The effectiveness of parent-child interaction therapy with depressive mothers: the changing relationship as the agent of individual change

Applying the PRECEDE-PROCEED model to develop MommaConnect: a digital healthcare platform for addressing postpartum depression and improving infant well-being

The PRECEDE-PROCEED model is a comprehensive planning and theoretical framework that incorporates epidemiological, environmental, behavioral, and social factors systematically to design, implement, and evaluate health promotion programs. As such, PRECEDE-PROCEED is a highly effective tool for addressing complex and significant public health concerns like postpartum depression (PPD). PPD negatively impacts mothers and their infants, with studies showing that approximately one in eight mothers experience PPD, leading to adverse effects on maternal functioning and infant development. However, access to specialized evidence-based treatment remains significantly limited due to barriers including social determinants of health. This paper explores the application of the PRECEDE-PROCEED model as a planning and theoretical framework for the design and development of MommaConnect, an innovative digital healthcare platform aimed at reducing PPD symptoms and improving maternal-infant interaction while overcoming barriers to treatment. Key components of the MommaConnect design and development process are mapped onto the steps of the PRECEDE-PROCEED model. MommaConnect features are aligned with specific stages of the model, from assessing, predisposing, enabling, and reinforcing factors to designing, implementing, and evaluating the intervention. By leveraging this model, MommaConnect represents a promising innovative approach to address PPD to improve maternal functioning and infant health in a digitally-enabled era. This paper underscores the importance of utilizing a framework like the PRECEDE-PROCEED model in the design and development of innovative healthcare solutions.

A positive parenting program to enhance positive affect in children of previously depressed mothers

Children of mothers with a history of depression are at heightened risk for developing depression and other maladaptive outcomes. Deficits in parenting are one putative mechanism underlying this transmission of risk from mother to child. The present study evaluated whether a brief intervention with mothers with a history of depression produced greater use of positive parenting behaviors and an increase in observed positive affect in their 8- to 10-year-old children. Mothers with a history of depression (n = 65) were randomly assigned to either a positive parenting intervention or an attention control intervention condition. In addition, a comparison group of 66 mothers with no history of depression was evaluated one time. Results revealed significant increases in positive parenting behaviors (e.g., active listening, praise) immediately postintervention in mothers randomized to the positive parenting intervention as compared to those in the attention control condition. Children of mothers in the positive parenting intervention showed increases in positive affect as compared to children of mothers in the attention control intervention. Increases in mothers' active listening and smiling/laughing significantly predicted increases in children's positive affect. The intervention did not increase the rate of children's moment-by-moment positive affect contingent on mothers' positive parenting behaviors. This study showed the short-term effectiveness of a brief parenting intervention for enhancing interactions between mothers with a history of depression and their children by directly targeting mothers' positive parenting and, indirectly, children's expressions of positive affect. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Risk Factors for Potential Mental Illness Among Brazilians in Quarantine Due To COVID-19

BACKGROUND

During quarantine, both physical and mental health are a concern. To the same extent that physicians are a scarce resource during this crisis, psychiatrists and psychologists are also limited in number. To help practitioners and public managers decide where to invest their resources, the present research investigated the relationships of stress, depression and state anxiety levels with sociodemographic and behavioural variables.

METHODS

Data were collected in Brazil between March, 18 and 22, 2020 in 1,468 volunteers during quarantine. Participants with a history of or current mental health illnesses were excluded leaving 1,460 individuals in the final sample. The online assessment included instruments for psychological stress, depression and state anxiety. A sociodemographic and behavioural questionnaire with 15 items was used to assess other factors. Multiple linear regression was performed for each psychological outcome to determine a hierarchy of significant predictors.

FINDINGS

Stress, depression and state anxiety levels were all predicted by gender (women higher than men), quality of nutrition, attendance in tele-psychotherapy, exercise frequency, presence of elderly persons in quarantine with the person, obligation to work outside the home, level of education (more educated, lesser risk for mental illness) and age (younger age, greater risk). Having a perceived risk factor for COVID-19 predicted depression and state anxiety, but not stress. Finally, the presence of children in quarantine with the participant was a protective factor for depression.

INTERPRETATION

Even though this research is limited by its cross-sectional design, it is possible to infer that mental health varies by demographic attributes, obligations and health behaviours. Those who report higher distress must work outside the home during quarantine, live with an elderly person and carry a risk factor for COVID-19, among other factors. Identifying those who are most vulnerable would help to prioritize those who may need the greatest psychological aid and assist public health practitioners in developing support strategies.

