Community‐delivered infant–parent psychotherapy improves maternal sensitive caregiving: Evaluation of the Michigan model of infant mental health home visiting

Partnering for the future clinic: A multidisciplinary perinatal substance use program

OBJECTIVE

The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes.

METHODS

We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed.

RESULTS

Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched.

CONCLUSIONS

Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.

Can mothers' representations of their infants be improved in primary care? A randomized controlled trial of a parenting intervention using video feedback in a predominantly low- to moderate-risk sample

Introduction

Mothers' representations of their infants are important intervention targets because they predict the observed quality of infant-mother interactions. The current study investigated the influence of a video-feedback infant-parent intervention on mothers' representations of their infants beyond the effect of standard treatment.

Methods

Data from a naturalistic, randomized controlled trial of 152 predominantly low- to moderate-risk mothers (mean age = 29.7 years) with infants (mean age = 7.3 months) were used. At Well Baby Centers, all families followed the universal program, which was treatment as usual (TAU), whereas half of the families also received the intervention. The Working Model of the Child Interview categories and scales as well as three latent factors generated from a factor analysis were used to assess maternal representations at baseline and follow-up (9-13 months after baseline). A linear mixed model analysis was used to analyze the data.

Results

There were no differences in representation changes from baseline to follow-up between the control group (TAU) and intervention group. When both groups were combined, there were minor improvements in the mothers' representations at the follow-up.

Discussion

Aspects of the intervention, the quality of TAU, and the homogeneity scores of the predominantly low-risk sample may explain the intervention's lack of effect on mothers' representations beyond TAU. The supportive services at Norwegian Well Baby Centers as well as the infants' increasing age putatively contributed to the improved features of the mothers' representations in the total sample. That standard community care may affect maternal representations has not been shown before. Future research should identify the core components in interventions targeting maternal representations and examine whether those components can be incorporated in primary care. Including measures of mothers' reflective functioning could broaden our knowledge of representations and their changeability.

Clinical trial registration

This study is registered in the International Standard Randomized Controlled Trial Number registry under the reference number ISRCTN 99793905.

A qualitative exploration of caregivers' experiences with the Attachment and Biobehavioral Catch-up (ABC) parenting program

In the face of childhood adversity, services and interventions can improve a child's life trajectory by promoting healthy development, enhancing protective factors, and building resilience through stable and supportive relationships. One such service, a specific and highly researched home visiting intervention, Attachment and Biobehavioral Catch-up (ABC), is often provided to families through home visiting service programs. This qualitative descriptive study examines the experiences of caregivers (N = 18) who received ABC as part of a statewide early childhood initiative in one midwestern state. Participants provided insight into the context of their lives before and during the intervention. They described their perspectives of the utility of the program and its influence on their family's behaviors and interactions. Findings demonstrate that coaching support bolstered caregivers' confidence in effective strategies and guided them through caregiving challenges. Caregivers observed growth in their caregiving practices, their infants' and young children's social and emotional skills, and their dyadic caregiver-child relationships, demonstrating the benefits of participating in and completing the ABC intervention.

Mental health prevention and treatment programs for infants experiencing homelessness: A systematic review

Experiencing homelessness in infancy has been linked to negative physical and mental health outcomes. Parental well-being and the parent-infant relationship can also be negatively impacted by experiencing homelessness. While numerous parent-based infant mental health programs have been identified by a recent review, the goal of this study was to further determine the extent to which these existing programs were developed and/or examined with at-risk populations such as families experiencing homelessness. Out of 60 programs identified by Hare et al., in press, only three had been implemented specifically in shelter settings with infants 0-12 months (Parent-Infant Psychotherapy, New Beginnings, and My Baby's First Teacher). Additionally, when examining programs that began in later infancy (after 12 months), only 2 programs were implemented in shelter settings (Incredible Years and Parent-Child Interaction Therapy). Implications for research, policy, and clinicians regarding implementation of evidence-based prevention/treatment programs for parents and their infants experiencing homelessness are discussed.

Relationships reduce risks for child maltreatment: Results of an experimental trial of Infant Mental Health Home Visiting

BACKGROUND

Research examining the effectiveness of home visiting programs that reduce child maltreatment or associated risks yield mixed findings; some find positive significant impacts on maltreatment, whereas others find small to no effects. The Michigan Model of Infant Mental Health Home Visiting (IMH-HV) is a manualized, needs-driven, relationship-focused, home-based intervention service that significantly impacts maternal and child outcomes; the effect of this intervention on child maltreatment has not been sufficiently evaluated.

OBJECTIVE

The current study examined associations between treatment and dosage of IMH-HV and child abuse potential in a longitudinal, randomized controlled trial (RCT).

PARTICIPANTS AND SETTING

Participants included 66 mother-infant dyads (Mother M age = 31.93 years at baseline; child M age = 11.22 months at baseline) who received up to 1 year of IMH-HV treatment (Mdn = 32 visits) or no IMH-HV treatment during the study period.

METHODS

Mothers completed a battery of assessments including the Brief Child Abuse Potential Inventory (BCAP) at baseline and at the 12-month follow-up assessment.

