(p. 487) Family-Based Interventions for Children with Prenatal Substance Exposure
As noted elsewhere (see Salo, Chapter 10, this volume) and in a burgeoning scientific literature, children with prenatal substance exposure (PSE) face a multitude of risks. These include an increased likelihood of developmental delays, emotional and behavioral disorders, psychiatric diagnoses, academic difficulties, substance abuse, and juvenile justice system involvement (Delaney-Black et al., 1998; Hellemans et al., 2010; Lester et al., 2009; Levine et al., 2008; Seifer et al., 2004; Sood et al., 2001; Streissguth et al., 2004). Because these children typically experience many known environmental risk factors for poor outcomes (e.g., poor parenting, poverty, and increased family stress), it is difficult to determine which poor outcomes result from PSE, other risk factors, or some combination of risk factors.
Due to the interplay between PSE and complex family and environmental factors, individual children with PSE are likely to struggle with a constellation of difficulties in their everyday functioning. While some children with substance-using parents can demonstrate normal functioning, researchers have shown that there is a considerable variation in the effects of PSE and that individual children and adolescents with PSE are likely to experience one or more of the following difficulties: externalizing/internalizing behavior problems, social competence deficits, oppositional behavior, language delays, fine motor deficits, academic under-achievement, memory deficits, inattention, hyperactivity and poor impulse control, poor executive function, sleep difficulties, cognitive inflexibility, learning difficulties, delinquency, inappropriate sexualized behavior, and substance abuse (Acra, Bono, Mundy, & Scott, 2009; Goldschmidt, Richardson, Cornelius, & Day, 2004; Hellemans et al., 2010; Janzen, Nanson, & Block; T. J. Linares et al., 2006; McLaughlin, Williams, & Howard, 1998; O’Leary et al., 2009; Olson, Feldman, Streissguth, Sampson, & Bookstein, 1998; Streissguth, Barr, Kogan, & Bookstein, 1997; Streissguth et al., 2004).
Further complicating research on the effects of prenatal exposure is the extent of heterogeneity in maternal substance use. It is increasingly common for substance abusers to use multiple substances (Rounsaville, Petry, & Carroll, 2003; Staines et al., (p. 488) 2001). Research on the comorbidity of alcohol dependence and other substance use indicates that the majority of women admitted to alcohol-abuse treatment programs report using another substance at least once a week in the year preceding treatment (Caetano & Weisner, 1995), and two-thirds of individuals entering treatment have used another substance within 90 days of beginning treatment (Staines et al., 2001). Estimates of specific drug-use among alcoholics are strikingly high. In the general population, alcoholics report abusing cocaine (30%–60%), marijuana (20%–50%), and benzodiazepines (12%–20%; Petry, 2001).
Given the high incidence of polysubstance use in the general population, it is likely that infants prenatally exposed to an identified substance have been exposed to other substances in utero. However, prenatal polysubstance exposure has not adequately been addressed in the current literature, which tends to focus on the in utero effects of substance-specific exposure. Heterogeneity of substance exposure might explain, in part, the varied constellation of symptoms found among infants and children with PSE.
It is also becoming apparent that children with PSE manifest not only psychological difficulties but also neurodevelopmental deficits. Although the nature and extent of these deficits can vary, there appears to be a coherent behavioral endophenotype involving neurobehavioral disinhibition among children with PSE (Chapman, Tarter, Kirisci, & Cornelius, 2007; Kirisci, Tarter, Reynolds, & Vanyukov, 2006; McNamee et al., 2008). Neurobehavioral disinhibition may reflect difficulties in executive functioning, alterations in reward sensitivity, and difficulties with stress regulation (Lester & Padbury, 2009). Prior studies have found alterations in underlying neural systems (e.g., prefrontal cortex function, hypothalamic-pituitary-adrenal axis) in children with PSE (Fisher, Kim, Bruce, & Pears, 2012; Fisher, Lester, et al., 2011).
Behavioral difficulties that can indicate poor neurological functioning include increased symptoms of attention deficit hyperactivity disorder (ADHD), emotion dysregulation, deficits in executive functioning, and poor response-inhibition and impulse control as evidenced by increased rates of conduct disorder and oppositional defiant disorder (Kirisci et al., 2006; Tarter et al., 2003). Given the breadth of these difficulties, underlying neurodevelopmental deficits might explain why conventional mental health services have limited utility in addressing the multifaceted needs of this population.
