoolers. These include: The provision of high quality education; Improved access to care via home visitation and transportation; Attention to the families’ needs such as nutrition, finances and healthcare; Increased emphasis on children’s social problem solving skills; Creative ways of delivering school-oriented curricula e.g. use of role play and puppets; Efforts to engage families by addressing parental stress and offering treatment in more than one format; and Continued education for teachers and therapists. The author concluded by highlighting the need for ongoing research to investigate the effectiveness of translating laboratory based interventions into clinical practice. Further information on parent training programmes is given in the section on specific interventions.

SLEEP BEHAVIOUR DISORDER There are some difficulties with assessing the literature on interventions for sleep behaviour disorder. Many of the interventions target night-waking, which is very common, especially under the age of 12 months and which is often stressful for parents. In DC 0-3R, a diagnosis of Sleep Behaviour Disorder is given only after the age of 12 months and is limited to difficulties initiating sleep (Sleep-Onset Protodyssomnia) and difficulties maintaining sleep (waking up during the night and difficulties returning to sleep). For each of these, the difficulty has to have been present for at least four weeks and occur five to seven times per week. The categories complement the DSM-IV-TR diagnoses of sleep terrors, sleepwalking disorder, breathing related sleep disorder and nightmare disorder. The most extensive reviews of interventions for sleep disorders, on the other hand, use the 1997 International Classification of Sleep Disorders, with two categories, Sleep Onset Association Disorder and Limit Setting Sleep 16

Disorder, now both subsumed under Behavioural Insomnia of Childhood. In the reviews below, the authors comment that studies in the area use research criteria, which are similar to, but are not the same as, the criteria for sleep disorders. Generally, the sleep difficulties studied are frequent, chronic and severe. However, a number of studies include infants under the age of 12 months, as well as older children.

Mindell et al 2006 This is the most extensive review of behavioural treatment of “bedtime problems and night waking” in infants and young children (aged from 0 to 4 years and 11months) [27]. The review is of a high standard and summarises literature from 1970 through to January 2005. From a total of 3008 articles, 52 studies involving over 2,500 infants and young children were identified. These were studies that had been published in peer reviewed journals and included case studies and single subject designs. Of these, 13 studies were well-designed randomised controlled trials, 26 studies were well-designed non-randomised prospective studies with control groups, three were large well-designed prospective studies with historical controls or were small prospective studies with a control group and ten were small prospective studies or case series without control groups. The best designed studies evaluated the effectiveness of a number of behavioural interventions that included Unmodified Extinction (four studies), Graduated Extinction (three studies), Parent Education/Prevention (four studies), Standard Bedtime Routines (two studies) and Positive Reinforcement (two studies). The latter two were always included in a larger treatment package. The authors conclude that there is clear evidence to support Unmodified Extinction and Parent Education/Prevention and support for the use of Graduated Extinction (summarised in Appendix 3). Overall, 82% of subjects improved (with a range of 10-100%). The timing of assessment of improvement varied. Direct head-to-head comparison of methods showed little difference between behavioural protocols. There is some evidence to suggest that Unmodified Extinction may produce a more immediate effect that Scheduled Awakenings, and that combining a sedative medication with Extinction may reduce infant distress. Extinction has also been compared with Positive Routines with comparable results at week 4 but continued improvement with Positive Routines. Faded Bedtime has been studied more extensively in children with developmental disabilities and appears a promising alternative. A summary of all studies is available online at http://www.aasmnet.org/Resources/PracticeParameters/Review_NightWakingsChildren_ET.pdf The authors outline the difficulties with selection criteria for the studies, and the lack of clear differentiation between sleep disorders and sleep problems that most likely fall short of a diagnosis. However, they conclude that there is strong evidence to support the use of behavioural programmes and parent education to prevent and treat sleep disorders in young children.

Morgenthaler et al 2006 These authors have developed Practice Parameters for the management of bedtime problems and night waking [28]. The Parameters are based on the review by Mindell et al [27]. They conclude that there is evidence to support the use of unmodified extinction, parent education/prevention, graduated extinction and delayed bedtime/removal from bed, and positive bedtime routines in the management of sleep problems infants and young children up to the age of five years (see Appendix 3 for a description of the techniques). The authors also conclude that these interventions are effective at improving children’s daytime functioning and parental well-being [28]

Ramchandani et al 2000

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This well-conducted review [29] is essentially an earlier version of the review by Morgenthaler (above). It concludes that scheduled wakenings and extinction reduced night waking in 0-5 year old children compared with a control group, with extinction slightly more effective, but less acceptable to parents than scheduled wakenings. Positive routines and graduated extinction were effective for settling problems. Unsettled sleep is common in babies and under the DC 0-3R classification, disorders should not be diagnosed until over the age of 12 months. There is evidence that educating parents about how to settle their babies for sleep by putting them to bed when sleepy but still awake, possibly with a comforting toy or blanket, may teach the baby how to “self-sooth” and help prevent later sleep difficulties. Using strategies such as unmodified extinction can be stressful for parents and for babies and children.

FEEDING BEHAVIOUR DISORDER Piazza 2008 This is a brief review that outlines diagnosis, assessment and treatment of feeding disorders [30]. The search strategy was not described. The author describes several approaches but these are not clearly linked to subcategories of feeding disorders outlined in diagnostic systems. The author concludes that treatments with the most empirical support are based on applied behavioural analysis but does little to support this conclusion.

Chatoor 2003 In this review Chatoor [31] proposes sub-categories of food refusal, namely unpredictable food refusal, selective food refusal and fear-based food refusal. These categories overlap with the categories outlined below and the interventions are identical to those below. The new categories are not in line with the DC 0-3R categories so the interventions and evidence for these are best understood in context of the 2002 publication.

Chatoor 2002 Chatoor [32] has outlined a diagnostic system for feeding disorders that is in line with DC 0-3R and have reviewed the literature on each sub-category. This is a descriptive review. There were no clear search criteria, the quality of the studies was not assessed and the descriptions of each study are brief so that it is hard to evaluate them. However, this was the most extensive review identified in this search and for each category of feeding disorders Chatoor recommends a treatment approach, while acknowledging that there is no evidence to support this.

Feeding disorder of state regulation There are no empirical studies to guide treatment decisions. Chatoor recommends: Helping the caregiver to modulate the environment to reduce stimulation. Possible nasogastric feeding if growth is seriously impaired. Assessing for an intervening in anxiety, fatigue and depression in the caregiver.

Feeding disorder of reciprocity (neglect) There are two studies addressing growth deficiency related to neglect by the caregiver included in this review. In a study by Black et al [33] 130 infants with a mean age of 12.7 months were randomly assigned to weekly home visits 18

for a year by lay visitors supervised by a community nurse or a feeding and nutrition clinic. Children in both interventions improved [33]. In the second study, 59 infants with non-organic failure to thrive were randomly assigned to three treatment approaches that included short-term advocacy, a family centred intervention and a parent-infant intervention. All children improved although one third still had mild wasting. There was no difference between interventions [34].

Infantile anorexia In this disorder the infant shows little interests in food but is often interested in exploration. Feeding difficulties often arise in context of a problematic infant parent relationship. Chatoor has developed a treatment model for this feeding disorder that takes into account the infant’s temperament and the contribution this makes to the problem, the parents’ vulnerability related to past relationship or eating difficulties, and the relationship between the infant and parent. In an open clinical trial, 20 infants and their parents received this model of treatment and were followed up for two years. The outcomes were good for 17 out of the 20 infants.

Sensory food aversions Chatoor reports that a series of studies has shown that infants are more likely to accept new food in the first year of life than are toddlers. The author outlines the potential negative impact of coaxing toddlers to try new food. She recommends food supplements when nutrition is compromised and removing pressure from children to eat food that they dislike.

Feeding disorders associated with concurrent medical condition No trials were identified in this review that addressed this potentially difficult problem. Chatoor recommends taking into account the antecedents of the difficulties, the likely distress of parents and the pragmatic use of supplements where feeding is very difficult.

Post-traumatic feeding disorder This disorder arises where the infant refuses to feed after a traumatic event to the oropharynx or gastrointestinal tract. This can become life-threatening. One controlled clinical trial showed that behaviour therapy using extinction was effective for young children dependent on tube feeding. Chatoor has described a more gradual desensitisation approach but has not tested this in a controlled study.

Kerwin 1999 This is a comprehensive review of the literature from 1970 to 1997 and included studies of psychological or behavioural interventions for an identified “oral feeding problem” [35]. It included children from birth to the age of 18. The modified criteria for the Task Force for Dissemination and Promotion of Psychological Practice were used to establish the quality of the studies and 29 studies were identified that met all the criteria. Kerwin divided these into three main treatment approaches; differential attention, physical guidance and extinction interventions. Most studies of infants were very small and included subjects with complicated co-morbidities. There were two studies of relatively uncomplicated presentations in infants. Both used parents training approaches using differential attention. In one (N=20) children aged 18-60 months were randomly assigned to behavioural parent training or to dietary education. Both groups improved over time and there were no differences between groups. One study (N=3) used a multiple baseline design and showed home-based parent training resulted in an increased acceptance of targeted foods.

