Psychiatric Times.
No. 9
Infant Psychiatry
By Mary Margaret Gleason, MD and Greta L. Doctoroff, PhD |
September 1, 2006
In randomized controlled trials, the BASIC program has demonstrated clinically significant improvements in parenting practices and child conduct problems, including remission from oppositional defiant disorder.34-36 Similarly, the ADVANCE program is associated with notable improvements in parent-child interaction, communication, problem solving, and child adjustment.37
Parent-child interaction therapy (PCIT) is an individualized, relationship-focused intervention based on behavior theory for children aged 2 to 6 years who are referred for disruptive behavior disorders.38 PCIT has been effectively adapted for use in high-risk populations, including children with physically abusive parents.39 In PCIT dyadic sessions, parents receive live coaching from the therapist behind a one-way mirror using a "bug-in-the-ear" microphone. Parent collaborative teaching sessions are followed by in-session and at-home practice. PCIT uses a 2-stage model to target parent behaviors: (1) child-directed behavior play therapy skills (ie, praise, reflection, imitation, description) and effective reinforcement, and (2) parent-directed interaction techniques, including effective commands, consistent limit setting, ignoring, and time-out. Growing research evidence supports the efficacy of PCIT in improving parenting skills and providing clinically significant reductions in oppositional and aggressive behavior.40
Efficacy and safety data regarding the use of psychopharmacologic treatment in children under 5 years are lacking.41 These agents are used with caution in this age group and should be considered only after a trial of appropriate psychotherapy is unsuccessful. On the other hand, parental psychopharmacologic treatment when indicated can be very useful in combination with dyadic interventions.
SUMMARY
Infant psychiatry offers exciting opportunities in clinical and research settings. The specialty requires true integration of biologic, psychological, and social intervention strategies--with collaboration across disciplines. Infant psychiatrists can intervene early to promote current and future healthy development and relationships and treat a wide range of psychopathology in infants. The growth and development of this specialty, like early childhood development itself, is rapid and holds extraordinary potential to promote family mental health and treat psychopathology.
Dr Gleason is a clinical assistant professor in the department of psychiatry and human behavior at Brown Medical School in Providence, RI, and at the Institute of Infant and Early Childhood Mental Health at Tulane University Health Science Center in New Orleans as well as a research fellow in child psychiatry at Rhode Island Hospital in Providence.
Dr Doctoroff is a clinical psychology research fellow in the department of psychiatry and human behavior at the Brown Medical School and at the Bradley Early Childhood Clinical Research Center at Rhode Island Hospital.Both authors report that they have no conflicts of interest regarding this article.
References
1. Emde RN. A developmental psychiatrist looks at infant mental health challenges for Early Head Start. Zero to Three. 2001;22:21-24.
2. Lavigne JV, Gibbons RD, Christoffel KK, et al. Prevalence rates and correlates of psychiatric disorders among preschool children. J Am Acad Child Adolesc Psychiatry. 1996;35:204-214.
3. Zeanah CH, Boris NW, Larrieu JA. Infant development and developmental risk: a review of the past 10 years [published correction appears in J Am Acad Child Adolesc Psychiatry. 1998;37:240]. J Am Acad Child Adolesc Psychiatry 1997;36:165-178.
4. American Academy of Child and Adolescent Psychiatry. Infant Psychiatry Fellowships 2000. Available at: http://aacap.org/page.ww?section=Early+Career+ Psychiatrists&name=Subspecialty+Training+ Information. Accessed July 27, 2006.
5. Zero to Three Diagnostic Classification Task Force. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Washington, DC: Zero to Three Press; 1994.
6. Zero to Three Diagnostic Classification Task Force. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised (DC:0-3R). Washington, DC: Zero to Three Press; 2005.
7. Egger HL, Erkanli A, Keeler GM, et al. Test-retest reliability of the preschool age psychiatric assessment (PAPA). J Am Acad Child Adolesc Psychiatry. 2006; 45:538-549.
8. Task Force on Research Diagnostic Criteria: Infancy Preschool. Research diagnostic criteria for infants and preschool children: the process and empirical support. J Am Acad Child Adolesc Psychiatry. 2003;42: 1504-1512.
9. Boris NW, Hinshaw-Fuselier SS, Smyke AT, et al. Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples. J Am Acad Child Adolesc Psychiatry. 2004;43:568-577.
10. Scheeringa MS, Zeanah CH, Myers L, Putnam FW. Predictive validity in a prospective follow-up of PTSD in preschool children. J Am Acad Child Adolesc Psychiatry. 2005;44:899-906.
11. Luby JL, Mrakotsky C, Heffelfinger A, et al. Modification of DSM-IV criteria for depressed preschool children. Am J Psychiatry. 2003;160:1169-1172.
12. Zeanah CH, Smyke AT, Koga SF, et al. Attachment in institutionalized and community children in Romania. Child Dev. 2005;76:1015-1028.
13. Schechter DS, Zeanah CH Jr, Myers MM, et al. Psychobiological dysregulation in violence-exposed mothers: salivary cortisol of mothers with very young children pre-and post-separation stress. Bull Menninger Clin. 2004;68:319-336.