A Learning Theory Approach to Attachment Theory: Exploring Clinical Applications

Although clinicians typically acknowledge the importance of insecure attachment as one factor that can contribute to children's psychopathology, translating attachment theory into clinical practice has proved a challenge. By specifying some of the mechanisms through which the child's attachment develops and changes, learning theory can enhance attachment based approaches to therapy. Specifically, interventions building on operant (parent management training) and classical (exposure therapy) learning can be used to stimulate new learning that increases the child's security and confidence in the parent's availability and responsiveness. To explore the clinical application and utility of a Learning Theory of Attachment (LTA), we focus on two attachment-focused interventions: Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) and Middle Childhood Attachment-based Family Therapy (MCAT). VIPP-SD is an evidence-based parent management training designed to promote sensitive parenting and secure attachment in early childhood. MCAT is a recently developed intervention that uses exposure to stimulate secure attachment in middle childhood. LTA sheds light on the mechanisms set in train by VIPP-SD and MCAT facilitating the induction of professionals in clinical applications.

Longitudinal Outcomes of Child Parent Psychotherapy: Response to Commentaries

In response to the commentaries provided by Chu et al. (2020), Harmon et al. (2020), and McMahon & Maxwell (2020) on our longitudinal follow-up of Child-Parent Psychotherapy (CPP) with mothers with depression and their children, we focus on two domains: accessibility and scalability of CPP and identifying empirically supported mechanisms of change in attachment intervention research. In considering the accessibility and scalability of CPP, we discuss issues related to attrition, length of intervention, and implementation with caregivers with depression. Our discussion of mechanisms of change in attachment interventions explores active comparison conditions, theorized mediators, intervention modalities, assessment methods, and longitudinal research designs. This conversation is intended to highlight important areas for future research in the field of attachment interventions, with the goal of informing clinical and systems-level policies and practices.

Parent-Child Interaction Therapy with Toddlers in a community-based setting: Improvements in parenting behavior, emotional availability, child behavior, and attachment

Parent-Child Interaction Therapy with Toddlers (PCIT-T) is a new attachment-based parenting intervention designed to meet the needs of children aged 12-24 months presenting with challenging behaviors. This study examined outcomes of the first phase of PCIT-T, Child Directed Interaction-Toddler (CDI-T), 4-months post treatment. Participants were 56 toddlers (Child Mage = 19.13 months) referred to receive CDI-T over an 8-week period at an Australian community-based child behavior treatment clinic for treatment of difficult toddler behaviors. Participants completed questionnaires and observational measures at baseline (Time 1), post-treatment (Time 2), and 4-month follow-up (Time 3). At both Time 2 and Time 3, there were statistically significant increases in observed positive parenting skills and emotional availability and decreases in negative parenting behaviors and child noncompliance. There were also significant improvements in parent-reported child externalizing and internalizing behaviors, parental stress, and maternal depression. There was a pattern of a shift away from attachment insecurity and attachment disorganization. Results suggest that the CDI-T phase of PCIT-T is a promising intervention for toddlers presenting with behavioral issues. Future studies should be conducted to assess efficacy in other settings, using larger samples and utilizing randomized controlled designs.

Mother-Infant Bonding and Emotional Availability at 12-Months of Age: The Role of Early Postnatal Bonding, Maternal Substance Use and Mental Health

INTRODUCTION

The quality of the mother-child relationship in the first year of life has far reaching implications across the life course (Bornstein in Annu Rev Psychol 65:121-158, 2014). Yet little is known about predictors of maternal bonding and emotional availability in early infancy. In this study we examined the extent to which postnatal bonding, maternal mental health, and substance use at 8-weeks postpartum predicted mother-infant bonding (self-report) and mother emotional availability (observational) at 12-months of age.

METHODS

Data were obtained from an Australian longitudinal cohort study of pregnancy (n = 308). Data were collected during pregnancy, at birth, and postnatally at 8-weeks and 12-months.

RESULTS

The results show strong continuity between postnatal bonding at 8-weeks and 12-months. Early postpartum stress and depression were associated with bonding at 12-months; however, the effect did not persist after adjustment for bonding at 8-weeks. Tobacco use at 8-weeks, but no other indicators of mental health, predicted lower emotional availability scores at 12-months.

DISCUSSION

Results suggest that the mother's felt bond to her child is stable across the first year of life and that early bonding is a more robust indicator of bonding at 12-months than a mother's mental health or substance use. These findings point to the importance of clinical and public health investments in establishing a strong bond between mother and child in the early postpartum period.