Because of the neurodevelopmental effects of PSE and the complexity of the environments in which children with PSE typically live, effective treatments should be more comprehensive and intensive than those for children without PSE. Of particular importance when identifying effective interventions is a focus on decreasing risk factors and increasing protective factors, maintaining stable home placements and positive parent–child interactions, and providing services that are developmentally and age-appropriate (Bertrand et al., 2004; Streissguth et al., 1997). Family-based interventions may be a particularly promising approach for children with PSE because they address individual and environmental factors.
Parenting children with PSE is highly challenging. For biological parents managing their own addiction and recovery, the added stress of parenting a special-needs child can be overwhelming. Higher levels of parenting stress and maladaptive (p. 489) parenting practices (e.g., abuse and neglect) have been observed among mothers who used drugs during pregnancy (Kelley, 1998). Parenting stress has been shown to predict externalizing and internalizing behavior problems in children regardless of drug exposure (Accornero, Morrow, Bandstra, Johnson, & Anthony, 2002; Bagner et al., 2009).
Additionally, high rates of maternal distress coupled with substance abuse during pregnancy have been shown to negatively impact children’s cognitive functioning (Singer et al., 1997). Johnson, Nusbaum, Bejarano, and Rosen (1999) found that maternal stress and a lack of social support interfered with a mother’s emotional availability and responsiveness, predicting, in turn, poorer functioning in toddlers with PSE. Conversely, children with PSE have been shown to demonstrate improved functioning in multiple developmental domains when placed with kinship or foster caregivers (who exhibited significantly less parenting stress) compared to children with PSE who lived with their biological parents (Brown, Bakeman, Coles, Platzman, & Lynch, 2004).
Additional environmental risk factors commonly associated with substance abuse (e.g., maternal depression, negative life events, psychiatric problems, and incarceration) are likely to increase overall stress, potentially decreasing effective parenting practices and increasing the likelihood of abuse and neglect (Nair, Schuler, Black, Kettinger, & Harrington, 2003).
As noted above, when providing family-based services for children with PSE, there is likely to be a host of contextual risk factors that must be considered. Hutchins and Dipietro (1997) found that women who had used cocaine during pregnancy were more likely to suffer from depression and to have family histories of substance abuse, personal histories of abuse (particularly sexual abuse), less social support, partners who are currently using substances, and less stable living conditions. Many concomitant environmental factors can contribute to or exacerbate the prevalence of sociobehavioral and mental health problems for children with PSE (e.g., living with a parent who has a substance abuse problem, early parental death, maternal depression, maltreatment, transient living, child welfare involvement and subsequent out-of-home placement, and being raised by foster or adoptive parents; O’Connor & Kasari, 2000; Streissguth et al., 2004).
Among children with PSE, potentially diverse developmental challenges, heterogeneity of problems, and potentially diverse caregiver risk factors make treatment selection increasingly complicated. These complexities highlight the need for comprehensive, multidimensional treatment modalities to address skill development across several domains and settings in this population. Early intervention is particularly important for these children. Consistent with diathesis–stress formulations (Zuckerman, 1999), early adversity can cause individuals to be highly vulnerable to later stressors, which mediate poor outcomes. These vulnerabilities sensitize children to environmental stressors that are more prevalent for children with PSE. This increased vulnerability to stressors negatively influences neurophysiological and socioemotional-behavioral development (Gutman & Nemeroff, 2003; Jutras-Aswad, DiNieri, Harkany, & Hurd, 2009). Furthermore, the fact that the developmental windows during infancy and childhood in which integral skills (p. 490) can be remediated are potent, but limited, increases the need for targeted and effective intervention.
In the following section, we describe a number of family-based interventions. Some of these programs were designed specifically for children with PSE and their caregivers. We also present several evidence-based therapies that are likely to be effective with, but were not originally designed for, this population; these are discussed because they target salient outcomes and the methods of treatment delivery are suitable to the needs of this population.
Family-based interventions are emphasized over child-only treatments for several reasons. First, children are more likely to generalize skills that have been practiced in a naturalistic setting. By training a family in therapeutic techniques, the child can be immersed in a learning environment that fosters skill development and a positive parent–child dynamic. When children receive therapy or training in a removed context (e.g., in an individual therapist’s office), they are less likely to transfer skills to the intended settings (e.g., home, school, and community). Secondly, given the extant risks, comorbid factors, and familial issues noted above, it is imperative that families be included in the treatment process. Parents play an unparalleled role in developing and maintaining skills and behaviors in their children by their use of encouragement and limit-setting. Without parents’ inclusion in the therapeutic process, children might not sustain their gains and master new skills and behaviors. Third, family-based interventions allow parents to voice their values and priorities in treatment planning. Such participation is likely to increase parents’ ownership of their roles in treatment and increase their involvement.
