Julie A. Larrieu

Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood.

OBJECTIVE The reliability and validity of DSM-IV criteria and an alternative set of criteria for posttraumatic stress disorder (PTSD) are assessed in infants and young children (younger than 4 years of age). METHOD This study was conducted in three phases. Phase 1 applied DSM-IV criteria for PTSD to 20 case reports of severely traumatized infants from the literature. Phase 2 used an expanded checklist of symptoms that were developmentally sensitive and behaviorally anchored to create an alternative set of criteria for PTSD in infants. Phase 3 compared the DSM-IV criteria to the alternative criteria on 12 new cases of traumatized infants. RESULTS Infants and young children who have experienced severe traumas show many symptoms of impairment, similar to posttraumatic symptoms in older children and adults. The alternative criteria were more reliable and more valid for diagnosing PTSD in infancy than DSM-IV criteria. CONCLUSIONS Clinicians ought to be aware that infants and young children can develop posttraumatic disorders after traumatic events. Criteria for diagnosing these disorders in standard nosologies may need revision for use with children younger than 48 months of age.

Infant Development and Developmental Risk: A Review of the Past 10 Years

OBJECTIVE To review critically the research on infant developmental risk published in the past 10 years. METHOD A brief framework on development in the first 3 years is provided. This is followed by a review of pertinent studies of developmental risk, chosen to illustrate major risk conditions and the protective factors known to affect infant development. Illustrative risk conditions include prematurity and serious medical illness and infant temperament, infant-caregiver attachment, parental psychopathology, marital quality and interactions, poverty and social class, adolescent parenthood, and family violence. RESULTS Risk and protective factors interact complexly. There are few examples of specific or linear links between risk conditions and outcomes during or beyond the first 3 years of life. Infant development is best appreciated within the context of caregiving relationships, which mediate the effects of both intrinsic and extrinsic risk conditions. CONCLUSIONS Complex and evolving interrelationships among risk factors are beginning to be elucidated. Linear models of cause and effect are of little use in understanding the development of psychopathology. Refining our markers of risk and demonstrating effective preventive interventions are the next important challenges.

Research on resilience to child maltreatment: empirical considerations.

OBJECTIVE To review the current research literature on resilience to maltreatment in childhood and adolescence. METHOD First, this paper addresses the methodological issues applicable to this area of research. Second, it reviews the empirical literature on the protective factors believed to contribute to resilience to maltreatment and offers commentary on specific issues raised in each study. RESULTS The current findings are summarized and an integrated descriptive picture, based on the extant literature of the processes and factors contributing to the development of resilience to childhood maltreatment is outlined. CONCLUSION Based on this extensive review and critique of the current empirical literature on resilience to maltreatment, suggestions for future investigations in this area are recommended.

Evaluation of a Preventive Intervention for Maltreated Infants and Toddlers in Foster Care

OBJECTIVE To determine the effectiveness of an intervention designed to improve outcomes for infants and toddlers in foster care. METHOD Records were reviewed for all children who were adjudicated as in need of care in a specific parish in Louisiana between 1991 and 1998. This period included 4 years before and 4 years after a comprehensive intervention was implemented. Children adjudicated between 1991 and 1994 were the comparison group, and those adjudicated between 1995 and 1998 were the intervention group. RESULTS After the intervention, more children were freed for adoption and fewer children were returned to their birth families than before the intervention. There was no difference in length of time in care before and after the intervention. With regard to the same child returning in a subsequent incident of maltreatment, relative risk reduction for the intervention group ranged from 53% to 68%. With regard to the same mother maltreating another child subsequently, relative risk reduction for the intervention group ranged from 63% to 75%. CONCLUSIONS A comprehensive preventive intervention for maltreated infants and toddlers in foster care substantially reduced rates of recidivism but had no effect on length of time in care.