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DEVELOPMENTAL DISABILITIES AND BEHAVIOURAL PROBLEMS Children with developmental disabilities are at risk of behavioural problems and where there are dual diagnoses, behavioural problems can impose a significant burden of care on families. Two reviews of interventions for children with disability and problem behaviours were identified.

Roberts et al 2003 Roberts et al [36] conducted a review of early interventions for young children with disabilities and behavioural problems. In this well conducted review, the authors described a clear search strategy and identified 48 articles addressing the issue of behavioural problems in children aged six years or younger. They identified no epidemiological surveys of behaviour problems in pre-school children but, extrapolating from studies that include older children, concluded that behavioural problems, including severe behaviour problems, are common in children with disability. The prevalence of any psychiatric disorder in children with disabilities ranges from 40-64%, with parents of 64% of preschoolers with severe intellectual disability reporting challenging behaviours [36]. Most of the literature on intervention for young children with developmental disabilities has a focus on the development of practical skills and cognitive development. Fewer studies include interventions for behavioural problems although there are a number of comprehensive programmes that investigate the impact on behavioural problems. All the studies of comprehensive programmes in this age group were for children with autism and are reviewed below. Roberts et al also described the results for early intervention for behaviour problems. They identified two earlier reviews (Breiner and Beck 1984 and Grazianao and Diament 1992 cited in [36]). Breiner and Beck concluded that parent management training may be effective in reducing problem behaviours in young children with disability but pointed to the need for more controlled studies. Grazianao and Diament extended the earlier review and investigated the effect of parent training. They showed that results were mixed. Although parents’ knowledge and skills improved, these results did not necessarily result in improved behaviour in the children. Including role-play and modeling appeared to improve outcomes, and higher-functioning children did better than their lower functioning peers. Roberts et al [36] reviewed studies conducted since the Grazianao review and divided the results into group and individual interventions. There were four studies of group interventions, only one of which was methodologically rigorous. These studies showed some improvement in parental levels of stress and in parents’ perceptions of their efficacy but various authors from these studies suggested that parents of children with disabilities might need specific interventions tailored to the needs of the family. There were more studies on individual approaches and many of these were on children with autism and disruptive behaviour. There were a number of studies on the effectiveness of parent management training with some evidence that this is effective for managing behaviour problems in these children, with not only improved behaviour in the children but also gains for the parents. There was some evidence for gains from Contingency Management Training (CMT), which is training in providing an effective response to undesirable behaviour and Planned Activities Training (PAT), which is training in structuring activities so that opportunities for disruptive behaviour are minimised. Parents expressed satisfaction with both approaches, with a small preference for PAT over CMT. Functional communication training (FCT) has evolved from parent management training and is predicated on the idea that some child behaviour problems in this population are related to nonverbal means of communication. In two very small studies this approach appeared to reduce tantrums and aggression in the children. However, most studies to date are in single subjects or multiple baseline designs. Only one study used a control condition, and this

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was in one family. Roberts et al [36]concluded their review by highlighting the need for RCTs in this area, with outcome measures not only of child behaviour but also of family adversity, stress and parental interaction.

Gavidia-Payne and Hudson 2002 Gavidia-Payne and Hudson [37] provided an overview of interventions for parents of children with intellectual disability and problem behaviours. This is an overview of the literature rather than a systematic review, and addresses the needs of all children, not just pre-schoolers. They pointed to a need for thorough, systematic behavioural evaluations to guide intervention and identified parent training as the intervention most likely to succeed for this group of children. They suggested the need for adjunctive interventions, e.g. marital therapy and problem-solving but there are data on the reduced effectiveness of parent training when this is delivered in conjunction with other therapies (see reviews of parent training programmes).

AUTISTIC SPECTRUM DISORDER Rogers and Vismari 2008 This is a comprehensive review of the evidence for the treatment of autism in young children predominantly under the age of five. The review includes studies from 1998 to 2006 [38] and follows an earlier review [39]. The authors review: a) studies using RCT design; b) studies replicating Lovaas’ treatment approach of applied behavioural analysis; c) a review of empirical studies of other treatment approaches; d) a review of moderating and mediating variables; and e) pharmacological interventions.

Infants The diagnosis of autism can be made with validity at the age of two years and most children should be diagnosed before the age of three. There are no empirically supported interventions for this very young age group and is a need for further studies. However, there are studies of children aged two and older and it is worth summarising the findings from these studies.

Randomised controlled studies There were five RCT studies. Two of these were replications of the Lovaas method of intervention. In the first of these, Lovaas’ approach was compared with a scaled down less intensive version and a chart review. Although the study replicated the findings on changes to IQ the dramatic finding of a 50%”recovery” rate by Lovaas was not replicated. In fact, the children with full autism syndrome (compared with those with pervasive developmental disorder not otherwise specified) showed little acceleration in development over the course of intervention. The second partial replication study compared parent-led and expert-led versions of the Lovaas method. There were no significant differences between groups and both groups resulted in marked improvement in almost half the children. At follow-up, these children were succeeding in regular classrooms, speaking fluently and interacting with peers regularly. The three other trials were all one off studies of interventions. The results of all three were positive so that the interventions were judged to be “possibly efficacious” by the authors. The first intervention comprised a 12 week education intervention for parents and child-care workers in community day-care centres which resulted in greater parental knowledge and significantly better language development. The second was an intervention to improve language development delivered by parents and resulted not only in improved language but also better child communication and increased parental responsiveness. The third was a home-based intervention targeting

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social communication and behavioural management delivered by parents and showed better speech development in the intervention group.

Replications of the Lovaas interventions As well as the RCTs above, there have been several other studies that were controlled but not randomised, investigating the effectiveness of the intervention. One of these compared Lovaas’ intervention with an alternative intervention, although this study was in older children aged four to seven years and in a second study the Lovaas intervention was compared with another intervention chosen by the parents. Overall, the findings suggest that the Lovaas’ treatment, if delivered intensively and supervised by experts, results in significant improvements in a number of areas for half of the children who receive it. However, the treatment has little or no effect in the other half. Whether the intervention itself, or the intensity of contact causes the change is unknown, and the group of children most likely to benefit is also unclear.

Studies of other interventions There were no RCTs and few controlled trials of other interventions in this time period. Those studies that were identified had significant methodological flaws.

Mediators and moderators of outcome There is little information to determine who does well in which treatment and why. The authors summarise guidelines for clinicians that include: Locating appropriate interventions for unwanted or challenging behaviours, building spontaneous functional communication, engaging the child in meaningful activities, effective early intervention, supporting peer interactions, generalising new skills and including family members in the interventions; Monitoring progress; Coordinating care; Supporting the IEP process; and Monitoring the overall situation.

NZ Guidelines for the management of Autistic Spectrum Disorders 2008 This review [40] makes extensive recommendations that do not target infants so these results are not summarised here.

McConachie and Diggle 2007 In this systematic review the authors report the result of a search for studies investigating the effectiveness of involving parents in the implementation of interventions for children aged one to six years with ASD [41]. They identified 12 studies that met the criteria for inclusion in their review which were studies:

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in which parents implemented the intervention; there was a concurrent control of comparison group of children ; children were aged between one and six years and 11 months; and children had a diagnosis of ASD, Asperger’s syndrome, or PDD. They found that very few studies had a randomised controlled design, all had small sample sizes and all studies had a number of methodological shortcomings. They concluded that there was sufficient evidence to show that parent training can lead to improvements in the children’s social communication skills. Results from studies that are not RCTs indicate that parent training leads to improved child behaviour, skills and performance and reduced parental depression. However, they caution that these conclusions are tentative because of the limitations of the studies included in the review. In the four RCTs in this review, the extent of training and involvement of parents varied widely. In one study the extent of training and involvement is likely to make this intervention impractical. In this study [42] parents received five hours of instruction a week for three to nine months. The intervention was for 30 hours per week for two to three years. The other studies had a more realistic regimen with training in a workshop or in 15 hours over 10 weeks and with the intervention implemented for 30 – 60 minutes/day. The authors conclude that parent training does appear to be promising for young children with ASD but that further research is needed.

Rao et al 2008 In this recent review the authors identified studies assessing the effectiveness of social skills training for children and adolescents aged 0-18 years with Asperger’s syndrome or high functioning autism [43]. Only ten studies were identified for inclusion in the review, four were single case studies, four were open trials and only one was an RCT. None of the studies were in children under the age of five.

DC: 0-3R AXIS 2 RELATIONSHIP DISORDERS Although in DC 0-3R an understanding of the quality of the parent-infant relationship is seen as a vital in diagnosis and in developing interventions that provide the required support [pg 41, DC: 0-3R] there were no specific reviews of interventions for relationship disorders. The method of describing relationship problems outlined in DC 0-3R does not map well onto the literature on interventions. However, there are a number of interventions that have a focus on the quality of the relationship between the infant and caregiver. Some use attachment patterns from the attachment theory literature (see [12, 15] for a good overview) as a criterion for participation in studies and as an outcome variable. The most clinically useful of these are likely to be the interventions that measure changes in disorganised attachment. It should be noted that although attachment patterns can be detected reliably within a research situation in two to three year old children, the assessment process is not suitable for most clinical settings and the relationship of attachment patterns to actual disorder is not well established. Disorganised attachment is most clearly linked to psychopathology. There is evidence from longitudinal studies that this pattern of attachment is associated with subsequent aggression and disruptive behaviours [44], although this association is modest. Despite this, the interventions that improve disorganised attachment are worth considering for use in clinical services, particularly if this improvement is linked to a decrease in disruptive behaviour. Interventions that address insecure attachment have not been included but are summarised in Appendix 2 for clarity.