There is a paucity of interventions developed specifically for children with PSE and their families. In fact, there are very few comprehensive and ecologically informed intervention approaches that have been designed for this population. Of those that are available, many have only been field-tested, and few have been studied with methodological rigor. Most of the programs described below were not developed specifically for children with PSE but were developed for children with similar prevalent, significant social-behavioral problems. These programs generally target issues germane to this population: social-behavioral deficits, self-regulatory deficits, effective parenting practices, family wellness, and parenting stress. Not every program addresses each issue; similarly, not every child with PSE or their caregiver needs treatment across all of these domains. Treatment selection must be guided by the child and family’s unique needs. Although several of the programs discussed below were not explicitly studied with children with PSE, there is reason to believe that they would have similar positive outcomes. Ultimately, these should be empirically examined. In the meantime, however, children with PSE, their families, and their treatment providers must make decisions in good faith regarding care from the options currently available.
In the following section, we describe family-based intervention programs that involve the parent and child in treatment and/or utilize the parent as a therapeutic agent for change. These programs range in age and intervention targets and are categorized into two primary types: home-based programs for children living with their biological caregivers, and child welfare programs for children living in kinship or foster care.
(p. 491) Home-Based Programs
Children’s Friendship Training
Although initially developed for children with autism spectrum disorders (Frankel & Myatt, 2003; Frankel et al., 2010), Children’s Friendship Training (CFT) was adapted for use for children with fetal alcohol spectrum disorders (FASD) due to a prevalence of social skill deficits in both populations. CFT is rooted in social learning theory and is a manualized, evidence-based social skills intervention that has demonstrated efficacy with children who have autism spectrum disorders, ADHD (Frankel, Myatt, Cantwell, & Feinberg, 1997), and oppositional defiant disorder (Frankel & Myatt, 2003). In modifying the program, researchers took into account the neurocognitive deficits typical among children with FASD (e.g., poor language performance, problems with memory, poor executive functioning, and inadequate play skills) and addressed them by adapting the treatment delivery process without changing the core content or intervention components (Keil, Paley, Frankel, & O’Connor, 2010; Laugeson et al., 2007). Adaptations to address language deficits included breaking down content into smaller components, increasing opportunities for exposure and rehearsal of new material, presenting information in multiple formats, and emphasizing the use of simpler and repetitive language appropriate to children’s developmental levels. Adaptations to address memory and executive functioning deficits included increased use of verbal prompts, increased use of role-playing, and requests of parents to increase rehearsal and review of homework assignments. Behavioral issues were addressed in the adaptation by regularly reviewing the group rules and expectations for behavior, utilizing positive reinforcement techniques to increase prosocial behavior and minimize behavior problems, and providing children who demonstrated significant problem behaviors with more intensive individualized supports, such as incentives for targeted behavior goals. Lastly, to accommodate deficits in play skills and limited peer networks, the parents were asked to schedule regular game times to provide additional practice selecting and playing games the children would be likely to play with a peer. Parents were also encouraged to enroll children in extracurricular activities with children of a similar developmental (not chronological) age to increase the likelihood of social success and acceptance (Laugeson et al., 2007).
The intervention consists of 12 concurrent child and parent group sessions that occur once weekly for 90 minutes and are designed to teach 6- to 12-year-olds specific social skill behaviors (e.g., social communication, reciprocal peer interactions, and conflict resolution) and to encourage parents to facilitate prosocial peer-relationship development by coaching children in navigating social situations and facilitating relationship development with potential playmates. Examples of group topics for children include having a conversation, joining a group of children at play, being a good sport, and handling bullies and conflict situations. Parents explore topics such as supporting child friendships and play dates, and handling teasing. Key features are taught through simple rules of social behavior, modeling, rehearsal, and feedback during intervention sessions and through home-based rehearsal and practice assignments.
(p. 492) Researchers have examined CFT’s impact on social skills development and maintenance over time (O’Connor et al., 2006) and changes in social information processing, focusing specifically on the impact of social information processing on hostile attribution (Keil et al., 2010) in a sample of 100 children with FASD. The results showed that, three months after receiving CFT, the intervention children demonstrated significantly improved social skills and decreased hostile attribution compared to the control children who also had documented prenatal alcohol exposure (Keil et al., 2010). The results were not observed, however, by the children’s regular teachers in the school setting (O’Connor et al., 2006), indicating the need for further research and strategies to improve the generalization of skills to other settings.