Introducing mother-baby interaction therapy for mothers with postpartum depression and their infants

Postpartum depression (PPD) and other perinatal mental health disorders have profound adverse effects on maternal-infant interaction and child health. However, standard psychiatric treatment does not necessarily improve the quality of mother-infant interaction. The purpose of this article is to describe the evidence-based CARE intervention and its translation to practice as Mother-Baby Interaction (MBI) Therapy to promote infant outcomes by supporting mothers' sensitive, responsive, and contingent interactions with their infants. Two vignettes illustrate MBI. We advocate that MBI needs to be a requisite adjunct treatment for PPD, and other perinatal mental health disorders, to promote maternal functioning, and positive long-term infant health outcomes.

An Examination of the Relationship between Maternal Depression and Barriers to Child Mental Health Services

OBJECTIVE

Maternal depression is a common, chronic set of disorders associated with significant burden to caregivers, children and families. Some evidence suggests that depression is associated with perceptions of barriers to child mental health treatment and premature termination from services. However, this relationship has not yet been examined among a predominantly low-income sample, which is at disproportionately high risk of depression, child mental health problems, and treatment drop out. Accordingly, the purpose of this study is to examine the relationships between caregiver depression and perceived barriers to treatment.

METHODS

Three hundred twenty (n=320) children between the ages of 7 to 11 and their caregivers were assigned to either the 4 Rs and 2Ss for Strengthening Families, which is a multiple family group intervention, or services as usual (SAU) consisting of typical outpatient mental health services. Caregiver depression was measured by the Center for Epidemiologic Depression Scale; perceived barriers to treatment were assessed via the Kazdin Barriers to Treatment Scale.

RESULTS

Clinically significant levels of depressive symptoms at baseline were significantly associated with greater scores in all four barriers to treatment subscales (stressors and obstacles competing with treatment, treatment demands and issues, perceived relevance, relationship with therapist) at post-test.

CONCLUSIONS

Addressing maternal mental health, and attending to stressors that impede poverty-impacted families from child services is critical for the health and functioning of caregivers, and to ensure that children with mental health problems receive treatment.

Efficacy or Chaos? Parent-Child Interaction Therapy in Maltreating Populations: A Review of Research

Child abuse remains a serious and expensive social problem in the United States. Few evidence-based treatments (EBTs) exist for at-risk families and/or maltreating families where neglect or abuse has occurred, limiting the ability of social service agencies to comply with legislative mandates to use EBTs with clients. One promising intervention, parent-child interaction therapy (PCIT), has been tested in 11 separate trials with this population. This review of research on PCIT with abusive adults found that overall PCIT is an appropriate, efficacious intervention method to prevent future maltreatment by targeting parenting skills and child externalizing behaviors. These findings must be taken with caution, since the key factor to determine efficacy is completion of treatment, and all the studies involved showed significant problems with sample attrition. While the current studies are promising, there is a need for research that focuses on measuring parental sensitivity and attachment levels, explores use in the foster and adoptive communities, and studies that use tertiary subjects to serve as unbiased reporters of perceived levels of behavioral changes.

Cascading effects of BPT for child internalizing problems and caregiver depression

Behavioral Parent Training (BPT) is the standard of care for early onset (3 to 8years old) disruptive behavior disorders (DBDs). Preliminary evidence suggests that BPT may also produce cascading treatment effects for comorbid and interrelated symptomatology in children, primarily internalizing problems, as well as symptomatology in multiple systems of the family, including caregiver depressive symptomatology. What is less well understood, however, is why and how BPT functions to impact these multiple symptom clusters within and between family members. Accordingly, this manuscript aims to serve as a conceptual and theoretical consideration of the mechanisms through which BPT may produce generalized treatment effects among children with early onset DBDs and internalizing problems, as well as the psychosocial difficulties among their caregivers. It is our intention that the hypothesized mechanisms highlighted in this review may guide advances in clinical research, as well as assessment and practice.