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Bakermans-Kranenberg et al 2005 This is one of two meta-analyses by Bakermans-Kranenburg [45] which focussed on infant attachment. This was a review of disorganised attachment and because of the association between disorganised attachment and subsequent psychopathology, has been included in this section. The other review by these authors has been included in Appendix 2. This review provided data on 10 studies and 15 preventive interventions [45]. The metaanalysis showed that the effects of intervention ranged from negative (effect size -0.49) to positive (effect size 0.53). They had three groups of studies that are pertinent to this review, clinically referred groups, children at risk and parents at risk.

Clinically referred groups There were three studies in this category. Only one study showed any effect. In this study, infants were referred to a clinic for sleeping or behaviour problems, or their mothers were referred for maternal depression or feelings of failure in bonding. The dyads were randomly assigned to the main intervention, ‘Watch, Wait and Wonder’ (WWW), or to psychodynamic psychotherapy based on the work by Selma Fraiberg. WWW led to a significant reduction in disorganised attachment post-test. This intervention is reviewed in more detail under “Specific Interventions”. In the other two studies, the criterion for participation was maternal depression. In one, home visits by publichealth nurses were compared with usual care and led to a small but statistically insignificant improvement in disorganised attachment. In the other, dynamic psychotherapy and cognitive behavioural therapy actually made the attachment disorganisation worse compared with nondirective counselling.

Children at risk Surprisingly, overall the studies in children at risk showed a greater effect than those in children and parents who had been referred for clinical services. There were three studies in children at risk. All interventions were delivered between the ages of 6 and 12 months. In the first the children were at risk because of adoption. Families were randomly assigned to one of three groups, the first (N=49) was a control group, the families in the second group (N= 49) were given a book to promote parental sensitivity and families in the third group (N=30) were given the book and this was supplemented with video feedback. The book alone did not lead to a change in disorganised attachment but the book plus video feedback did appear effective. The second study was in families with low socioeconomic status and an irritable first-born infant. The intervention consisted of three home visits by a psychologist who provided feedback to the mothers to help her provide sensitive soothing to her infant and to increase “reciprocal attunement”. Families were randomly assigned to intervention or to control. There was no impact on disorganised attachment but infants in the intervention were more securely attached than those in the control group, where insecure attachment was more of a problem. The third study was in families with very low birth-weight infants. An occupational therapist visited the families weekly to provide them with support and information about how to deal with the infant over an extended period (the mean number of sessions was 20). Overall, 52 families received the intervention and outcomes were compared with matched controls. Infants in the intervention group were more securely attached and fewer had “atypical” attachment (equivalent to disorganised attachment).

Parents at risk 24

The studies of parents at risk reported in this study would usually be considered targeted prevention as the risk factors include poverty, single-parenthood, inadequate care-giving, and insecure attachment representation in the mothers. One study included some mothers with depression, and this was just one of a number of risk factors in this study. The results of this part of the review are more relevant to planning for preventive interventions and so have not been included in this report.

SPECIFIC INTERVENTIONS As well as searching for interventions for specific disorders, I conducted a search for reviews of specific interventions used in this age group.

PARENT TRAINING PROGRAMMES Parent management training is an intervention devised for children with disruptive behaviour and has been extensively researched with consistently promising results [46]. The intervention typically targets children aged at least two years and up. Parent training programmes have been derived from social learning theory. Parents are coached to promote prosocial behaviour and to limit disruptive behaviour in their children. Some programmes provide the parent training in groups (e.g. Incredible Years) and some provide individual coaching (e.g. Parent Child Interaction Therapy, PCIT). Some provide different levels of intervention - from preventative through to intervention for disruptive behaviour disorders and for other mental health problems (e.g. Triple P). Parent training programmes have been consistently identified as one of the interventions with the best evidence of efficacy and are recommended by the National Institute for Clinical Excellence (NICE) and by the National Registry of Evidence Based Programs and Practices Substance Abuse and Mental Health Service Administration (SAMHSA). NICE recommends group-based parent-training/education programmes in the management of children with conduct disorders who are 12 years or younger. Individual-based programmes are only recommended where the family’s needs are too complex for a group-based programme. Most evidence for effectiveness is in older age groups. There is some evidence to support the use of parent training for much younger children as well.

Programmes with a focus on pre-schoolers Incredible Years, Dina Dinosaur and related programmes Carolyn Webster-Stratton [47] has developed a range of effective programmes for disruptive behaviour disorders in children including Incredible Years Parent and Babies, and Parent and Toddlers programmes. The effectiveness of Incredible Years for older children is well established. The effectiveness of the 12-week toddler programme has been tested in a randomised controlled trial with parents (N=208) and teachers (N=77) of two to three year-olds in day care centres serving low-income families in Chicago. Eleven centres were randomly assigned to one of four conditions: (a) parent and teacher training, (b) parent training, (c) teacher training, and (d) waiting list control. Direct involvement of the parents resulted in reports of higher self-efficacy and less coercive discipline, and toddlers were observed to have more positive behaviours then control or teacher only groups. Toddlers in high-risk behaviour problem groups showed greater improvement in the intervention groups than in the control group. Most effects were retained at one year follow-up. Benefits were greatest when parents received training directly. The Dina Dinosaur Treatment Program has been designed for children aged four to eight years and targets children with early conduct problems but can also be used for children with attention problems or social difficulties. The curriculum consists of 18-22 weekly sessions, each of two hours duration, delivered by mental health professionals or early childhood specialists. It can ideally run alongside the parent training Incredible Years.

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Parent-Child Interaction Therapy Parent-Child Interaction Therapy (PCIT) is a short-term intervention designed for families with children between the ages of two and six who are experiencing a broad range of behavioural, emotional, and family problems. This programme has two distinct phases: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). The aim of the CDI is to strengthen parent-child attachment (although attachment has not been measured as an outcome) as a foundation for PDI, which emphasises a structured and consistent approach to discipline. Throughout treatment, emphasis is placed on the interaction between the parents and their child. PCIT is structured so that for each phase of treatment, CDI and PDI, parents attend one didactic session during which the therapist describes the skills of the interaction and provides the rationales for their use. Modeling and role-playing are incorporated into these sessions to facilitate learning of the skills. Following the initial didactic session, parents and their child attend weekly coaching sessions together. During CDI, parents are taught to use the PRIDE skills (Praise, Reflection, Imitation, Description, and Enthusiasm) at high rates to avoid questions, commands, and criticism while they play with their child. During the coaching sessions, parents typically wear a bug-in-the-ear hearing device and are coached on their use of the skills by a therapist who is observing the parent-child interaction from behind a one-way mirror. Once the parent’s CDI skill level meets a predetermined set of criteria, the second phase of PCIT is initiated. During PDI, parents are taught to issue clear, developmentally appropriate, direct commands to provide consistent consequences for both their child’s compliance and non-compliance. For most families, the full course of treatment is completed in 10 to 16 weekly, one-hour sessions. Over 30 published studies have lent support to the efficacy of this clinic-based programme in a range of populations with a variety of developmental and parenting problems including children in foster care, children with externalising behaviour, chronic paediatric illness, developmental disorders, children with symptoms of attentiondeficit/hyperactivity disorder (for a review see [48]). It has also been translated and used successfully in a study of Puerto Rican parents of children with hyperactivity [49]. In addition to finding that PCIT is efficacious in helping them manage their child’s behaviour, parents report high levels of satisfaction with the content and process of PCIT, less personal distress as their child’s behaviour improves, and more confidence in their ability to control their child’s behavior [50]. The effects of PCIT have been shown to generalise to other members of the family, including the behaviour of untreated siblings of referred children and the psychological function of the parent [51]. Although PCIT has been evaluated rigorously and found to be effective, most studies have not been done on an “intent to treat” basis, there are some high-risk parents for whom this intervention has not been as successful; these include mothers who are highly critical or severely depressed or where the parents are actively abusing drugs or experiencing psychopathology.

Triple P- Positive Parenting Programme Triple P draws on social learning, cognitive-behavioural and developmental theory, as well as research into risk and protective factors associated with the development of social and behavioural problems in children. Triple P was designed to promote positive parenting of children aged 2-16 years and a tiered structure of interventions has been developed that include Standard, Group, Enhanced, Self-directed and Media (the latter being a universal prevention programme) [52]. Triple P interventions include the use of television programmes to present messages on positive parenting, resources such as tip sheets and videos, interventions designed for primary care (Levels 2 and 3) through to more intensive parent training (Levels 4 and Level 5).

REVIEWS OF PARENT TRAINING PROGRAMMES

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Kaminski 2008 The best of the reviews and meta-analyses identified is one by Kaminski and colleagues [53]. This is an exhaustive review of parent training programmes for 0-7 year olds and covers the literature from 1990-2002. The authors identified 47 studies of preventive programmes and 30 of treatment programmes. They divided effects into those on parents and children and showed a moderate effect on both (effect sizes of approximately 0.42 for parents and 0.3 for children). The effects on parenting behaviours were smaller than those on parental attitudes. Interestingly, effects were greater for the child’s internalising problems than for externalising problems. They investigated the factors associated with more effective programmes and identified four factors associated with the most improvement in parenting skills and behaviours and the greatest reduction in problem behaviour in the children were: Requiring in vivo practice of parenting skills with the parent’s own children; o

E.g. the parent directed his/her child thorough an activity observed by programme facilitators.