Families Moving Forward
Families Moving Forward (FMF) is a low-intensity behavioral consultation intervention carried out by local mental health providers with specified FMF training that lasts from nine to 11 months and provides the parents of children with FASD at least 16 bimonthly sessions. FMF, based on social learning theory, is designed to help caregivers learn new behavioral strategies to increase positive parental behavior when confronting challenging child behavior. FMF consists of basic training concepts and a host of additional topics for individualization. The core concepts include providing information regarding FASD, altering caregiver negative thoughts about his/her child by increasing their knowledge of how the neurodevelopmental effects of FASD influence a child’s acting-out behaviors, advocating for certain accommodations that a child might need, increasing access to community resources, and addressing caregiver-related issues (e.g., addiction, recovery, and self-care). The parents can also have consultations on behavior management, medical issues, coping, and relationship issues.
The program is currently being studied at the University of Washington and Seattle Children’s Research Institute, but some preliminary evidence of the program’s efficacy is available. In a small randomized control trial, 52 families with children (ages 5–11 years) were assigned to either the FMF intervention group or a standard-of-care group that received available community services (Bertrand, 2009). All children had FASD diagnoses and externalizing and/or attention problems. After participating in FMF, the parents in the experimental group had significantly improved parenting-related self-efficacy and increased self-care behaviors compared to the control parents. The FMF parents also reported that their family needs were being met more frequently, they had higher satisfaction with service providers, and their children had decreased disruptive behavior problems. Parental social satisfaction with FMF was also extremely high: parents reported that the intervention included the right amount of services.
Parent Management Training
Parent Management Training (PMT) is an individual- or group-based intervention designed to educate parents in effective practices for improving parent–child (p. 493) interactions, decreasing child inappropriate or problem behaviors, and increasing child prosocial behavior (Kazdin, 2003). PMT is built upon the principle that parent–child interaction is central to shaping child prosocial or antisocial behavior (Patterson, Reid, & Dishion, 1992; Reid, Patterson, & Snyder, 2002).
The dynamics underlying the coercive family process (Patterson, 1982) have particularly influenced the treatment components of PMT. Coercive parent–child processes serve to interfere with the development of prosocial behavior due to ineffective, harsh, or inconsistent discipline practices from parents that tend to reinforce children’s negative behavior. In PMT, families are taught to condition the desired prosocial behaviors through contingency management (reinforcement balanced with limit-setting) and reconceptualizing problem behaviors as shaping and teaching opportunities. The parents are encouraged to think of problem behaviors as skill deficits and are taught to provide a high rate of encouragement and feedback toward the development of prosocial behaviors, in balance with setting predictable and consistent limits on inappropriate behaviors. A typical example might include establishing a token-economy or sticker-chart system that encourages a desired behavior and giving the child a brief time-out or removing a privilege for a problem behavior.
PMT Oregon (PMTO), a variation of PMT that is highly structured and based on social learning theory and interaction principles (Forgatch, 1994), is intended for use with the parents of children who have severe and chronic behavior problems. In PMTO, the parents learn how to reduce problem behaviors and prevent subsequent escalations through encouragement, discipline, positive involvement, monitoring, and problem-solving (Forgatch & Martinez, 1999).
PMT is one of the best-investigated interventions for children and adolescents and has been studied in scores of randomized controlled trials with children (ages 12–17 years; Kazdin, 1997). Clinically significant improvements have been observed in up to two-thirds of children with disruptive behavior disorders (Kronenberger & Meyer, 2001). Forgatch and DeGarmo (1999) discussed the positive impact that PMTO has been shown to have on parenting practices. Furthermore, other researchers examining PMTO have shown parenting practices to mediate long-term child outcomes such as noncompliance, delinquency, and internalizing and externalizing behavior problems (DeGarmo & Forgatch, 2005; DeGarmo, Patterson, & Forgatch, 2004; Martinez & Forgatch, 2001). The principles of PMT have been integrated into numerous program variations to address particular populations.
Although there is no literature on PMT and its effectiveness specifically in children with PSE, several principles of PMT could be highly effective with this population. PMT asks parents to give clear and specific directions when making requests. This is particularly salient for children with cognitive difficulties and developmental delays, as the parents are encouraged to identify their child’s unique learning and understanding capabilities and modify parenting accordingly. Similarly, PMT guides parents to identify meaningful targets for child skill development and utilize encouragement and limit-setting methods that the child will be most responsive to. This highly individualizable approach is ideal for children with PSE due to the heterogeneity of behavioral concerns. Lastly, PMT emphasizes structuring the (p. 494) environment to increase predictability, using therapeutic parenting approaches consistently, and providing many practice opportunities. For children with cognitive and learning deficits, this approach is integral to shaping skills and increasing the likelihood of generalization across settings.
