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Review of reviews-Child Health Promotion Programme
Abstract
Increasing recognition of the importance of maternal mental health and early parenting in optimising the later mental health of the child has given rise to new ways of working during the perinatal period. Aims: The objective of this review is to identify effective health-led interventions to support parents, parenting and the parent-infant relationship during the perinatal period,1 and beyond. Method: A systematic search of key electronic databases was undertaken to identify secondary and primary sources of data addressing the research question. Twenty-four reviews addressed the effectiveness of interventions delivered during the postnatal period in promoting closeness and sensitive parenting, infant sensory and perceptual
capabilities, and positive parenting, and in addressing infant regulatory problems, maternal mental health problems, and parent-infant relationship problems. Conclusions: A number of methods of working are recommended as part of a model of progressive-universalism beginning ante-natally and continuing through the first two post-natal years, and beyond. The implications for universal, targeted and specialist healthcare services are explored, alongside the role and contribution of CAMHS practitioners.
Introduction Emotional maltreatment (or psychological maltreatment, as it is more commonly called in the US) is an inadequately researched and poorly understood concept, despite increasing awareness about the harm it can cause to children's lives. This review of the literature summarises the evidence about what works to prevent child emotional maltreatment before if occurs and also to prevent its recurrence (i.e. once it has taken place), and focuses on the parents or primary carers of children aged 0-19 years. Key Findings • Emotional abuse is a complex issue resulting in part from learned behaviours, psychopathology and/or unmet emotional needs in the parents, and often compounded by factors in the families' immediate and wider social environment. As such, a 'one-approach-fits-all' is unlikely to lead to sustained change. • Intervention Approaches: Four major theoretical accounts have been provided to explain the occurrence of emotional abuse: psychodynamic, attachment, behavioural / cognitive and family systems theory. Each of these has shaped the development of interventions to prevent, halt or address the effects of parental negative affect. • There was overall, a paucity of evaluations of the effectiveness of interventions in the treatment of emotional maltreatment. The evidence was drawn from studies evaluating the effectiveness of wide-ranging interventions, with populations as diverse as substance-abusing parents and parents of infants with faltering growth. Notwithstanding the wide variation in definitions of child emotional maltreatment currently in use, there appears to be a number of common themes in terms of the type of parenting that is emotionally harmful to children, and the need to implement both population-based and targeted intervention to prevent its occurrence, and effective therapeutic-based interventions to prevent its recurrence (i.e. treatment). • Two types of approach have been used to the prevention of emotional abuse before it occurs, population based and targeted methods. There is currently limited evidence to suggest that the use of population strategies of this nature can reduce child abuse. Targeted approaches use a range of interventions that are aimed primarily at improving maternal sensitivity of parents of infants. The results of one recent systematic review showed that a number of attachment-based interventions improved maternal sensitivity and infant attachment security (ibid), particularly brief interventions focused on improving maternal sensitivity and beginning six-month post natally. • The evidence about what works to prevent the recurrence of emotional abuse is limited but compatible with the belief that some forms of emotionally abusive parenting respond to cognitive behavioural therapy. However, the characteristics that define parents who respond well to CBT approaches are not clear. The use of this intervention alone in the treatment of severely emotionally abusive parent remains unproven. Research Brief • Absence of evidence does not equate with evidence of absence of efficacy, and much uni-disciplinary to inter-agency work is undertaken with families whose children suffer emotionally because of the harmful behaviours of their parents / carers, whether intentional or otherwise. Practitioners and commissioners of services within which such complex work is undertaken should acknowledge and facilitate the importance of research to practice, and further routine evaluation of interventions and services is needed.
• There was overall, a paucity of evaluations of the effectiveness of interventions in the treatment of emotional maltreatment. The evidence was drawn from studies evaluating the effectiveness of wide- ranging interventions, with populations as diverse as substance-abusing parents and parents of infants with faltering growth. Notwithstanding the wide variation in definitions of child emotional maltreatment currently in use, there appears to be a number of common themes in terms of the type of parenting that is emotionally harmful to children, and the need to implement both population-based and targeted intervention to prevent its occurrence, and effective therapeutic-based interventions to prevent its recurrence (i.e. treatment). • Two types of approach have been used to the prevention of emotional abuse before it occurs, population based and targeted methods. There is currently limited evidence to suggest that the use of population strategies of this nature can reduce child abuse. Targeted approaches use a range of interventions that are aimed primarily at improving maternal sensitivity of parents of infants. The results of one recent systematic review showed that a number of attachment-based interventions improved maternal sensitivity and infant attachment security (ibid), particularly brief interventions focused on improving maternal sensitivity and beginning six-month post natally. • The evidence about what works to prevent the recurrence of emotional abuse is limited but compatible with the belief that some forms of emotionally abusive parenting respond to cognitive behavioural therapy. However, the characteristics that define parents who respond well to CBT approaches are not clear. The use of this intervention alone in the treatment of severely emotionally abusive parent remains unproven.