Teaching skills related to emotional communication; o

E.g. training in active listening skills such as reflecting back what the child says, teaching parents how to help their child identify and deal with emotions, teaching parents to reduce negative communication such as criticism.

Teaching parents to interact positively with their child; o

E.g. teaching parents how to show enthusiasm and positive attention for appropriate behaviour, how to play with their children in a way that is appropriate for the child’s development level, how to let the child take the lead and how to choose games that are appropriate developmentally.

Disciplinary consistency including time-out for externalising problems. Providing parents with other services rather than sole parent training resulted in smaller effect sizes, possibly because of a decrease in focus. There were a number of components that were not related to effect sizes. These included education about child development, and the use of a standardised curriculum or manual. These authors identified three components that were associated with negative outcomes, namely: problem solving, promoting children’s academic and cognitive skills and promoting children’s social skills. The authors did not compare the effects of treatment and prevention programmes and there is no information in the article to allow for a comparison between these two. Although this is a well conducted meta-analysis, there are some limitations. The age range was wider than the one specified for this review, and findings may not be directly applicable to the younger age group. The analysis included non-randomised as well as randomised controlled trials and often the comparison group received no intervention. In addition, the outcome variables are often rating scales completed by parents. Only published studies were included in the literature. These shortcomings would all be likely to inflate apparent effectiveness. Finally, this review included only studies up to 2002.

Nowak and Heinrichs 2008 Nowak and Heinrichs identified 55 studies of Triple P-Positive Parenting Programme for their recent meta-analysis [54]. The aim of the analysis was to identify variables that moderated the programme’s effectiveness. The studies 27

comprised 29 RCTs, 11 quasi-experimental studies and 15 uncontrolled studies and included both preventive and treatment approaches. Different formats for intervention (group, self-directed and individual) were included in the review and all levels of Triple P were included, although the majority of studies (84%) were of Levels 4 and 5. The review showed that Triple P results in improved parenting skills and reduced child problem behaviour with greater effect for more intensive interventions and, as would be expected, where there were more severe problems at entry to the study. It should be noted that in this review there were greater effects on all measures for younger children (less than 5.5 years).

Thomas and Zimmer-Gembeck 2007 A recently published review and meta-analysis compared the effectiveness of PCIT and Triple P [52]. Although not limited to pre-schoolers this is an extensive and well-conducted review and included children aged 3-12 years. The review included results from 24 studies, 13 of PCIT and 11 of Triple P. Both interventions were efficacious, although when intervention was compared with a waitlist control on parental reports of problem behaviours in children and on observations of negative parental behaviours, standard PCIT had a larger effect that Triple P. There was no difference between the two programmes on observed child behaviours. PCIT and enhanced Triple P both resulted in improved child behaviours.

Nixon 2002 Nixon published a review of parent training programmes for the treatment of behaviour problems in preschoolers in 2002 [55]. This is a descriptive review that divided the interventions into parent training programmes, PCIT, enhanced training programmes and programmes with different methods of delivery of the intervention. The review of parent training programmes was limited to those studies in preschoolers conducted by WebsterStratton [47]. The review supported the use of parent training with pre-schoolers. PCIT was considered separately as it is considered related but distinct from other parent management training programmes. There have been controlled and uncontrolled evaluations of PCIT, showing reduction in oppositional behaviour with some evidence of maintenance of improvement to 12 months, but reversion of most difficulties to pre-treatment levels by 18 months. Sample sizes in the studies tend to be small. Parent training programmes are not universally effective and tend not to be effective for families with high levels of marital discord, low socioeconomic status, single parent status and parental mental illness. In order to address these difficulties parent training programmes have been enhanced in a number of ways including focussing on personal and marital adjustment in the parents (with an increase in effectiveness in one small study), “planned activity training” to manage behaviour in high risk situations (findings unclear), “partner support training” (which improved outcome in one small study), adding interpersonal skills training to parent training (which improved parenting but not child outcomes) and problem solving which appeared to result in small gains on some measures immediately after intervention but with no difference at 4-6 month follow-up. Another approach is to enhance programmes to address specific child risk factors. There have been studies addressing child temperament, and those that provide adjunctive cognitive-behavioural play therapy and in-patient work but none of the evaluations have been rigorous so the effect of these enhancements remains unclear. Some studies have reported the effects of using different methods of delivery of programmes. The effectiveness of intervention by telephone for parents of preschoolers was investigated in two studies and both had promising results. Videotape modelling interventions have been investigated by Webster-Stratton and colleagues [47] and have been shown to be as effective as individual intervention and more effective that wait-list control. There is

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evidence that providing both parents and children with the opportunity for video modelling results in improved outcomes, although some suggestion that this may be more effective for the four to eight year olds than young preschoolers (although the latter was a very small study). Combining telephone and video interventions and replacing some therapist sessions with these interventions did not seem to reduce efficacy in one study. Nixon [55] concluded that there are a number of promising interventions for preschoolers but cautioned that studies he reviewed have a number of methodological short-comings. He highlighted the considerable commitment required from families to attend the interventions some of which required weekly two-hour sessions for six months, while others required in excess of 15 sessions. He supported further investigation of options for delivery of interventions using the phone or video as this might improve access and commented that contact with the therapist might be needed to maintain improved outcomes.

Barlow and Parsons (2008) Barlow and Parsons [56] conducted a Cochrane Collaboration systematic review of group-based parent training programmes for improving emotional and behavioural adjustment in 0-3 year old children. Five studies were included in the review and all had data suitable for inclusion in a meta-analysis. Independent observations of children’s behaviour showed a significant effect from intervention (ES –0.54, CI -0.84 to -0.23). Parent reports showed a non-significant advantage for the intervention group and there was no clear advantage from intervention at longer term follow-up.

BEHAVIOURAL TREATMENT No reviews were identified in this search although behavioural interventions are key components of many programmes. This may reflect the age group limitations applied in this review and there is clear evidence that programmes that include behavioural strategies (such as parent training) are effective with this age group.

INTERVENTIONS BASED ON A PSYCHOTHERAPEUTIC FRAMEWORK There are a number of psychotherapeutic interventions for parents and infants. These are widely used and although no reviews of the whole field of psychotherapeutic interventions were identified, I have reviewed the evidence for the models of intervention in common use or for which there is support by experts in New Zealand and Australia. Much of the psychotherapeutic work focussing jointly on parents and infants has followed the initial work by Selma Fraiberg with blind infants in the 1970s. Since then, psychologists and psychiatrists interested in working with the mother-infant dyad have developed the model further. The mother is encouraged to respond sensitively to her infant or toddler (zero to three) and she is helped to read, interpret, and respond to her infant’s cues. The therapist also encourages the mother to express her own emotions in the context of the mother-child relationship. In some interventions the therapist ‘talks’ for the baby and describes how the baby might be feeling as the mother takes care of or plays with him or her. The ‘speaking for the baby’ technique helps the mother tune in to the baby without feeling ordered to do so by the therapist. The therapist guides the mother in recognising how her own needs influence her responses to her baby. Role-playing with their infants allows the mothers the opportunity to uncover the ‘ghosts’ they bring into the nursery, or their own childhood experiences, and may assist the mother in looking at the interactions from the infant’s point of view [22].