Parent–Child Interaction Therapy
Parent–Child Interaction Therapy (PCIT; Eyberg & Boggs, 1998) is an evidence-based, behavioral parent-training model designed to decrease child behavior problems. Originally designed for preschool-age children, PCIT has been studied with the parents of children up to 12 years old with positive outcomes. PCIT’s intervention targets include improving the quality of the parent–child relationship, decreasing child behavior problems, increasing child prosocial skills, and establishing parental use of positive discipline practices. The PCIT therapist observes the parent and the child interacting in a clinic setting and coaches the parent on using effective parenting techniques via a headset or earbuds. The intervention is short-term, typically lasting 12 to 16 weeks (one-hour weekly sessions). Similar to PMT, PCIT is a highly individualizable intervention that readily adapts to variety of presenting problems that are typical for children with PSE and their parents. The intensive in vivo coaching available to parents has a great deal of utility when working with high-risk families such as those with histories of substance abuse problems; these families are likely to struggle with numerous extraneous stressors and have difficulty adopting new parenting practices, and could benefit from intensive feedback.
The theoretical underpinnings for PCIT identify the root of child behavior problems as being within the parent–child relationship. The intervention model posits that improving the parent–child dynamic will result in reductions of externalizing behavior problems (Eyberg, Nelson, & Boggs, 2008). The treatment is characterized by two distinct phases. Phase 1, Child-Directed Interaction, is focused on relationship enhancement: strengthening parent–child attachment and increasing child prosocial skills and positive parenting practices. Phase 2, Parent–Child Interaction, is focused on the use of effective discipline practices to reduce child noncompliance and other problem behaviors and on supporting parents in developing appropriate expectations for the child.
To date, there has only been one study examining the effects of PCIT in children with PSE (Bertrand, 2009). Bertrand reviewed a study from the University of Oklahoma Health Sciences Center in which researchers compared a group version of PCIT to a less intensive parenting support and management intervention comprising components from other effective behavioral interventions. No attempts were made to modify PCIT for this population. Children with FASD were randomly assigned to the treatment groups, and both groups demonstrated significant reductions in problem behavior, though not significantly differing from each other.
In addition to this study, the results from a number of other studies lend credence to implementing PCIT with this population; the effectiveness of PCIT has been examined in children who demonstrate many of the comorbid issues present (p. 495) among children with PSE. Bagner and Eyberg (2007) examined the effectiveness of PCIT for treating disruptive behavior problems in children with mental retardation through a small randomized control trial. Their results indicated fewer disruptive behaviors, increased compliance, decreased parenting stress, and increases in positive parent–child interactions post-intervention. More extensive exploration is warranted, however, to examine whether the different etiologies of comparable problem behaviors among children with mental retardation and children with PSE underscore inimitable treatment needs.
Further, although McDiarmid and Bagner (2005) did not explicitly study children with developmental disabilities, they argued that a number of critical features in the PCIT program map onto the learning needs of such children, and that, with slight modifications (i.e., word simplification), PCIT could effectively reduce disruptive behaviors among this population.
In another study, Bagner, Sheinkopf, Vohr, and Lester (2010) examined the effects of PCIT with children born prematurely, a common occurrence among infants with PSE. Their results indicated that, compared to the families that did not receive the intervention, the PCIT families reported fewer attention problems, decreased aggression, decreased internalizing and externalizing problems, and increased compliance among their children. In addition, the parents were observed to engage in more positive parenting practices and reported lowered stress related to child behavior problems.
Nixon (2001) found that, compared to their same-age peers, the behavior-disordered children of parents who received PCIT demonstrated significant decreases in hyperactivity and exhibited more temperamental flexibility. These changes were sustained at a six-month follow-up.
PCIT has also been found to be effective at improving parent–child interactions and discipline practices among families with histories of physically abusing their children (ages 4–12; Borrego, Urquiza, Rasmussen, & Zebell, 1999; Chaffin et al., 2004). This is particularly meaningful given the co-occurrence of maltreatment among many families with substance abuse problems. In fact, some of the families in the study by Chaffin et al. reported prior and/or current substance abuse problems. Although these reports do not indicate that the children in the study were prenatally exposed to substances, there is an increased likelihood that some may have been. In an alternate child welfare context, PCIT foster caregivers have reported lower levels of parenting stress and high rates of satisfaction with the intervention model (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Timmer, Urquiza, & Zebell, 2006).