Nurse home visiting: Perspectives from nurses

Nurses working in the Nurse Family Partnership (NFP) program provide intensive home-visitation services for first-time, low-income mothers. The goals are to improve maternal health outcomes, child health and development outcomes, and to enhance maternal life-course development; however, many of the families face significant psychosocial and mental health issues that can impede progress achieving their goals. Because of the importance of the nurse-client relationship in achieving positive outcomes, these non-mental-health nurses must shift their approaches and techniques from a medical to a psychosocial model. In this article, we examine the role of the nurse in the NFP and present results of focus groups with experienced NFP nurses regarding their perspectives, challenges, and rewards in conducting this work.

The process and promise of mental health augmentation of nurse home-visiting programs: Data from the Louisiana Nurse–Family Partnership

The Nurse-Family Partnership (NFP) model is a well-studied and effective preventive intervention program targeting first-time, impoverished mothers and their families. Data documenting the negative impact of maternal depression and partner violence on the developing young child can be used to make a strong case for augmenting NFP programs to focus on mental health problems impacting the mother-child relationship. This article reviews the rationale for and process of augmenting an NFP program in Louisiana. Data on the prevalence of depression and partner violence in our sample are presented alongside a training protocol for nurses and mental health consultants designed to increase the focus on infant mental health. The use of a weekly case conference and telephone supervision of mental health consultants as well as reflections on the roles of the mental health consultant and the nurse supervisor are presented.

Predictors of permanent loss of custody for mothers of infants and toddlers in foster care

The maltreating mothers of abused and neglected infants and toddlers were evaluated as part of an intensive intervention program. The purpose of this study was to examine cumulative risk versus specific risk factors that led to permanent loss of custody by mothers, predicated upon decisions by the Juvenile Court with regard to permanency planning. The following risk factors were analyzed as potential predictors of placement outcomes: maternal education, maternal history of abuse as a child, history of psychiatric difficulties, substance-abuse history, conviction history (excluding child-abuse charges), depressive symptomatology, degree of partner violence experienced, and cumulative number of risks the mother experienced. Results indicated that mothers who lost custody had significantly more risk factors than those who were reunified with their children. Cumulative risk was a stronger predictor than specific risk factors. Implications for intervention are discussed.

Conceptual and Clinical Dilemmas in Defining and Assessing Role Reversal in Young Child-Caregiver Relationships

SUMMARY Recent advances in theory and developmental science have contributed to a more thorough clinical understanding of role reversal in the young child-caregiver relationship. A comprehensive review of published literature in the areas of attachment theory, developmental capacities of the infant, child rearing practices, and parental beliefs was undertaken to determine how each of these areas inform the definition, assessment, and treatment of role reversal. It is suggested that a micro-analytic approach to the assessment of caregiver and young child interactions holds merit and may provide guiding principles for intervention.

Attachment and Trauma in Early Childhood: A Review

Attachment relationships are critical to a young child’s optimal development. Both the presence and quality of attachment matter. Experiences of trauma can affect caregiver/child attachment relationships in a variety of ways. This article explores possible associations among trauma and the presence and quality of attachment relationships between young children and their caregivers. The nature of attachment, phases in the development of attachment relationships, and classifications of the quality of attachment are presented. Possible linkages among past traumatic experiences, parental states of mind, parental interactive behaviors, and infant attachment relationships are postulated. The most severe attachment disturbance, reactive attachment disorder, is discussed, including evidence that suggests modification of the current formulation of reactive attachment disorder subtypes; namely, that the indiscriminate subtype of reactive attachment disorder may not qualify as an attachment disorder. More research is needed to better understand reactive attachment disorder and the reciprocal relationships between attachment and trauma experienced by both parents and children.

Reflective practice in infant mental health training and consultation

This article describes models of training in infant mental health that utilize reflective supervision as a fundamental component of the educational and clinical experiences. The design and structure of these programs, offered by two medical centers, are described. Benefits and challenges to the adoption of infant mental health practice by trainees are outlined. Incorporation of reflective supervision in the training is discussed, and clinical examples are provided to illustrate its essential role in the development of the infant mental health clinician.