Child-Parent Psychotherapy/Infant-Parent Psychotherapy

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Child-Parent Psychotherapy (CPP) is an attachment-based intervention targeting the parent-infant dyad for young children (0-6 years) exposed to family violence. It is a psychotherapy model that integrates psychodynamic, attachment, trauma, cognitive behavioural, and social learning theories into a dyadic treatment approach [57]. This treatment targets infants, toddlers, and preschoolers who have witnessed potentially traumatising levels of domestic violence and/or who display symptoms of violence-related trauma including Post Traumatic Stress Disorder (PTSD), aggression, defiance, noncompliance, recklessness, excessive tantrums, multiple fears, inconsolability, separation anxiety, difficulties sleeping, and social and emotional withdrawal. The intervention is 50 sessions long. The child-parent relationship is used to improve the child’s emotional, cognitive, and social functioning through a focus on safety, affect regulation, the joint construction of a trauma narrative, and engagement in developmentally appropriate goals and activities [58]. The child and mother are seen together, and the mother is offered extra individual sessions when indicated. The interventions focus on promoting affect regulation in the child and in the parent; changing maladaptive behaviours in the child, the mother and their interaction; supporting and encouraging developmentally appropriate interactions and activities; and guiding the child and the mother in creating a joint trauma narrative that includes finding avenues for conflict resolution and restoration of hope and trust in their relationship. An online review of CPP on the website of The National Child Traumatic Stress Network [59] reported that there have been three randomised control trials of CPP with trauma-exposed children. Lieberman [57] assessed its effectiveness in an RCT in which children who had witnessed domestic violence were assigned to CPP, or case management plus community referral for individual treatment. After intervention the children given CPP showed a significantly greater reduction in behaviour problems (effect size d=.24) and traumatic stress symptoms (effect size d=.64). Their mothers showed significantly greater reductions in avoidant symptoms (effect size d=.50) [58]. At 6-month follow up, improvements in children’s behaviour problems (effect d=.41) and in maternal symptoms (effect size d=.38) remained [57]. Toth et al [60] examined the efficacy of CPP to alter preschoolers’ representations of their mothers and themselves. In a study of 112 preschoolers, including a high proportion from ethnic minorities, who had been exposed to a variety of abuse and neglect, CPP resulted in improved representations of self and caregivers [59].In the third study by Cicchetti et al [61] 137 12-month maltreated infants and their mothers (three quarters of whom were from ethnic minorities) were randomly assigned to one of three groups: CPP; a psycho-educational intervention; and a control group. A fourth group of non-maltreated infants and parents was also recruited. There were high levels of disorganised attachment in the infants who had been maltreated (83-93%) compared with 42% in the non-maltreated group. After intervention, levels of disorganised attachment had dropped dramatically in the CPP (down to 32%) and in the psycho-educational intervention (down to 46%) and remained high in the control group (78%). Levels of attrition in the study were high and about a fifth of the parents did not complete the CPP intervention. In addition, there are studies showing that CPP can be effective in reducing anxious attachment in one year-olds [62] and for toddlers of depressed mothers [63] [64]. In a randomised controlled trial depressed mothers of toddlers (N=130) were randomly assigned to Toddler-Parent Psychotherapy (TPP) or to a control group. Nondepressed mothers (N=68) were also recruited to form a second comparison group. Maternal depression was found to be related to insecure attachment. TPP led to an increase in secure attachment and a reduction in disorganised attachment [60]. This body of evidence resulted in CPP being classified as “well supported and efficacious” on the practices grid of the NCTSN Empirically Supported and Promising Practices [59],and a “model” programme by the criteria set out by SAMSHA.

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Watch, Wait and Wonder Watch, Wait and Wonder (WWW) is a further form of infant-parent psychotherapy, the difference is that WWW uses an infant/child-led approach to intervention. As a relational therapy, this intervention was developed to find ways to fully involve the infant and young child as agents of change in their own treatment and to enable the parent to directly work therapeutically through play with their own child. In this intervention, the infant’s self-initiatives are encouraged over those of the mother’s and therapist’s [65]. WWW is both behavioural, with instructions to the mother to follow her infant’s lead, and psychotherapeutic through discussion of the mother’s observations and experience. Watch, Wait and Wonder has been evaluated in a comparative study of 58 mothers and their infants attending a mental health clinic [66]. In this study mothers and infants between 10 and 30 months of age were randomly assigned to receive treatment using the WWW protocol or a more frequently used psychodynamic psychotherapeutic approach (PPT) that worked primarily with the mother or with the family after the method developed by Fraiberg. After intervention, the WWW group showed more organised or secure attachment, and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Mothers in the WWW group reported greater satisfaction in their parenting and their sense of competence, and less depression than mothers receiving PPT. Both interventions were successful in reducing infant problems, decreasing parenting stress, and reducing maternal intrusiveness and mother-infant conflict. To determine whether the effects of WWW persisted post-treatment, a further assessment of infants and mothers was conducted at six months after treatment was completed [67]. At follow up, the two groups were similar on all measures. The WWW group had retained its positive gains, while the group receiving PPT had “caught up”. However, in the WWW group, an advantage persisted in relation to mothers’ comfort in dealing with the infant behaviours that brought them to treatment and in their ratings of parenting stress generally. There were significant changes in the infant-mother play interactions, both at the end of treatment and at six-month follow-up, but only approximately one-third of the sample moved to a more secure or organised attachment. The WWW intervention was more successful than PPT in bringing about changes in disorganised attachment in this clinically referred group.

Circle of Security It is worth reviewing the evidence for Circle of Security. It is an attachment-based approach that has wide acceptance by clinicians and is recommended by some of the most respected clinicians in this field. The Circle of Security (COS) project has been developed specifically for high-risk toddlers, pre-schoolers and their caregivers [68]. Both the assessments and the intervention [COSI] are explicitly based on contemporary attachment theories and a psychodynamic understanding of adult interpersonal function. A key component of the protocol is based on the Mutual Regulatory Model of mother-infant interaction. This model suggests that emotional regulation, trust in the caregiver and ultimately secure attachment comes about through the reparation of disrupted mother-infant interactions. The main goal of the intervention is to help the parent learn to identify the infant cues that lead to these disruptions, and to acquire the skills to repair them or to respond appropriately to the infant’s bids for interaction. The intervention involves small (N=6) groups of at-risk mothers (or fathers or other primary caregivers) of toddlers or pre-schoolers (1 to 4 years of age) who meet as a group with a psychotherapist for 20 weeks for 1¼ hours each week. During the group meeting, each parent reviews edited video vignettes of herself or himself interacting with her or his child. The videos, and the related psycho-education and therapeutic discussions, are individualised to each dyad’s specific attachment-caregiving pattern. This pattern has been established through a pre-intervention

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assessment. The dyads are reassessed midway and the pre-intervention assessments are repeated after the 20week intervention to track changes in patterns of child-caregiver interaction. The COS protocol is currently being tested within the Head Start/Early Head Start Program with the goal being to develop a theory- and evidence-based intervention that can be use in a partnership between professionals trained in scientifically-based attachment procedures, and appropriately trained community-based practitioners. Early outcomes suggest this as a theoretically sound and promising intervention [69] and a recent article has reported favourable outcomes in 65 toddler/preschooler- parent dyads recruited from Head Start and Early Head Start programmes. There were significant changes from disorganised to secure attachment patterns [70]. This was an open trial. As yet, no RCTs have been done. In addition, the significance of the change in pattern of attachment is unclear. Although disorganised attachment is associated with higher levels of behavioural difficulty and aggression [44] there is also contradictory evidence of stability of attachment patterns over time [71] and lack of clarity over the relationship with attachment disorders [19]. Nevertheless, this intervention is based on a clear theoretical model and initial findings support the underlying theory.

Interaction guidance Interaction guidance is a psychotherapeutic intervention that focuses on strengths, emphasises caregiver involvement and includes reflection on and discussion about videotaped interactions between caregiver and child. The focus is on current interactions between the parent and child. Typically, this intervention lasts for four to six months and includes 12 sessions. A partial randomised controlled trial was conducted with 38 mother-infant dyads in which interaction guidance was compared with psychodynamic brief psychotherapy [72]. Just over 61% of infants presented with sleeping problems. Both interventions led to improvement, with some evidence for a greater effect for the interaction guidance group, although this was a very small study. There have been two studies that have compared the effects of interaction guidance and brief psychodynamic psychotherapy. Both trials showed symptomatic improvement with no difference in effect between interventions.

Mellow Parenting Mellow Parenting was specifically designed to meet the needs of families who have a number of factors that put them at risk of parenting failure including: mental illness, social isolation, domestic violence, and parental literacy problems. The main focus of the programme is to work directly on parenting behaviours in the environment of family centres rather than mental health clinics. The protocol for this intervention is carried out through 14 weekly sessions and targets families with children under five years of age. The child and parent, usually the mother, attend for a full day each week. The parents are in a personal group while the children attend a children’s group in the morning. All children in the family who are under five are offered a place. This offers the parents the opportunity to explore their past and current relationships and how these may facilitate or impair their ability to form a good relationship with their children. Parents, children and staff take lunch together and then have an opportunity to play together through simple activities, nursery rhymes and games. These activities are designed to promote parent-child interaction and to help parents who do not enjoy their children’s company to build a repertoire of mutually enjoyable activities. In the afternoon, the children return to their group while the parents take part in a parenting workshop, based around a structured model of parenting and the use of individual video-taped recordings of the families at home during their normal mealtimes. From this work, parents are set homework to enable them to try new ways of managing child behaviour. The group work involves the use of very simple worksheets and planned activities that make low demands on literacy. Mellow Parenting has been evaluated in one study [73] of families who were referred to the programme based on the following criteria: 1) parenting difficulties or relationship problems, including child protection issues; 2) family 32

violence; 3) at least two of the following: child behaviour problems, maternal mental health problems, difficulties in current family relationships or family of origin. The outcomes of the families in this programme were compared to existing models of good practice offered to similarly deprived families at family centres. Measures of maternal wellbeing, child development and behaviour and observed mother-child interaction were collected before group involvement, after the intervention was complete, and one year later. Results of this study showed that Mellow Parenting was successful in engaging families who were at risk of parenting failure. Of the 93 referrals to the project, 70 consented and completed at least part of the data collection. Eight never attended a group and a further 13 dropped out after one or two sessions. The remaining 49 women attended at least two thirds of sessions (9/14). Participants in the Mellow Parenting reported higher levels of satisfaction and self-reported change in parenting than the comparison participants. Child behaviour problems and mother-child interaction also showed a significant improvement with mothers demonstrating more positive interactions with her child. Mellow Parenting has been adapted for use in New Zealand (Hoki ki te Rito) and has been piloted with a group of Maori mothers in 2008. Initial results from the pilot are promising, with high acceptability and adherence and marked improvement in maternal mental health and reduction in perceived stress related to parenting. A larger study in two South Auckland sites was carried out in 2009 using a stepped wedge design and again the result were positive [74]

OTHER INTERVENTIONS Developmental, Individual-Differences, Relationship-Based Model (DIR) The developmental, individual-differences, relationship-based (DIR) model is perhaps one of the most comprehensive models of early intervention with infants and children. It differs from other interventions discussed in this review in that instead of providing a specific treatment it provides a biopsychosocial framework to understand and organise programmes of assessment and intervention for children with developmental delays and mental health problems [75]. It was initially developed for children with autistic spectrum disorder and was then extended for use with children more generally. The DIR encompasses three dynamically related influences that work together to direct human development. First, the biological and genetic makeup that the infant brings into the world. This includes the child’s relative strengths or weaknesses in auditory processing and language, visuospatial processing, motor planning and sequencing, and sensory and affective modulation. These biological capacities are important as they mediate the way a child interacts with those around him or her. Second, the social environment, including the family dynamics and cultural characteristics, in which the child resides. Family, cultural, and other environmental factors help shape the thoughts, feelings, and behaviours that caregivers and others bring to their interactions with the child. Third, interaction patterns with others are shaped by the child’s biological and genetic makeup and the child’s social environment. These interaction patterns determine the extent to which the child masters or fails to master several of the six core developmental capacities set out by this model. Functional capacities include the ability to: 1.