To be modified effectively for use with the PSE population, additional consideration must be given to developmental principles. Children with PSE are likely to demonstrate inattention (Leech, Richardson, Goldschmidt, & Day, 1999), and their parents will probably need guidance in giving clear directions and using frequent prompts and redirection. Such children might also be struggling with receptive and expressive language delays (Morrow et al., 2004), necessitating that parents emphasize clear and repetitive wording for commands or prompts. Lastly, PCIT therapists might need to provide additional guidance regarding a parent’s expectations for growth and behavior change: the (p. 496) trajectories of children with PSE often differ from children with more typical development.
The Incredible Years
The Incredible Years parent-training program is rooted in social learning theory and the principles of negating the coercive family process; it is one component of a three-part series (which also includes teacher- and child-training modules) designed to promote parenting competencies and strengthen families with children (ages 0–12 years; Webster-Stratton & Reid, 2003). The parent-training module targets parental nurturance and self-confidence regarding parenting, positive and therapeutic discipline practices, problem-solving, communication, support, school involvement, and collaboration with teachers. The program is delivered via basic or advanced curricula, and the number of group-based training sessions varies by age range.
The Basic curriculum is completed across eight to 20 group-based sessions that occur weekly for two hours. These sessions include brief videotape vignettes modeling parenting skills focused on social learning and child development principles. The group facilitator discusses the vignettes, which serves to stimulate problem-solving and collaborative learning. The Advanced curriculum (completed after the Basic training) includes additional vignettes to be viewed and discussed over nine to 12 sessions and targets the complex personal and interpersonal risk factors salient to families at greater risk (e.g., parental depression, marital discord, lack of social support, poor problem-solving, and environmental stressors) that contribute to coercive family processes and inhibit the use of positive parenting practices. The Advanced curriculum provides training on four domains: personal self-control, communication skills, problem-solving skills, and strengthening social support and self-care.
Although training programs exist for children as old as 12 in The Incredible Years, the developers focused primarily on ages three to eight for several reasons (Webster-Stratton & Reid, 2003). First, the beginnings of oppositional defiant disorder and conduct disorder can be seen as early as age four. Second, early intervention is more effective at preventing subsequent maladjustment at home and at school. Third, school readiness and a positive early school experience predict greater achievement over time. Fourth, young children with significant conduct problems frequently go untreated, which results in a negative developmental trajectory.
The Incredible Years has been researched extensively, including six randomized control trials designed by the developer and colleagues (Webster-Stratton, 1981, 1982, 1984, 1990, 1994, 1998; Webster-Stratton & Hammond, 1997; Webster-Stratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988). Several independent replication studies have also been conducted (Brotman et al., 2003; Jones, Daley, Hutchings, Bywater, & Eames, 2007; Larsson et al., 2009; J. Patterson et al., 2002; Scott, Spender, Doolan, Jacobs, & Aspland, 2001; Spaccarelli, Cotler, & Penman, 1992; Taylor, Schmidt, Pepler, & Hodgins, 1998), and effect sizes have been moderate to strong. Compared to the (p. 497) control groups, the children of parents using this program have been shown to exhibit significant reductions in aggressive and destructive behavior, decreased oppositional and defiant behavior, increased prosocial behavior and social competence, and improved problem-solving. Further, compared to the control groups, the parents using this program have been shown to exhibit decreased harsh and inconsistent discipline practices, increased use of effective discipline practices, and improved marital problem-solving as compared to controls. In addition, all of these studies have indicated long-term effects that were not differentially affected by child gender, parental ethnicity, socioeconomic status (SES), or level of parental education.
Although the program has been studied as a prevention strategy with high-risk populations (Barrera et al., 2002; Brotman et al., 2003; Gross et al., 2003; Webster-Stratton, 1998; Webster-Stratton, Reid, & Hammond, 2001), no studies have been conducted using The Incredible Years specifically with the parents of children PSE and little attention has been paid to examining the effectiveness of the program with special-needs children. However, some level of generalizability for children with PSE can be argued.
Linares, Montalto, Li, and Oza (2006) piloted The Incredible Years as a co-parenting training program for foster caregivers paired with mandated biological parents. Their results indicated increased positive parenting in the foster and biological parents and increased collaborative co-parenting in the treatment condition. Similarly, the program was piloted with 136 families who had open child welfare cases; the results indicated significantly decreased levels of parenting-related stress and child behavior problems compared to baseline measures (Webster-Stratton & Reid, 2010). McIntyre (2008a, 2008b) adapted the program for children with intellectual and developmental disabilities. The results indicated reductions in negative parent and child behavior after receiving the intervention. Lastly, Jones et al. (2007) found that The Incredible Years program resulted in significant reductions in ADHD symptomatology. These findings held even after controlling for post-intervention changes in rates of defiance.
