The Efficacy of Brief Parent-Infant Psychotherapy for Treating Early Regulatory Disorders: A Randomized Controlled Trial

Within- and between-session changes of in-session reflective functioning of mothers in dyadic parent-infant psychotherapy

This study investigated if in-session reflective functioning (RF) of mothers improved between and within sessions of brief dyadic focused parent-infant psychotherapy (fPIP) for the treatment of regulatory disorders in infants.

In-session RF was coded for 44 therapy sessions from N = 11 mothers randomly selected from a RCT on the efficacy of fPIP as part of secondary analyses. A new rating system distinguished self-focused and child-focused in-session RF. Cumulative ordinal regression models were applied to analyze the dynamics of in-session RF within and across sessions, controlling for word count of each statement.

While in-session RF improved significantly within sessions, between-session RF improved significantly only in the second session compared to the first with a significant decrease observed in the last session. Child-focused in-session RF was significantly lower than self-focused in-session RF at the beginning of the sessions but improved significantly stronger than self-focused in-session RF during sessions.

In-session RF (particularly in child-focused statements) can be regarded as a dynamic change process relevant within each session of dyadic fPIP. Improvements made on a session-by-session basis may not be maintained until the next session. Implications for practitioners and in-session RF research are discussed.

Is the association between infant regulatory problems and trajectories of childhood co-developing internalizing and externalizing symptoms moderated by early screen media exposure?

Regulatory problems in infancy are associated with internalizing and externalizing symptom trajectories across childhood, however, it is unknown whether early screen media exposure exacerbates this association. We studied 10,170 individuals from the Growing Up in Ireland '08 cohort. Parents reported on their children's regulatory problems at 9 months, screen media exposure at 3 years, and internalizing and externalizing symptoms at 3, 5, 7, and 9 years. Children were categorized based on their patterns of co-developing internalizing and externalizing symptoms. Subsequently, multinominal logistic regression analyses were conducted to estimate whether screen media exposure (> 1 h or > 2 h) moderated the association between regulatory problems in infancy and co-developing internalizing and externalizing symptom classes across childhood. There were four groups of children with distinct patterns of co-developing internalizing and externalizing symptoms. Presence of regulatory problems at 9 months and excessive screen media exposure at 3 years (particularly > 2 h) were independently associated with increased likelihood of all classes. Excessive screen media exposure at 3 years did not significantly moderate the association between regulatory problems at 9 months and internalizing and externalizing symptom trajectories.

Current perspectives on perinatal mental health and neurobehavioral development: focus on regulation, coregulation and self-regulation

PURPOSE OF REVIEW

Perinatal mental health research provides an important perspective on neurobehavioral development. Here, we aim to review the association of maternal perinatal health with offspring neurodevelopment, providing an update on (self-)regulation problems, hypothesized mechanistic pathways, progress and challenges, and implications for mental health.

RECENT FINDINGS

(1) Meta-analyses confirm that maternal perinatal mental distress is associated with (self-)regulation problems which constitute cognitive, behavioral, and affective social-emotional problems, while exposure to positive parental mental health has a positive impact. However, effect sizes are small. (2) Hypothesized mechanistic pathways underlying this association are complex. Interactive and compensatory mechanisms across developmental time are neglected topics. (3) Progress has been made in multiexposure studies. However, challenges remain and these are shared by clinical, translational and public health sciences. (4) From a mental healthcare perspective, a multidisciplinary and system level approach employing developmentally-sensitive measures and timely treatment of (self-)regulation and coregulation problems in a dyadic caregiver-child and family level approach seems needed. The existing evidence-base is sparse.

SUMMARY

During the perinatal period, addressing vulnerable contexts and building resilient systems may promote neurobehavioral development. A pluralistic approach to research, taking a multidisciplinary approach to theoretical models and empirical investigation needs to be fostered.

Supporting the transition to parenthood: a systematic review of empirical studies on emotional and psychological interventions for first-time parents

OBJECTIVES

The transition to parenthood can evoke a range of concerns in parents, profoundly impacting their psychological well-being. The literature regarding the transition to parenthood focuses primarily on functional aspects of parenthood, generally overlooking the psychological well-being of parents.

METHOD

This comprehensive review synthesized studies describing emotional and psychological interventions during the transition to parenthood among participants between 2013 and 2022. A rigorous screening process, conducted by three of the authors, resulted in 18 studies that met the inclusion criteria.

RESULTS

This report provides detailed descriptions of these studies, including their characteristics, demographics, types of interventions, and main outcomes. The majority of interventions focused on mothers and mother-infant dyads, with fewer interventions targeting couples, and none addressing fathers or father-infant dyads.