Attend to multi-sensory affective experience and, at the same time, attain a calm, regulated state. For example, looking at, listening to, and following the movement of a caregiver.

2.

Engage with and display preference and affection toward familiar caregivers. For instance, greet mother, father or regular babysitter with joyful smiles.

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3.

Initiate and respond to two-way pre-symbolic gestural communication. This involves, interactions between the child and caregiver where smiles or other facial or vocal emotions are traded back and forth in an “early (pre-language) conversational style”.

4.

Organise chains of two-way social problem-solving communications, maintain communication across space, and organize behaviours and affects or emotions into purposeful patterns. For example, taking Dad by the hand and leading him to the refrigerator, Dad responds by opening the refrigerator door, and the child responds by pointing to desired milk, juice, Dad responds by picking up the juice, and child smiles or frowns depending on whether Dad has responded appropriately. In this example, the child needs to have motivation, access to the appropriate emotional expressions, motor skills and planning.

5.

Create and use ideas as a basis for creative or imaginative thinking, giving meaning to symbols. For instance, engaging in pretend play, using words—“juice”—to meet needs.

6.

Build bridges between two or more ideas. This ability is the basis for logic, reality testing, thinking, and judgement. For example, engaging in debates, opinion-oriented conversations, or elaborate, planned pretend dramas.

These “functional capacities” reflect the child’s progression through developmental stages or levels; each capacity builds on the ones previously attained. A child must first learn to attend and engage before he or she can exchange a series of coos and smiles with the mother. No stage is ever finished; however, the capacities already attained continue to be strengthened and refined. As children grow, they ideally learn to focus attention for longer periods. Their relationships continue to become more subtle and reciprocal. Emotional signalling becomes richer, deeper and broader. Each stage involves the simultaneous mastery of what are ordinarily thought of as emotional abilities and cognitive, or intellectual abilities. A baby learns “causality” through the exchange of emotional signals. For instance, by smiling the child can make his or her parents smile back. This developmental framework of assessment and intervention is based on a great deal of developmental research and clinical experience with infants and young children. It has been used successfully with children with special needs, including autism spectrum disorders, with mental health disorders and in working with multi-risk families and organising prevention and education programmes [75].

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MĀORI MODELS Atawhaingia Te Pa Harakeke (Nurture the Family) Atawhaingia Te Pa Harakeke (Nurture the family) is a holistic, culturally relevant, educationally based training and whanau support programme based on the four principles of Te Whariki, the National Early Childhood Curriculum. It was developed by Māori early childhood specialists, Te Komako, the Māori training unit of the Early Childhood Development, now Early Childhood Education (ECE), within the Ministry of Education. ECE focuses on the nurturing and development of young children within the context of their Whanau and communities. They believe in a ‘…holistic approach to child development, which recognises and actively supports the role of parents and Whanau as their children’s first teachers. Enhancing parents’ and Whanau skills to benefit their children’s developmental experiences is a key strategy to achieving this’. Te Komako “…falls back on Māori customs, practices and values from which positive mauri emanate. This ethos underpins training, mentoring and support delivery that is fully cognisant of Māori learning and communication styles.” The key philosophy of the Atawhaingia Te Pa Harakeke (ATA) programme is based on the belief that all parents desire the best for their children, are affected by their own experiences of parenting and may, at times, require support in understanding and applying strategies that will contribute to positive outcomes for their families. Thus, the programme allows participants to counteract the negative parenting they might have experienced themselves as children and move on to planning for positive outcomes within their own children’s lives. The ATA programme marks the amalgamation of two fully structured and previously evaluated programmes in a new and holistic way. The parenting programme is called Hakuitanga, Hakorotanga (and was originally called Atawhaingia Te Pa Harakeke). The original Atawhaingia Te Pa Harakeke programme was delivered as a Tikanga Māori based parenting programme to male inmates in prison. A report of the evaluation of this programme by the Māori and Psychology Research Unit (MPRU) at the University of Waikato was released in 1999. The overall findings indicated that the programme had the “…potential to have a significant long-term impact on men who attended the programme. If the behaviour and attitude changes that were observed are able to be sustained and transferred into the post-release environment then there is a high likelihood of long-term positive impacts which would see a reduction in the level of family abuse and the transmission of inter-generational family violence.” He Taonga Te Mokopuna is a children’s programme that offers a realistic and practical process of support for children who are affected by domestic violence. It is a 10-session programme that aims to transfer the knowledge and skills required to rebuild children’s self-esteem and confidence. Skilled adult facilitators help children develop strategies for keeping themselves safe. He Taonga Te Mokopuna has approval and funding under the Domestic Violence (Programmes) Regulations 1996. It was evaluated in 2001 by IRI (International Research Institute for Māori and Indigenous Education, University of Auckland), and the findings indicated that the programme was positively received by Māori caregivers and their children. Originally, Te Komako were funded by Child, Youth and Family (CYF) to train staff from selected Iwi and Māori Social Services working with whanau who were at risk from violence, neglect or were dysfunctional in other areas, in the ATA programme. The expectation was that staff from these services would be known in their communities and so could deliver the programme to those Māori parents and caregivers who are referred though government and 35

community referral agencies. The training programme was delivered nationally (on various marae), in an intensive four week live-in programme and had three aims: • To train providers in the management functions and systems for the safe and effective delivery of He Taonga Te Mokopuna and/or Hakuitanga, Hakorotanga. • To train facilitators for the safe and effective delivery of support to children who have been affected by domestic violence, through the programme He Taonga Te Mokopuna. • To train facilitators for the safe and effective delivery of support to parents who demonstrate critical lack of knowledge, understanding and practice in positive parenting, through the programme Hakuitanga, Hakorotanga. In 2003, the training programme was independently evaluated by the International Research Institute for Māori and Indigenous Education, University of Auckland. The evaluators reported that the training was well-structured, delivered by highly qualified Māori educationalists (a key success factor) and responsive to trainees’ needs. The fact that Te Komako utilises traditional Māori tikanga, worldviews and interactive teaching styles in delivering the training was highly valued by the overwhelming majority of Māori trainees who reported it as “best training they had ever been part of”. After receiving the ATA training, services continue to be supported by Early Childhood Education. There are specialist support people (Waewae Taha) who provide mentoring, monitoring and support in the delivery of the ATA programme. Those who provide the intervention also have access to a variety of resources such as parenting/education videos, pamphlets and CD’s which are specifically for Māori whanau as well as other online ECE resources. They are encouraged to maintain region support groups and provided with a national conference yearly. This continued support probably contributes to ongoing delivery of the programme. The ATA programme has the potential to be a valuable and effective parenting support programme for ‘at risk’ Māori whanau because it is culturally relevant, educationally sound and delivered by Iwi and Māori Social Services. ECE collate their own evaluation studies however no published evaluations of the ATA programme are as yet available. This is an important next step as the anecdotal reports from whanau who have received the programme support that it is an incredibly useful and appropriate, by Māori for Māori programme.

Hoki ki te Rito A small pilot study was carried out in South Auckland and subsequently a larger study across two sites was carried out in 2009. The pilot study show high levels of engagement with the programme by Māori, improved maternal mental health and reduced levels of parental stress. The larger study showed improved maternal mental health and improved outcomes for children. Both studies were limited by small sample sizes and incomplete data collection related to the high levels of stress in families participating in the studies, but both indicate probable effectiveness and suggest a need for further research.

PACIFIC MODELS No Pacific models of intervention for infants with mental health problems were identified.