The Nurse-Family Partnership (NFP) program is an evidence-based community intervention that supports the health care needs of low-income, first-time mothers. The mothers are enrolled in the program early in their pregnancy and begin receiving home visits from a NFP-registered nurse no later than their twenty-eighth week of pregnancy. Approximately 64 home visits are conducted until the child is two years old. The NFP nurse works with the mother from a strength-based perspective to provide education regarding preventive health and prenatal care practices (e.g., diet and substance use); emotional support to prepare for motherhood; education regarding child development and positive parenting practices; and life coaching for the mother and her family regarding self-efficacy, economic self-sufficiency, and personal future-oriented goals.
Ongoing research has been conducted on the NFP program for over 30 years based on three large-scale randomized control trials with almost 20 years of (p. 498) longitudinal follow-up. The program has been shown to improve prenatal health–related behavior (Olds, Henderson, Chamberlin, & Tatelbaum, 1986), reduce rates of child abuse and neglect, decrease unintended subsequent pregnancies, increase intervals between pregnancies, reduce welfare dependence, decrease maternal criminality, decrease maternal substance abuse, reduce the rate of child intellectual impairment due to tobacco exposure in utero, reduce childhood injuries, reduce juvenile criminality and antisocial behavior, reduce juvenile substance use, and increase child school readiness and academic achievement (Eckenrode et al., 2000; Eckenrode et al., 2010; Kitzman et al., 2000; Kitzman et al., 2010; Olds, Henderson, Chamberlin et al., 1986; Olds, Henderson, Tatelbaum, & Chamberlin, 1986; Olds, Henderson, & Tatelbaum, 1994a, 1994b; Olds et al., 1997; Olds et al., 2004). Moreover, the NFP program has been shown to significantly reduce government spending as compared to matched controls, even after accounting for the program cost (Olds et al., 2010).
Although the NFP program’s effectiveness for at-risk families has been well demonstrated, no specific information regarding children with PSE in the treatment or control groups or differential effects has been reported. However, a number of the program’s components might be well suited to this population. First, the program is highly individualizable, allowing unique child and family-related factors to be addressed in treatment. Second, the program’s strong emphasis on development and health-related factors is essential for the parents of children with PSE. Third, the program relies on the early identification and recruitment of mothers for enrollment and treatment, enabling intervention during crucial early development.
SafeCare, an evidence-based parent-training model rooted in social learning theory, is designed for families who are at risk for, or who have already been reported for, child maltreatment (Lutzker & Bigelow, 2002). Based on an ecobehavioral approach, the SafeCare treatment components were derived from the understanding that maltreatment arises in combination with individual parental factors, parent–child interactions, family factors, and greater societal and cultural factors (Edwards & Lutzker, 2008). The program has four primary modules: Health (e.g., preventing and treating common illnesses), Home Safety (e.g., identifying and eliminating safety hazards in the home), Parent–Child or Parent–Infant Interactions (e.g., training parents to promote development, increase positive interactions, and manage difficult behaviors), and Problem-Solving/Counseling (e.g., offering solution-oriented problem-solving and counseling techniques to be used across the three content modules and to address parent needs that fall outside the range of the SafeCare model). The intervention is delivered via home visitors who work with the parents until they reach a set of skill-based criteria for each module.
Compared to the control families, the SafeCare families have been shown to be less likely to have an initial child maltreatment report or recurrence or to have a child removed from their home (Gershater-Molko, Lutzker, & Wesch, 2002). (p. 499) High rates of accuracy in skill demonstration have also been observed. Further, the SafeCare children have demonstrated 85% compliance with parent requests (compared to 69% compliance at baseline), and the SafeCare parents have demonstrated at least 85% reductions in overall hazards in the home (Edwards & Lutzker, 2008).
Due to the complex and multifaceted risks of families with substance abuse problems and children with PSE, the risk for maltreatment is high. Although this program could be an excellent targeted prevention measure for families with histories of substance abuse and children with PSE, no researchers have examined the effectiveness of SafeCare in this population.