CONCLUSIONS

The interventions examined were found to be effective in reducing symptoms such as depression, anxiety, and stress among mothers and had positive effects on infants' behaviors, mother-infant synchrony, and co-parenting.

PRACTICE IMPLICATIONS

This review stresses the necessity of interventions targeting the transition to parenthood, especially among fathers and marginalized populations, as well as serves to identify barriers faced by vulnerable and minority populations.

Assessment and Diagnostic Classification Using DC:0-5 in Early Childhood Mental Health Clinics: The Protocol for the Developmental Psychiatry Diagnostic Challenges Study (DePsy)

Mental health problems in early childhood are common, but there is a lack of psychiatric research on this age group. DC:0-5 is a multiaxial classification system for mental disorders in early childhood, providing a framework for standardizing clinical practice and research. However, research on the validity of DC:0-5 is scarce. The Developmental Psychiatry Diagnostic Challenges Study (DePsy) is a multi-site, prospective clinical study including six German early childhood mental health (ECMH) clinics. The main objective of the study is to contribute to the validation of Axis I and Axis II of DC:0-5. A second aim of the study is to describe the population of the participating clinics regarding diagnoses, family context, and treatment outcomes. Additionally, the impact of environmental risk factors, including parental Adverse Childhood Experiences (ACEs) and media use, on child psychopathology and caregiver-child relationships will be examined. Over two years, patients aged 0.0-5.9 years old will be enrolled in the study. Assessments include ICD-10 and DC:0-5 diagnoses, developmental tests, video-based observations of caregiver-child interactions, and questionnaires on child psychopathology, media use, parental stress, and treatment satisfaction. Study results will promote the standardization of assessment and treatment in ECMH clinics aiming to improve the development of patients and their families.

[The parent-child relationship in the context of parental mental illness-Possibilities for intervention]

The parent-child relationship is the earliest and one of the most important close social relationships in a person's life. It begins even during pregnancy, is expressed in interactions and is accompanied by many neurobiological processes. A sensitive interaction with the parent who is well-adapted to the needs of the child, is necessary for a healthy child development; however, parents with mental disorders often face more difficulties in parenting than healthy parents. They tend to exhibit more intrusive or withdrawn behavior and report experiencing increased stress in parenting, which in turn can be a risk factor for the mental disorder. At the same time, parenting can be a great resource. Early recognition of stress in parenting is central to healthy child development and also to the parent's mental health. In addition to disorder-specific treatment for parents, parent-child focused interventions can be used in relationship or interaction disorders. This article presents and discusses different prevention and intervention approaches.

[Early childhood mental disorders: excessive crying, sleep and feeding disorders, and interventions using the "Munich model" as an example]

About 20% of all healthy infants and toddlers show problems in the area of mental health during their first years of life such as inconsolable crying (so-called cry-babies), sleeping problems, and feeding problems. The prevalence of enduring feeding problems and sleeping problems is distinctly higher in premature children and in children with neuropediatric disorders. These problems present a higher risk for the development of internalizing and externalizing disorders of mental health in later childhood. The parent-child relationship is often strained. Parents report experiencing severe exhaustion, extreme uncertainty, and helplessness.Pediatricians and midwives are the first points of contact for families. Outpatient clinics for cry-babies such as the "Munich Consultation for Cry-Babies," founded by Mechthild Papoušek in 1991 at the kbo-Children's Center Munich, provide a low-threshold service for the highly stressed families. They can contribute to the prevention of neglect, maltreatment, and psychological secondary disorders of the child. Intervention strategies are based on parent-infant and attachment research and integrate child- and parent-oriented approaches.During the COVID-19 pandemic, psychosocial stress factors in families increased. This development was also observable in the outpatient clinics for cry-babies.

The impact of crying, sleeping, and eating problems in infants on childhood behavioral outcomes: A meta-analysis

Background

There is increasing evidence that regulatory problems (RPs), such as excessive crying, sleeping or feeding problems in infancy, could be associated with the development of behavioral problems in childhood. In this meta-analysis we aimed to investigate the strength and characteristics of this association.

Methods

A systematic literature search (PubMed/PsycInfo, until 15/08/2021) for longitudinal prospective studies of infants with RPs and at least one follow-up assessment reporting incidence and/or severity of behavioral problems was conducted. The primary outcomes were (i) the cumulative incidence of behavioral problems in children (2-14 years) with previous RPs and (ii) the difference between children with/without previous RPs with regard to the incidence and severity of externalizing, internalizing and/or attention-deficit/hyperactivity disorder (ADHD) symptoms. Additionally, we analyzed behavioral problems of children with previous single, multiple or no RPs and with respect to age at follow-up. Subgroup and meta-regression analyses were added.