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SUMMARY A number of promising therapies have been developed to treat early social and emotional problems in children. Those summarised in this review can be divided into two general categories: behavioural interventions such as Parent-Child Interaction Therapy and psychotherapeutic interventions such as Child Parent Psychotherapy for children affected by family violence. Both target the interactive relationship between the child and primary caregiver and both have been used to treat infants 0 to 4 years of age who may be experiencing a broad range of behavioural, emotional, and family problems. Although both behavioural and psychotherapeutic programmes have been rigorously tested and found to be effective, results of some studies suggest that these interventions may need to be specifically tailored to the parent’s psychological functioning. For instance, mothers who were highly critical or severely depressed or were actively abusing drugs did not show favourable outcomes from Parent-Child Interaction Therapy. Much of the research has been conducted with small samples and there are methodological problems with many of the studies. The most robust evidence is for parent training programmes, with evidence that these improve outcomes not only for disruptive behaviour but also for emotional problems and for Autistic Spectrum Disorder. There is also a body of support for psychotherapeutic techniques. Mental health teams working at Child and Adolescent Mental Health Services level or above should have the ability to deliver both types of intervention. Pharmacological interventions have not been reviewed in this report. Any specialist infant mental health team should include a child psychiatrist with a specialist knowledge about the effectiveness and place for pharmacological interventions in this very young population. There are promising interventions that have been developed locally and which have as much evidence as some of the widely accepted but poorly researched infant mental health interventions from overseas. If we are to develop world class infant mental health services, we should incorporate a mechanism for ongoing rigorous evaluation of both local and international programmes to develop a system of care that is robustly supported by evidence.

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APPENDIX 1: SEARCH STRATEGIES The following search terms were used:

CINAHL (Cumulative Index to Nursing and Allied Health Literature (1982 -May Week 2 2008)): 1.

exp Mental Health/

2.

exp Mental Disorders/

3.

1 or 2

4.

limit 3 to (english and (newborn infant or infant or preschool child ))

5.

exp Attachment Behavior/ or exp Child Behavior Disorders/ or exp Parent-Child Relations/ or exp Social Behavior Disorders/ or exp Mental Disorders Diagnosed in Childhood/

6.

exp Autistic Disorder/

7.

exp Infant Development Disorders/

8.

exp Parent-Child Relations/

9.

exp Child Development Disorders, Pervasive/

10. 5 or 6 or 7 or 8 or 9 11. 3 or 10 12. 4 and 10 13. limit 11 to (english and (newborn infant or infant or preschool child )) 14. exp CRISIS INTERVENTION/ or EARLY CHILDHOOD INTERVENTION/ 15. exp Cognitive Therapy/ 16. exp Psychotherapy/ 17. exp Self Regulation/ 18. exp therapeutics/ or exp drug therapy/ 19. 14 or 15 or 16 or 17 or 18 38

20. 13 and 19 21. limit 20 to journal article 22. 21 not genetic screening.mp. [mp=title, subject heading word, abstract, instrumentation] 23. limit 22 to research 24. 23 not cystic fibrosis.mp. [mp=title, subject heading word, abstract, instrumentation] 25. 24 not rehabilitation.mp. [mp=title, subject heading word, abstract, instrumentation]

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Ovid MEDLINE(R) (1950-May Week 4 2008) 1.

*Mental Health/

2.

*Mental Disorders/

3.

*Reactive Attachment Disorder/

4.

*Child Behavior Disorders/

5.

*Parent-Child Relations/

6.

*Social Behavior Disorders/

7.

*Autistic Disorder/

8.

*Child Development Disorders, Pervasive

9.

*”Early Intervention (Education)”/ or *Crisis Intervention/ or *Intervention Studies/

10. *Adjustment Disorders/ 11. exp Behavior Therapy/ or exp Psychotherapy/ or exp Cognitive Therapy/ or exp Psychotherapy, Group/ 12. exp Therapeutics/ 13. exp Drug Therapy/ 14. (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 10) and (9 or 11 or 12 or 13) 15. limit 14 to (english language and humans and yr=“1990 – 2008” and (“newborn infant (birth to 1 month)” or “infant (1 to 23 months)” or “preschool child (2 to 5 years)”) and journal article) 16. *Behavior Therapy/ or *Psychotherapy/ or *Cognitive Therapy/ or *Psychotherapy, Group/ 17. *Therapeutics/ 18. *Drug Therapy/ 19. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 10 20. 9 or 16 or 17 or 18 21. 19 and 20

40

22. limit 21 to (english language and humans and yr=“1990 – 2008” and (“newborn infant (birth to 1 month)” or “infant (1 to 23 months)” or “preschool child (2 to 5 years)”) and journal article)

41

PsycINFO (1985-June Week 1 2008) 1.

*Mental Health/

2.

*Mental Disorders/

3.

*Attachment Disorders/

4.

*Behavior Problems/ or *Conduct Disorder/ or *Attention Deficit Disorder/ or *Behavior Disorders/ or *Major Depression/ or *Oppositional Defiant Disorder/

5.

*Parent Child Relations/

6.

*Attention Deficit Disorder with Hyperactivity/ or *Behavior Problems/

7.

*Autism/ or *Asperger’s Syndrome/

8.

*Pervasive Developmental Disorders/

9.

*Crisis Intervention/

10. *Early Intervention/ 11. *Cognitive Therapy/ 12. *Behavior Therapy/ 13. *CHILD PSYCHOTHERAPY/ or *GROUP PSYCHOTHERAPY/ or *PSYCHOTHERAPY/ 14. *THERAPEUTIC PROCESSES/ 15. *Drug Therapy/ 16. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 17. 9 or 10 or 11 or 12 or 13 or 14 or 15 18. 16 and 17 19. limit 18 to (human and english language and (120 neonatal or 140 infancy or 160 preschool age ) and journal article and yr=“1990 – 2008”)

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EBM Reviews – Cochrane Database of Systematic Reviews (3 rd Quarter 2008) 1.

mental health.mp. [mp=title, short title, abstract, full text, keywords, caption text]

2.

mental disorders.mp. [mp=title, short title, abstract, full text, keywords, caption text]

3.

reactive attachment disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

4.

conduct disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

5.

attention deficit disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

6.

depressive disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

7.

anxiety disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

8.

autistic disorder.mp. [mp=title, short title, abstract, full text, keywords, caption text]

9.

parent child relations.mp. [mp=title, short title, abstract, full text, keywords, caption text]

10. adjustment disorders.mp. [mp=title, short title, abstract, full text, keywords, caption text] 11. attachment.mp. [mp=title, short title, abstract, full text, keywords, caption text] 12. 6 or 11 or 3 or 7 or 9 or 2 or 8 or 1 or 4 or 10 or 5 13. limit 12 to full systematic reviews 14. limit 13 to full systematic reviews 15. infant.mp. [mp=title, short title, abstract, full text, keywords, caption text] 16. child.mp. [mp=title, short title, abstract, full text, keywords, caption text] 17. 16 or 15 18. 13 and 17 19. from 18 keep 1-10 20. from 18 keep 45, 47, 53, 56-57, 65, 81-82…

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Search Strategy for Guidelines and Practice Parameters National Institute for Clinical Excellence (NICE) rd

The NICE Guidelines were searched on 3 November 2008 using the search term “child”. Any guidelines specifically for very young children were identified. This resulted in one publication of relevance, “Conduct disorder in children - parent-training/education programmes”.

New Zealand Guidelines Group (NZGG) rd

The NZGG website was searched on 3 November 2008. Only the NZ Guidelines for Autistic Spectrum Disorders were identified [73].

National Child Traumatic Stress Network (NCTSN) All treatment strategies identified as having empirical support on the website of the NCTSN were scanned and those addressing the 0-5 age group were included in the review. Two treatments were identified in this search, Child Parent Psychotherapy and Parent Child Interaction Therapy.

The National Registry of Evidence Based Programs and Practices Substance Abuse and Mental Health Service Administration (SAMHSA) The registry was searched for mental health treatment for 0-5 year olds. Incredible Years was the only programme identified on this site.

AACAP Practice Parameter rd

All practice parameters on the AACAP website were accessed on 3 November 2008 to look for those specifically targeting children aged 0-5 years of age or those targeting disorders specific to this age group. Only one practice parameter met these criteria, and provided guidelines for the assessment and management of Reactive Attachment Disorder.

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APPENDIX 2: INTERVENTIONS FOCUSSING ON QUALITY OF ATTACHMENT Cornell and Hamrin 2008 Cornell and Hamrin [76] identified two common approaches to treating attachment problems. The first is a psychoeducational approach focused on increasing parental knowledge of development, child and self care and relationship building. The other is psychotherapy focusing specifically on the attachment relationship and dysfunctional internal representations. The authors conclude that both models are useful in improving the status of children with attachment disorders. In psycho-education the caregiver is educated about the child’s condition and taught how to care for and bond with the child and is given the tools to manage behaviour problems. This enables the caregiver to become more competent and leads to more satisfactory healthy interactions with her child. In psychotherapy the focus is on increasing the caregivers’ awareness of their own upbringing and providing corrective experiences with the therapist to allow the caregivers to better meet their children’s psychological and physical needs. Details of specific models of psychotherapy are discussed later in the report. Combining both methods is also thought to be effective in improving attachment styles in both parents and children. This review is limited by the lack of clear criteria for inclusion of studies in the review, the lack of description of the quality of the studies, and of outcome measures and as such is better regarded as an expert opinion rather than a systematic review.