RESULTS

Regression analyses indicated that after controlling for baseline BCAP scores, those who received any IMH-HV treatment had lower 12-month BCAP scores compared to those who received no treatment. Additionally, participation in more visits was associated with lower child abuse potential at 12 months, and a reduced likelihood of scoring in the risk range.

CONCLUSION

Findings suggest that greater participation in IMH-HV is associated with decreased risk for child maltreatment 1 year after initiating treatment. IMH-HV promotes parent-clinician therapeutic alliance and provides infant-parent psychotherapy which differentiate it from traditional home visiting programs.

Stressed Mothers Receiving Infant Mental Health-Based Early Head Start Increase in Mind-Mindedness

Maternal mind-mindedness is a characteristic of supportive parenting and contributes to many positive social–emotional outcomes in early childhood. However, there is limited knowledge of mind-mindedness among parents experiencing parenting stress from low-income settings. This is a critical gap in evidence given the robust role of supportive parenting in children’s development and the capacity of home-based interventions to improve children’s outcomes through enhancing supportive parenting. This study examined: (1) maternal mind-mindedness, operationalized as mothers’ appropriate mind-related comments (MRC), across toddlerhood in mothers of toddlers who participated in infant mental health (IMH) based Early Head Start (EHS) services; and (2) whether parenting stress moderated EHS program effects on appropriate MRC over time. Data from a primarily White midwestern site in the United States were collected at study enrollment and when toddlers were 14-, 24-, and 36-months of age (N = 152; mothers M_age = 22.4 years, SD = 5.1; toddlers M_age = 14.4 months, SD = 1.3; 51% females). Data included parent-completed questionnaires and observed parent–child interactions, which were coded for MRC. Although there were no main effects of EHS programming on mothers’ appropriate MRC over time, multilevel growth curve modeling indicated that parenting stress moderated EHS effects on mothers’ appropriate MRC over time. Among mothers with greater parenting stress, those who received IMH-based EHS services demonstrated greater proportions of MRC over time as compared to mothers with greater stress in the control group. IMH-based parenting interventions that target parenting stress may promote appropriate MRC in low-income populations during toddlerhood.

In-the-moment ratings on the Early Relational Health Screen: A pilot study of application in home visiting and primary care

Early infant-parent interaction sets a critical foundation for young children's well-being, and evidence regarding the protective role of secure early relationships has led to increased interest in effective screening and promotion of early relational health in pediatric primary care and home visiting settings. We report findings from two pilot studies conducted in the United States that describe the reliability and validity of a relational health screening tool, the Early Relational Health Screen (ERHS), implemented in two different contexts: an innovative model of relational health promotion in pediatric primary care (Study 1) and an Infant Mental Health Home Visiting (IMH-HV) model (Study 2). Across both studies, a trained clinician rated the ERHS following real-time observation of interaction (i.e., "in-the-moment" ratings). Reliability was assessed by comparing "in-the-moment" ERHS ratings to subsequent coding of the same interaction from video by an independent evaluator. In addition, Study 2 data permitted evaluation of the validity of "in-the-moment" ERHS ratings. Results from both studies indicated reliability of "in-the-moment" ERHS ratings. In addition, Study 2 clinician "in-the-moment" ratings were associated with maternal depression and ratings of child-parent interaction derived from a separate observational task coded by independent evaluators using a different well-validated research-based measure. Discussion highlights the potential of the ERHS as a screening, promotion, and prevention tool that may be feasibly administered by providers across pediatric primary care and home visiting settings.

The Family is the Patient: Promoting Early Childhood Mental Health in Pediatric Care

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

From the voices of supervisees: What is reflective supervision and how does it support their work? (Part I)

Reflective supervision/consultation (RS/C) is a relationship for learning that embraces reflection and reflective practice strategies. It is considered best practice within the infant and early childhood mental health (IECMH) field. Based on research with supervisors, essential components of RS/C have been operationalized and used to develop evaluative tools. Little is known, however, about the essential components that supervisees find most useful. This paper, part I of a two-part series, describes the essential components that supervisees identify as fundamental and ways they believe their work is supported by participation in RS/C. Fifty IECMH professionals located in the United States who received RS/C participated in focus groups or individual interviews. Data were analyzed using a Grounded Theory approach. Essential components of RS/C from the supervisee perspective included supervisee feelings of safety, the development of trust, holding a non-judgmental stance, being available and present, and consistency and predictability. Additionally, supervisees identified outcomes of RS/C that included components of professional wellness, personal growth, and infant and family engagement. This study adds the supervisee's voice to the identification and operationalization of essential RS/C components and elucidates outcomes of RS/C that supervisees view as connected to their professional role.

Maternal History of Adverse Experiences and Posttraumatic Stress Disorder Symptoms Impact Toddlers’ Early Socioemotional Wellbeing: The Benefits of Infant Mental Health-Home Visiting

Background

The present study examined the efficacy of the Michigan Model of Infant Mental Health-Home Visiting (IMH-HV) infant mental health treatment to promote the socioemotional wellbeing of infants and young children. Science illuminates the role of parental “co-regulation” of infant emotion as a pathway to young children’s capacity for self-regulation. The synchrony of parent–infant interaction begins to shape the infant’s own nascent regulatory capacities. Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, and who struggle with symptoms of post-traumatic stress may have greater challenges in co-regulating their infant, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression, and depression. Early intervention that targets the infant–parent relationship may help buffer the effect of parental risk on child outcomes.