[Parent-child interaction therapy (PCIT)]

Parent-child interaction therapy (PCIT), a manualized evidence-based intervention, was originally developed to treat disruptive behavior problems in children aged 2–6 years. It is also considered to be an evidence-based intervention for physical abuse among children. Moreover, PCIT has proved to be effective for attention deficit hyperactivity disorder, autism spectrum disorder, separation anxiety disorder, and depression. Thus, it could become the first evidence-based, transdiagnostic intervention method for 2–6-year-old children. PCIT is based on attachment theory as well as learning theory, combining aspects of play therapy and behavior therapy. It consists of two treatment phases: child-directed interaction (CDI) and parent-directed interaction (PDI). In both phases parents are taught special skills. When interacting with their child parents practice these skills and are live coached by the therapist. CDI aims at improving the parent-child relationship and is the basis for PDI. In CDI, parents learn to follow their child’s lead as long as the child shows appropriate behavior. In PDI, parents practice effectively taking the lead wherever necessary. On average, it takes about 15–20 sessions to complete PCIT, which can be terminated as soon as the parents demonstrate a mastery of the skills, when child disruptive behavior has been reduced to clearly normal levels, and when the parents have become confident in managing child behavior on their own.

The lasting impact of early-life adversity on individuals and their descendants: potential mechanisms and hope for intervention

The adverse effects of early-life stress are pervasive, with well-established mental and physical health consequences for exposed individuals. The impact of early adverse experiences is also highly persistent, with documented increases in risk for mental illness across the life span that are accompanied by stable alterations in neural function and hormonal responses to stress. Here, we review some of these 'stress phenotypes', with a focus on intermediary factors that may signal risk for long-term mental health outcomes, such as altered development of the fear regulation system. Intriguingly, recent research suggests that such stress phenotypes may persist even beyond the life span of the individuals, with consequences for their offspring and grand-offspring. Phenotypic characteristics may be transmitted to future generations via either the matriline or the patriline, a phenomenon that has been demonstrated in both human and animal studies. In this review, we highlight behavioral and epigenetic factors that may contribute to this multigenerational transmission and discuss the potential of various treatment approaches that may halt the cycle of stress phenotypes.

Skill acquisition and utilization during evidence-based psychosocial treatments for childhood disruptive behavior problems: a review and meta-analysis

We review 85 empirical articles published since 2000 that measured the acquisition and/or utilization of parent management skills and/or child cognitive-behavioral skills in the context of an evidence-based treatment (EBT) for childhood behavior problems. Results showed that: (1) there are no standardized measures of skill acquisition or skill utilization that are used across treatments, (2) little is known about predictors, correlates, or outcomes associated with skill acquisition and utilization, and (3) few studies systematically examined techniques to enhance the acquisition and utilization of specific skills. Meta-analytic results from a subset of 68 articles (59 studies) showed an overall treatment-control ES = .31, p < .01 for skill acquisition and ES = .20, p = ns for skill utilization. We recommend that future research focus on the following three areas: (1) development of standardized measures of skill acquisition and utilization from a "common elements" perspective that can used across EBTs; (2) assessment of the predictors, correlates, and outcomes associated with skill acquisition and utilization; and (3) development of innovative interventions to enhance the acquisition and utilization of cognitive-behavioral and parent management skills.

Parent-infant psychotherapy for improving parental and infant mental health

BACKGROUND

Parent-infant psychotherapy (PIP) is a dyadic intervention that works with parent and infant together, with the aim of improving the parent-infant relationship and promoting infant attachment and optimal infant development. PIP aims to achieve this by targeting the mother's view of her infant, which may be affected by her own experiences, and linking them to her current relationship to her child, in order to improve the parent-infant relationship directly.

OBJECTIVES

1. To assess the effectiveness of PIP in improving parental and infant mental health and the parent-infant relationship.2. To identify the programme components that appear to be associated with more effective outcomes and factors that modify intervention effectiveness (e.g. programme duration, programme focus).

SEARCH METHODS

We searched the following electronic databases on 13 January 2014: Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS Citation Index, Science Citation Index, ERIC, and Sociological Abstracts. We also searched the metaRegister of Controlled Trials, checked reference lists, and contacted study authors and other experts.

SELECTION CRITERIA

Two review authors assessed study eligibility independently. We included randomised controlled trials (RCT) and quasi-randomised controlled trials (quasi-RCT) that compared a PIP programme directed at parents with infants aged 24 months or less at study entry, with a control condition (i.e. waiting-list, no treatment or treatment-as-usual), and used at least one standardised measure of parental or infant functioning. We also included studies that only used a second treatment group.

DATA COLLECTION AND ANALYSIS

We adhered to the standard methodological procedures of The Cochrane Collaboration. We standardised the treatment effect for each outcome in each study by dividing the mean difference (MD) in post-intervention scores between the intervention and control groups by the pooled standard deviation. We presented standardised mean differences (SMDs) and 95% confidence intervals (CI) for continuous data, and risk ratios (RR) for dichotomous data. We undertook meta-analysis using a random-effects model.