Bakermans-Kranenburg et al 2003 Bakermans-Kranenburg et al have carried out two meta-analyses of sensitivity and attachment interventions in early childhood [21, 45]. One was reviewed in the body of this review [45]. This meta-analysis was of interventions addressing sensitivity and attachment. They identified 70 studies describing 88 interventions. Of these, 81 studies addressing parental sensitivity and 29 studies which aimed to increase attachment security were included in the analysis. This review includes preventive interventions and interventions in groups with few overt problems, however they have done a sub-group analysis for “troubled” families. Their results on these sub-groups were interesting:Interventions that enhanced parental sensitivity also enhanced attachment Fewer sessions were more effective than more sessions: < 5 sessions were equal in effectiveness to 5-16 sessions and both were more effective than > 16 sessions. Non-professional interveners did better than professional interveners One study using video as an intervention was effective. Interventions focussing only on parental sensitivity were more effective than those focussing on attachment. Limitations: the meta-analyses used a three-way classification of attachment, and did not address the issue of disorganised attachment. It is disorganised attachment that is linked to current and later psychopathology. Studies included in the review were not limited to randomised controlled trials and there was no appraisal of the quality of the studies. It is interesting finding that non-professional people were more effective than professional people.

45

This is in contrast to the evidence from the work of David Olds [77] which showed that health professionals were more efficacious than para-professionals in delivering the prevention programmes.

46

APPENDIX 3: INTERVENTIONS FOR SLEEP PROBLEMS Extinction The child is put to bed at a designated time and ignored until a set time the next morning although parents monitor for illness, injury etc. The disadvantage is the stress that results for parents, and the fact that if they respond they will reinforce the crying.

Graduated Extinction Typically, the parents ignore bedtime crying and tantrums for specified periods. The interval between check-ins as tailored to the child’s age and temperament.

Positive Routines/Faded Bedtime with Response Cost Parents are encouraged to develop a routine before bedtime that includes quiet but enjoyable activities. Faded bedtime with response cost involves taking the child out of bed for prescribed periods if the child does not fall asleep. Bedtime is delayed to ensure rapid sleep initiation. The aim is to pair positive parent- child interactions with the onset of sleep. Once the child is falling asleep quickly, the bedtime is gradually moved earlier by 15-30 minutes a night. A time to wake up is scheduled and daytime sleeping is not allowed apart from scheduled naps.

Scheduled Awakenings In this routine, parents wake their children 15-30 minutes before a typical spontaneous wakening. Parents then use their usual response to wakenings, such as rocking or nursing the child back to sleep.

Parent Education/Prevention Strategies for this approach include establishing bedtime routines and developing a consistent sleep schedule. Parents are taught to put their babies to bed drowsy but awake to help them to develop skills to go to sleep independently. In some studies parents were taught to do this antenatally, while in others parents received education after the baby was born.

47

TABLE 1. REVIEWS BY DISORDER Problem area/diagnosis

Review

Year

Type of review

No of articles &/or reviews (Treatment/Interv ention)

Age range

Publication years

Outcome

Post-traumatic stress disorder

None

Deprivation/

Newman & Mares

2007

Narrative review

4

N/S

2005-2006

Attachment based therapies alter parental sensitivity & behavioural symptoms in children.

Chaffin

2006

Narrative review

4

N/S

1995-2003

Treatment should involve parents & caregivers.

Bakermans Kranenburg

2005

Systematic review & meta-analysis

10

221.5months

1988-2005

WWW > IPP

Boris & Zeanah

2005

Practice parameters

Extended search on related articles, 456 references

N/S

1980-2003

Recommendations for treatment based on 'Minimal Standards', 'Clinical Guidelines', 'Options', &'Not Endorsed' therapies.

Haugaard & Hazan

2004

Narrative review

7

N/S

1988-2000

Children with RAD may benefit from: a single warm stable relationship, being taught relationship skills, fostering success, play therapy & short-term parent sensitivity training.

O’Connor & Zeanah

2003

Narrative review

5

N/S

1993-2001

No specific treatments shown to be effective for children with RAD.

Disruptive Behaviour

Tse

2006

Systematic review

19

2-5yrs

1978-2004

For RCT; significant gains in self concept & development. 2/4 showed reduction in disruptive behaviour & “developmental gains".

Sleep Behaviour Disorder

Mindell et al

2006

Systematic review

52

0-4yrs 11months

1970-2005

Evidence to support UE, Parent Education/Prevention, & GE

Maltreatment/ Attachment

Feeding disorder

Disorders of Relating & Communicating

ASD

PT programmes

49

Morgenthaler et al

2006

Practice Parameters

4

Up to 5yrs

1992-2006

Evidence to support UE, PE/prevention, GE & delayed bedtime/removal from bed & +ve bedtime routines.

Ramchandani et al

2000

Systematic review

9

0-5yrs

1985-1990

Specific behavioural treatments have more short & long term efficacy than drug treatments.

Piazza

2008

Descriptive

25

N/S

1993-2006

Treatments with the most empirical support use ABA

Chatoor

2002

Narrative review

4

N/S

1989-2000

No evidence, but lends support to treatment based approaches.

Kerwin

1999

Systematic review

29

0-18yrs

1970-1997

Differential attention is a common component in effective treatment packages for feeding problems.

Roberts et al

2003

Systematic review

48

0-6yrs

1975-2000

More RCTs needed, with measures of family adversary, stress & interaction included.

Gavidia-Payne & Hudson

2002

Literature Overview

Rogers & Vismara

2008

Systematic review

Guidelines for ASD

2009

Guideline

McConachie & Diggle

2007

Rao

N/S

PT most likely to succeed with children with intellectual disability & problem behaviours.

16

2-7yrs

1998-2006

Systematic review

12

1-6yrs 11months

1987-2004

PT an effective intervention for children with ASD but more research is needed.

2008

Systematic review

10

7-18yrs

1992-2008

7/10 studies showed positive treatment effects, for some only in a subset of participants.

Rogers

1998

Systematic review

8

Mean age 3257months

1984-1998

Kaminski

2008

Meta-analysis

77

1990-2002

Moderate effects for children & parents.

50

Nowak & Heinrichs

2008

Meta-analysis

55

0-15yrs

1997-2008

Triple P = improved parenting skills, reduced child problem behaviour; greater effect for more intensive interventions.

Thomas & ZimmerGembeck

2007

Meta-analysis

24

3-12yrs

1982-2004

Both PCIT & Triple P effective; PCIT more so on some measures.

Nixon

2002

Descriptive

30

2-7yrs

1982-2000

Barlow & Parsons

2008

Systematic review & meta-analysis

5

0-3yrs 3months

1992-2001

Meta analysis of limited follow up data shows small non-sig result favouring intervention group.

TABLE 2. SPECIFIC INTERVENTIONS Intervention Child Parent Psychotherapy (CPP)/Infant parent psychotherapy (IPP/TPP)

Interaction guidance (IG)

Individual studies identified

Year

Type of study/article

2005

RCT; CPP vs case management + community referrals

CPP= significantly greater reductions in problem behaviour & traumatic stress symptoms. Improvements in behaviour still evident at 6month follow up.

Toth et al

2002

RCT; Maltreated & nonmaltreated mother assigned to either IPP, psychoeducational home visitation (PHV) or community standard intervention (CS). Non-maltreated families as CG.

PPP= improvements in representations of self & caregivers over PHV and CS children.

Cicchetti et al

2006

RCT; CPP vs IPP vs CG

Lieberman, Weston & Pawl

1991

2 group intervention; anxiously attached infant dyads randomised to either intervention group or CG. Further non-anxious CG.

Cicchetti, Toth & Rogosch

1999

MDD mothers randomly assigned to either TPP or control group (DC). Also included ND-CG.

Cicchetti, Rogosch & Toth

Lieberman

Age range

Outcome

12months

CPP & PP groups < in disorganised attachment type

12months

Intervention group toddlers < CG in terms of avoidance resistance & anger. Intervention group also > CG in partnership with mother. However, Intervention group = CG on all measures.

2000

MDD mothers randomly assigned to either TPP or DC. Also included ND-CG

20months

At follow up (30months), relative decline in IQ for DC, whereas TPP & ND-CG were equivalent. Poorest outcomes for DC group who had further depressive episodes.

Toth, Rogosch, Manly & Cicchetti

2006

RCT; MDD mothers randomised to either IPP (DI) or DC. Also included ND-CG

Mean age 20.34months

Rate of secure attachment increased significantly in DI.

Cramer et al

1990

2 group intervention study (IG vs PD)

CG on: levels of satisfaction & self reported change, child behaviour problems, child behaviour & positive & negative maternal interaction.

Greenspan & Wieder

1997

200 cases of ASD children reviewed; therapy based on 'floor time' model

22months4years

Post therapy, 58% of children classed as 'good to outstanding', 25% as 'medium outcome', 17% showed

Cohen et al

Circle of Security (COS)

Mellow Parenting (MP)

Developmental, Individual Differences,

52

Improvements in children’s symptoms, IG=PD

Relationship-Based (DIR) Model

'ongoing difficulties' & a subgroup of 4% were 'loosing capabilities'. Of 53 children who received a 'traditional approach' to treatment, only 2% were classified as 'good to outstanding' in functioning.

Wieder & Greenspan

53

2005

10-15 year follow up of 16 children who received DIR/Floortime approach

12-18 years

75% showed no social problems, 95% in normal range for social competence. Children with ASD can develop healthy peer relationships and show empathy & creativity.

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