Results

30 meta-analyzed studies reported on 34,582 participants (nRP = 5091, ncontrol = 29,491; age: baseline = 6.5 ± 4.5 months, follow-up = 5.5 ± 2.8 years) with excessive crying (studies = 13, n = 1577), sleeping problems (studies = 9, n = 2014), eating problems (studies = 3, n = 105), any single (studies = 2, n = 201) or multiple RPs (studies = 9, n = 1194). The cumulative incidence for behavioral problems during childhood was 23.3% in children with RPs. Behavioral problems were significantly more pronounced in infants with RPs compared to healthy controls (SMD = 0.381, 95% CI = 0.296-0.466, p < .001), particularly with multiple RPs (SMD = 0.291, p = 0.018).

Conclusions

Findings suggest that RPs in infancy are associated with overall behavioral problems (externalizing or internalizing behavior and ADHD symptoms) in childhood. Our data cannot explain linked developmental trajectories and underlying factors. However, detection of affected infants may help to adapt supportive measures to the individual familial needs to promote the parent-child-relationship and prevent the development of child behavioral problems from early on.

Impacts of the Attachment and Child Health (ATTACHTM) Parenting Program on Mothers and Their Children at Risk of Maltreatment: Phase 2 Results

Early adversity (e.g., family violence, parental depression, low income) places children at risk for maltreatment and negatively impacts developmental outcomes. Optimal parental reflective function (RF), defined as the parent's ability to think about and identify thoughts, feelings, and mental states in themselves and in their children, is linked to secure attachment and may protect against suboptimal outcomes. We present the results of Phase 2 randomized control trials (RCTs) and quasi-experimental studies (QES) of the Attachment and Child Health (ATTACHTM) parental RF intervention for families with children at risk for maltreatment. Phase 2 parents experiencing adversity, along with their children aged 0-5 years (n = 45), received the 10-12-week ATTACHTM intervention. Building on completed Phase 1 pilot data, Phase 2 examined outcomes of long-standing interest, including parental RF and child development, as well as new outcomes, including parental perceived social support and executive function, and children's behavior, sleep, and executive function. RCTs and QES revealed significant improvements in parents' RF, perception of social support, and executive function, children's development (i.e., communication, problem-solving, personal-social, and fine motor skills), and a decrease in children's sleep and behavioral problems (i.e., anxiety/depression, attention problems, aggressive behavior, and externalizing problems), post-intervention. ATTACH™ positively impacts parental RF to prevent negative impacts on children at risk of maltreatment.

Associations of toddler mechanical/distress feeding problems with psychopathology symptoms five years later

BACKGROUND

Feeding problems are common in early childhood, and some evidence suggests that feeding problems may be associated with psychopathology. Few prospective studies have explored whether toddler feeding problems predict later psychopathology.

METHODS

Mothers of 1,136 children from the Upstate KIDS cohort study provided data when children were 2.5 and 8 years of age. Food refusal (picky eating) and mechanical/distress feeding problems and developmental delays were assessed at 2.5 years. Child eating behaviors (enjoyment of food, food fussiness, and emotional under and overeating) and child psychopathology (attention-deficit/hyperactivity (ADHD), oppositional-defiant (OD), conduct disorder (CD), and anxiety/depression) symptoms were assessed at 8 years.

RESULTS

Mechanical/distress feeding problems at age 2.5, but not food refusal problems, were associated with ADHD, problematic behavior (OD/CD), and anxiety/depression symptoms at 8 years in models adjusting for eating behaviors at 8 years and child and family covariates. Associations with mechanical/distress feeding problems were larger for ADHD and problematic behavior than anxiety/depression symptoms, though all were modest. Model estimates were similar for boys and girls.

CONCLUSIONS

Much of the research on feeding problems focuses on picky eating. This study suggests that early mechanical and mealtime distress problems may serve as better predictors of later psychopathology than food refusal. Parents and pediatricians could monitor children with mechanical/distress feeding problems for signs of developing psychopathology.

Learning from mothers who received focused parent-infant psychotherapy for the treatment of their child's regulatory disorders

OBJECTIVE

Gaining a deeper understanding of how focused parent-infant psychotherapy (fPIP) works by asking mothers about their experiences.

METHOD

Purposeful sampling was used to select participants who before had participated in an RCT on fPIP. Nine mothers of infants with early regulatory disorders who had received fPIP were interviewed. Eight cases received full-protocol treatment, one case was a treatment drop-out. Semi-structured interviews were audio-recorded, transcribed verbatim and analyzed applying grounded theory methodology.