14. Scheeringa MS, Zeanah CH, Myers L, Putnam F. Heart period and variability findings in preschool children with posttraumatic stress symptoms. Biol Psychiatry. 2004;55:685-691.
15. Thomas JM, Benham AL, Gean M, et al. Practice parameters for the psychiatric assessment of infants and toddlers (0-36 Months). J Am Acad Child Adolesc Psychiatry. 1997;36(suppl 10):21S-36S.
16. Sameroff A, Fiese B. Transactional regulation: the developmental ecology of early intervention. In: Zigler EF, Shonkoff JP, Meisels SJ, eds. Handbook of Early Childhood Intervention. New York: Cambridge University Press; 2000:135-159.
17. Sameroff AJ, Seifer R. Accumulation of environmental risk and child mental health. In: Fitzgerald HE, Lester BM, Zuckerman B, eds. Children of Poverty: Research, Health, and Policy Issues. New York: Garland Publishing, Inc; 1995:233-258.
18. Jellinek MS, McDermott JF. Formulation: putting the diagnosis into a therapeutic context and treatment plan. J Am Acad Child Adolesc Psychiatry. 2004;43:913-916.
19. Crowell JA, Fleischmann MA. Use of structured research procedures in clinical assessments of infants. In: Zeanah CH, ed. Handbook of Infant Mental Health. 2nd ed. New York: Guilford Press; 2000: 210-221.
20. Benoit D, Zeanah CH, Parker KCH, et al. "Working model of the child interview": infant clinical status related to maternal perceptions. Infant Mental Health Journal. 1997;18:107-121.
21. Task Force on Research Diagnostic Criteria: Infancy Preschool Age. Research diagnostic criteria for infants and preschool children: the process and empirical support. J Am Acad Child Adolesc Psychiatry. 2003;42: 1504-1512.
22. Zeanah PD, Stafford B, Nagle GA, Rice T. Addressing social-emotional development and infant mental health in early childhood systems. National Center for Infant and Early Childhood Health Policy. 2005. Available at: http://www.healthychild.ucla.edu/publications/ documents/IMHFinal.pdf. Accessed July 21, 2006.
23. Olds D, Henderson C, Cole R, et al. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA. 1998;280:1238-1244.
24. Olds DL, Eckenrode J, Henderson CRJ, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997;278:637-643.
25. Kitzman H, Olds DL, Henderson CRJ, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial. JAMA. 1997; 278:644-652.
26. Lieberman AF, Van Horn PJ, Ippen CG. Toward evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc Psychiatry. 2005;44:1241-1248.
27. Toth SL, Maughan A, Manly JT, et al. The relative efficacy of two interventions in altering maltreated preschool children's representational models: implications for attachment theory. Dev Psychopathol. 2002;14: 877-908.
28. Lieberman AF, Weston DR, Pawl JH. Preventive intervention and outcome with anxiously attached dyads. Child Dev. 1991;62:199-209.
29. Dozier M, Peloso E, Lindheim O, et al. Intervention effects on biobehavioral regulation. Unpublished manuscript.
30. Fisher PA, Gunnar MR, Chamberlain P, Reid JB. Preventive intervention for maltreated preschool children: impact on children's behavior, neuroendocrine activity, and foster parent functioning. J Am Acad Child Adolesc Psychiatry. 2000;39:1356-1364.
31. Cohen JA, Mannarino AP. A treatment study for sexually abused preschool children: outcome during a one-year follow-up. J Am Acad Child Adolesc Psychiatry. 1997;36:1228-1235.
32. Nixon RD. Treatment of behavior problems in preschoolers: a review of parent training programs. Clin Psychol Rev. 2002;22:525-546.
33. Webster-Stratton C, Mihalic S, Fagan A, et al. Blueprints for Violence Prevention Series. Book Eleven: The Incredible Years: Parent, Teacher and Child Training Series (IYS). Boulder, Colo: University of Colorado Center for the Study and Prevention of Violence; 2001.
34. Webster-Stratton C. A randomized trial of two parent-training programs for families with conduct-disordered children. J Consult Clin Psychol. 1984;52: 666-678.
35. Webster-Stratton C, Hollinsworth T, Kolpacoff M. The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. J Consult Clin Psychol. 1989;57:550-553.
36. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the Dina dinosaur treatment program. J Emot Behav Disorders. 2003;11:130-143.
37. Webster-Stratton C. Advancing videotape parent training: a comparison study. J Consult Clin Psychol. 1994;62:583-593.
38. Bell S, Eyberg S. Parent-child interaction therapy: a dyadic intervention for the treatment of young children with conduct problems. In: Vandecreek L, Jackson TL, eds. Innovations in Clinical Practice: A Source Book. Sarasota, Fla: Professional Resource Press; 2002: 57-74.
39. Chaffin M, Silovsky J, Funderburk B, et al. Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports. J Consult Clin Psychol. 2004;72:500-510.
40. Brinkmeyer MY, Eyberg SM. Parent-child interaction therapy for oppositional children. In: Kazdin AE, Weisz JR, eds. Evidence-Based Psychotherapies for Children and Adolescents. New York: Guilford Press; 2003:204-223.
41. Greenhill LL, Jensen PS, Abikoff H, et al. Developing strategies for psychopharmacological studies in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42:406-414.