The Mental Health Foundation commissioned this report on the basis of its National Enquiry into the Mental Health of Children and Young People, ‘Bright Futures’. It aims to summarise a variety of interventions designed to improve parenting, family functioning and young children’s mental health and to promote thinking about future work rather a definitive summary of existing knowledge. This summary defines the key points from the full report, which comprises two volumes. Volume 1 is a written report and Volume 2 summarises the research in a number of tables.
This research compared two forms of psychodynamic psychotherapeutic interventions for 67 clinically referred infants and their mothers. One was an infant-led psychotherapy delivered through a program called Watch, Wait, and Wonder (WWW). The other was a mother- infant psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately 5 months. A broad range of measures of attachment, qualities of the mother- infant relationship, maternal perception of parenting stress, parenting competence and satisfaction, depression, and infant cognition and emotion regulation were used. The WWW group showed a greater shift toward a more organized or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Moreover, mothers in the WWW group reported
Aims and Method
To identify problems with the management of perinatal mental health disorders and areas where improvements are thought-required. The study used qualitative methods comprising focus groups with recovered patients and interviews with health professionals.
Results
Issues we identified included a lack of knowledge, skills, integrated working, poor access to resources and ill-defined professional roles and responsibilities. Improving care and service provision requires the development of training and education programmes, care pathways and protocols, and referral guidelines and liaison services.
Clinical Implications
Difficulties over managing perinatal mental illnesses occur at all levels of healthcare provision. Our findings confirm best practice recommendations which emphasise improved joint working and the provision of specialist services in all localities.
Unipolar major depression is one of the most prevalent and serious of the mental health disorders. It can result in chronic mental and physical ill health, social difficulties and suicide. The disorder occurs across the lifespan; however, its characteristics and outcomes vary with the age of the sufferer. Children, adolescents, adults and the elderly may all present with a depressive illness but the characteristics, response to treatment and final outcome show considerable variations between age groups. The extent to which genetic and environmental factors and processes contribute to the onset may be influenced by the developmental components of human growth and ageing. Equally, the social context within which depressions occur are not the same at different points in life. There are also known to be differences in relative responses to psychological and pharmacological treatments across the lifespan. Unipolar Depression: A Lifespan Perspective examines these, and other, issues, focusing on the continuities and discontinuities that arise in the nature of the disorder and how genetic, hormonal, psychological and social processes operate differentially throughout life. The chapters are written by major figures from the field of clinical research into depressive illness.
Objective: To examine the evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years. Data Sources: Peer-reviewed publications addressing clinical evaluations of primary care services from the MEDLINE and PsychINFO databases. Study Selection: Criteria for selection were as follows: (1) publication between 1979 and 1999; (2) evaluation of efficacy or effectiveness of education, intervention, and care coordination services or validation of assessment approaches; (3) services applicable to an office practice setting; (4) target population including children aged birth to 3 years; and (5) publication in English. Data Extraction: A total of 312 publications were abstracted and reviewed by both of us; 47 were selected for inclusion. Data Synthesis: Assessments of parental concerns and psychosocial risk factors using validated approaches seem to be more accurate in identifying developmental problems than clinicians' appraisals. In general, study results support the efficacy of (1) primary care educational efforts toward promoting optimal parent-child interaction, parents' understanding of child temperament, book-sharing activities, and approaches to healthy sleep habits and (2) office interventions such as counseling for the management of excessive infant crying and sleep problems. Conclusions: The literature suggests that many primary care activities promoting the optimal development of children are efficacious. Evaluations of developmental assessment and services in primary care should be expanded in depth and breadth. The implications for clinical practice, training, and health care policy are discussed.
Objective:
To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.
Design:
The test characteristics of a two-question case-finding instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.
Setting:
Urgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.
Participants:
Five hundred thirty-six consecutive adult patients without mania or schizophrenia.
Measurements and main results:
Measurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Book Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90-99%) and a specificity of 57% (95% CI 53-62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.
Conclusions:
The two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.