RESULTS

Seven major categories evolved: (1) engaging in therapy while maintaining autonomy, (2) relating to an emotionally responsive therapist and resolving ruptures, (3) involvement of partners in therapy facilitates multiple perspectives, (4) understanding the meaning of the child's signals and increasing acceptance of difficult behaviors, (5) feeling supported by advice that is attuned to the families' needs, (6) insight into parental contributions to the child's problems and (7) feeling strengthened as a mother and recognizing one's own needs.

CONCLUSION

Findings highlight which aspects of fPIP mothers find most helpful and most challenging. Aspects that compromised the change process seemed related to the specific needs of this population and therapeutic setting. The results may guide therapists and inspire future development in interventions for treating infant regulatory disorders.

[The Importance of Adaptive Treatment Strategies for Treatment Outcome in fSKEPT]

The manualized focused infant/toddler-parent psychotherapy fSKEPT is a psychodynamic focal treatment of early childhood regulatory disorders, in which either a conflict-related or a personality functioning-related treatment focus is carried out. The aim of the study is to review the effectiveness of fSKEPT depending on two different therapeutic treatment focuses. For this purpose, n = 81 families who received fSKEPT were examined as part of secondary analyzes of a randomized controlled study. The therapeutic treatment focus did not predict the effectiveness for any of the examined target criteria (maternal psychological stress F(1,70) = 0.71, p = .401, maternal depression F(1,70) = 0.18, p = .678, infant regulatory symptoms F(1,70) = 0.11, p = .753, maternal self-efficacy F(1,70) = 0.038, p = .847, maternal reflective functioning F(1,50) = 0.56, p = .458). In a subsample of n = 33 families (40 % of the total sample) we tested whether the therapeutic interventions used in the therapy correspond to the treatment focus of the therapists. No significant difference was found between personality functioning-specific interventions (t(28) = 1.71, p = .099) and unspecific interventions (t(28) = 1.77, p = .087) when comparing the two treatment focus groups. In the conflict focus group significantly more conflict-specific interventions were used (t(28) = 2,71, p = .011). The results demonstrate the effectiveness of the focus concept of the fSKEPT treatment. The focus and the flexible individual adaptation of the interventions in the course of the treatment may help offering parents with different psychological vulnerabilities and ressources an equally effective treatment. In addition, the relevance of unspecific interventions and relationship-promoting aspects of the treatment are discussed.

Editorial: Infant Regulatory Disorders: Does Early Intervention Make a Difference?

Early regulatory disturbances (ERD), such as excessive crying, feeding, or sleeping difficulties and attachment problems, have a population prevalence in very young children (ie, at age 1.5 years) that is very similar to that for behavioral problems in older children¹ and for which the stability is similarly high (ie, 50%). They also predict longer-term difficulties including delays in motor, language and cognitive development, and parent-child relational problems.² Some types of regulatory disturbance (eg, insecure and disorganized attachment) are strongly associated with later psychopathology including behavioral problems³ and personality disorder.⁴.

Efficacy of parent-infant psychotherapy compared to care as usual in children with regulatory disorders in clinical and outpatient settings: study protocol of a randomised controlled trial as part of the SKKIPPI project

BACKGROUND

The first years of life are a significant period for child development, when children are particularly sensitive and prone to crises. This early phase lays the foundation for healthy growth. Clinical assessment of psychological symptoms in early infancy and adequate treatment are both important in improving the diagnostic outcome and preventing later long-term developmental consequences. The most common psychological problems in the first 3 years of life are regulatory disorders. The aim of this trial is to investigate the efficacy of Parent-Infant Psychotherapy (PIP) for infants and young children (aged 0-36 months, diagnosed with at least one regulatory disorder) and their mothers, compared to care as usual (CAU).

METHODS

In this open multicentre randomised controlled trial, 160 mother-infant dyads are randomised to receive PIP or CAU for 6 weeks of intervention in clinical or outpatient (including home treatment) settings. The primary outcome is the maternal sensitivity (sensitivity scale of the Emotional Availability Scales (EAS)) after 6 weeks. Secondary outcomes include assessment of interaction, mental health problems, attachment, development, psychological factors, treatment adherence, health care system utilisation, and costs, after 6 weeks and 12 months.

DISCUSSION

This study will evaluate whether a manualised focus-based short-term psychodynamic psychotherapeutic intervention in mother-child dyads improves the care situation for families of children diagnosed with regulatory disorders, and helps prevent long-term psychopathologies. Assessment of the intervention in different settings will support the development of more tailored interventions for affected infants and their mothers.

TRIAL REGISTRATION

German Clinical Trial Register, ID: DRKS00017008 . Registered 03/20/2019.