Methods

Participants were 58 mother–infant/toddler dyads enrolled in a longitudinal randomized control trial testing the efficacy of the relationship-based IMH-HV treatment model. Families were eligible based on child age (<24 months at enrollment) and endorsement of at least two of four socio-demographic factors commonly endorsed in community mental health settings: elevated depression symptoms, three or more Adverse Childhood Experiences (ACEs) parenting stress, and/or child behavior or development concerns. This study included dyads whose children were born at the time of study enrollment and completed 12-month post-baseline follow-up visits. Parents reported on their own history of ACEs and current posttraumatic stress disorder (PTSD) symptoms, as well as their toddler’s socioemotional development (e.g., empathy, prosocial skills, aggression, anxiety, prolonged tantrums).

Results

Maternal ACEs predicted more toddler emotional problems through their effect on maternal PTSD symptoms. Parents who received IMH-HV treatment reported more positive toddler socioemotional wellbeing at follow-up relative to the control condition. The most positive socioemotional outcomes were for toddlers of mothers with low to moderate PTSD symptoms who received IMH-HV treatment.

Conclusion

Results indicate the efficacy of IMH-HV services in promoting more optimal child socioemotional wellbeing even when mothers reported mild to moderate PTSD symptoms. Results also highlight the need to assess parental trauma when infants and young children present with socioemotional difficulties.

Family risk and early attachment development: The differential role of parental sensitivity

Family risks are known to be detrimental to children's attachment development. This study investigated whether parental sensitivity plays different roles in early attachment development in the context of risk: Sensitivity was hypothesized to mediate risk effects on attachment, as well as a moderator that shapes the relation between risk and attachment. Multiple family risks, parental sensitivity (defined as responsivity and supportive presence), and children's attachment security of 197 infants and toddlers (M_age  = 15.25 months) and their caregivers were assessed in a prospective study with a cohort-sequential-design in Germany. Caregivers' sensitivity served as a mediator of risk effects on attachment as well as a moderator that buffers adverse consequences of risk. Early sensitivity might be relevant in setting the stage for attachment development supporting resilience.

Infant mental health home visiting: intervention dosage and therapist experience interact to support improvements in maternal reflective functioning

This study examined changes in parental reflective functioning (PRF) among mothers enrolled in Infant Mental Health-Home Visiting (IMH-HV) and explored whether parental risk, treatment dosage or therapist experience predicted change in PRF. Participants included 75 mothers and their children who were enrolled in IMH-HV delivered by Community Mental Health therapists. Results indicated significant improvements in PRF from baseline to 12-months. Maternal demographic and psychosocial risk, therapist experience and treatment dosage were not directly associated with changes in PRF. However, Mothers who received more treatment sessions from therapists with six or more years of experience demonstrated the greatest improvements in PRF, while mothers who received more treatment sessions from therapists who had been practicing IMH for less than 15 months showed a decline in PRF. Therapists working with very high-risk families may need specific training and ongoing reflective supervision over a period of years to promote improvement in PRF.

Introduction to the special section: The development of infant mental health home visiting in Michigan state government

This issue of the Infant Mental Health Journal presents the first papers from a tripartite evaluation study of state-sponsored infant mental health home visiting program in Michigan, United States. This series of studies has been led by Kate Rosenblum PhD and Maria Muzik MD, Department of Psychiatry, the University of Michigan and faculty from the Michigan Collaborative for Infant Mental Health Research for the State of Michigan, Department of Health and Human Services, Mental Health Services for Children, to fulfill the requirements of state legislation (State of Michigan Act No. 291, Public Acts of 2013) that required that all home visiting programs meet certain requirements to be established as an evidence-based practice. In this introduction, we provide a historical context for the delivery of infant mental health home visiting through the community mental health system in the state of Michigan.

The Crying Clinic: Increasing accessibility to Infant Mental Health services for immigrant parents at risk for peripartum depression

Peripartum depression (PPD) is considered a major public health concern due to its profound impact on families, including infants. In this paper, we report on a pilot initiative designed to reduce barriers and stigma related to the use of traditional infant mental health services for immigrant parents deemed at high risk of PPD. The Crying Clinic (CC) is an innovative walk-in service offered in a culturally diverse Canadian community to support maternal well-being and healthy parent-infant relationships. The CC was designed to be a gateway to existing infant mental health services, through its emphasis on accessibility and cultural sensitivity. Support for concrete concerns, such as anxiety about normative infant behaviors like crying, is underscored in this approach to attract vulnerable families who would otherwise not access mental health support. A review of 44 users, utilization, plans for the use of additional services, and client evaluations suggests that the CC accomplished most of its goals. We conclude that gateway service models such as the CC have the potential to enhance traditional infant mental health programs by creatively addressing the challenge of engaging highly vulnerable parents from culturally diverse backgrounds.