MAIN RESULTS

We included eight studies comprising 846 randomised participants, of which four studies involved comparisons of PIP with control groups only. Four studies involved comparisons with another treatment group (i.e. another PIP, video-interaction guidance, psychoeducation, counselling or cognitive behavioural therapy (CBT)), two of these studies included a control group in addition to an alternative treatment group. Samples included women with postpartum depression, anxious or insecure attachment, maltreated, and prison populations. We assessed potential bias (random sequence generation, allocation concealment, incomplete outcome data, selective reporting, blinding of participants and personnel, blinding of outcome assessment, and other bias). Four studies were at low risk of bias in four or more domains. Four studies were at high risk of bias for allocation concealment, and no study blinded participants or personnel to the intervention. Five studies did not provide adequate information for assessment of risk of bias in at least one domain (rated as unclear).Six studies contributed data to the PIP versus control comparisons producing 19 meta-analyses of outcomes measured at post-intervention or follow-up, or both, for the primary outcomes of parental depression (both dichotomous and continuous data); measures of parent-child interaction (i.e. maternal sensitivity, child involvement and parent engagement; infant attachment category (secure, avoidant, disorganised, resistant); attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and secondary outcomes (e.g. infant cognitive development). The results favoured neither PIP nor control for incidence of parental depression (RR 0.74, 95% CI 0.52 to 1.04, 3 studies, 278 participants, low quality evidence) or parent-reported levels of depression (SMD -0.22, 95% CI -0.46 to 0.02, 4 studies, 356 participants, low quality evidence). There were improvements favouring PIP in the proportion of infants securely attached at post-intervention (RR 8.93, 95% CI 1.25 to 63.70, 2 studies, 168 participants, very low quality evidence); a reduction in the number of infants with an avoidant attachment style at post-intervention (RR 0.48, 95% CI 0.24 to 0.95, 2 studies, 168 participants, low quality evidence); fewer infants with disorganised attachment at post-intervention (RR 0.32, 95% CI 0.17 to 0.58, 2 studies, 168 participants, low quality evidence); and an increase in the proportion of infants moving from insecure to secure attachment at post-intervention (RR 11.45, 95% CI 3.11 to 42.08, 2 studies, 168 participants, low quality evidence). There were no differences between PIP and control in any of the meta-analyses for the remaining primary outcomes (i.e. adverse effects), or secondary outcomes.Four studies contributed data at post-intervention or follow-up to the PIP versus alternative treatment analyses producing 15 meta-analyses measuring parent mental health (depression); parent-infant interaction (maternal sensitivity); infant attachment category (secure, avoidant, resistant, disorganised) and attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and infant cognitive development. None of the remaining meta-analyses of PIP versus alternative treatment for primary outcomes (i.e. adverse effects), or secondary outcomes showed differences in outcome or any adverse changes.We used the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach to rate the overall quality of the evidence. For all comparisons, we rated the evidence as low or very low quality for parental depression and secure or disorganised infant attachment. Where we downgraded the evidence, it was because there was risk of bias in the study design or execution of the trial. The included studies also involved relatively few participants and wide CI values (imprecision), and, in some cases, we detected clinical and statistical heterogeneity (inconsistency). Lower quality evidence resulted in lower confidence in the estimate of effect for those outcomes.

AUTHORS' CONCLUSIONS

Although the findings of the current review suggest that PIP is a promising model in terms of improving infant attachment security in high-risk families, there were no significant differences compared with no treatment or treatment-as-usual for other parent-based or relationship-based outcomes, and no evidence that PIP is more effective than other methods of working with parents and infants. Further rigorous research is needed to establish the impact of PIP on potentially important mediating factors such as parental mental health, reflective functioning, and parent-infant interaction.

Parent-child interaction therapy: a manualized intervention for the therapeutic child welfare sector

Children who have experienced maltreatment can often display behavioral difficulties; their parents may lack disciplinary knowledge, be less sensitive to their children, and engage in coercive parenting practices. Parent-child interaction therapy (PCIT) is a well-known, evidence-based treatment (EBT) for child behavior problems and within the last decade has garnered significant evidence to suggest its utility for parents engaged in child maltreatment. This article uses a case example to describe PCIT treatment phases and PCIT research within the child maltreatment sector is synthesized with particular focus on treatment modifications. Successful augmentations and modifications include a motivation component, keeping therapeutic time shorter rather than longer, and whether to incorporate individual counseling and in-home PCIT are also considered. Practical strategies from both a therapeutic and research experience are discussed.