Child Welfare Programs
Children with PSE come to the attention of child protective service agencies for variety of reasons (e.g., identification at birth, community referral identifying a potential for child abuse or neglect, and parental criminal activity). Out-of-home care for these children is not uncommon. In one sample of 415 individuals with FASD, 80% were not raised by their biological mothers (Streissguth et al., 2004). Related to this, in a study reviewing the case records of 639 children in out-of-home care (kin or foster care placements), 79% of the caregivers met the criteria for substance abuse (Besinger, Garland, Litrownik, & Landsverk, 1999). Being a foster caregiver for children with emotional and behavioral difficulties is nothing short of challenging; these children often have significant social and behavioral difficulties that can lead to a multitude of negative outcomes (Brooks & Barth, 1998; Bruce, Fisher, Pears, & Levine, 2009; Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Fisher, Stoolmiller, Gunnar, & Burraston, 2007; Landsverk & Garland, 1999; Zima et al., 2000). Adding the developmental complexity typical of children with PSE makes the task exponentially more difficult. The factors leading to out-of-home placements for children with PSE (e.g., abuse and neglect) serve to significantly elevate risks to a child’s overall functioning and well-being. Foster children with PSE exhibit higher rates of social, thought, and attention problems; delinquency; and aggression than those being cared for by their biological mothers or kinship caregivers (Linares et al., 2006; Minnes et al., 2010). Effective family-based services for foster caregivers are critical for addressing child behavior problems and stabilizing placements, as placement disruptions are correlated with a host of negative outcomes (Albus & Dozier, 1999; Courtney, 1995; Proch & Taber, 1985). Although not all of these programs were developed for the PSE population, their efficacy in stabilizing placements and fostering behavior change suggests that they are appropriate for this population.
Support and Training for Adoptive and Foster Families
There is evidence to suggest that many children with PSE will be placed in foster care within months of birth (Eiden, Foote, & Schuetze, 2007), yet foster caregivers rarely receive the type of education and support necessary to care for such infants (Burry, 1999; Zukoski, 1999). The Support and Training for Adoptive and Foster (p. 500) Families (STAFF) Project was developed in response to this need (Burry & Noble, 2001). The STAFF Project focuses on securing permanency for infants (ages 0–2 years) by providing training and support services to foster and adoptive caregivers. The curriculum elements were derived from a comprehensive review of the literature and feedback from 132 adoptive families of children with PSE regarding developmental needs and special parenting considerations. The six-hour curriculum includes five modules: 1) Introductory Activities; 2) Information on Substance Abuse, Addiction, Attachment, and Confidentiality; 3/4) Information on Caregiving for Infants With PSE Specifying Effects of Both Alcohol and Drugs; and 5) Long-Term Resources for Information Gathering, Support, and Assistance.
In a non-randomized quasi-experimental study, the participants demonstrated significant increases in content knowledge after participating in the intervention and reported high levels of social satisfaction (Burry & Noble, 2001). More methodologically rigorous research is needed to study the effectiveness of this program and to confirm these promising preliminary results.
Safe Babies Program
The Safe Babies Program was also developed in response to the need for specialized foster care for infants with PSE and is implemented as part of the Vancouver (Canada) Ministry of Children and Family Development (D’Angiulli & Sullivan, 2010). It was modeled after a pilot project aimed at providing specialized education and support to the foster families of infants with PSE and working with families to maintain an optimal caregiving environment (Marcellus, 2004). The Safe Babies Program provides support to foster caregivers via the following: a community health nurse; resource workers; an advisory committee; six training sessions addressing developmental considerations, health-related issues, safety, respite, and permanency planning; monthly meetings with a support group; and biannual newsletters.
In a non-randomized, quasi-experimental study of the program (with a small sample of pre-term and full-term foster infants with PSE), the results indicated an association between the program and positive developmental outcomes and physiological regulation (D’Angiulli & Sullivan, 2010). Additional research is needed to further examine the program’s effectiveness.
Multidimensional Treatment Foster Care
The Multidimensional Treatment Foster Care (MTFC) program is an intensive, comprehensive intervention for foster children (Chamberlain, Leve, & DeGarmo, 2007; Chamberlain & Reid, 1991). The program was developed as an alternative to regular foster care, group or residential treatment, and incarceration for children with pervasive, chronic behavior problems. Derived from principles of social learning theory and ecological theory, MTFC coordinates multiple treatment components to address the needs of children, their foster caregivers, and their biological parents across settings. The children receive individual therapy and (p. 501) behavioral skills training. In the preschool adaptation of the program (MTFC-P), the children also participate in weekly therapeutic playgroups to develop school readiness (Fisher, Ellis, & Chamberlain, 1999). The foster caregivers receive ongoing training and support in PMT and are trained to participate as members of the clinical team by implementing therapeutic interventions with a high rate of consistency in the home under the direction of a clinical team. The biological parents receive ongoing family therapy and consultation to improve parent–child interactions while the child remains in care to prepare for reunification. The MTFC children also benefit from school consultation and case management with other service providers (e.g., social workers, physicians, legal representation, and speech/language therapists).
Several randomized trials and numerous other studies have been conducted with the MTFC programs, yielding a robust evidence base for the program’s feasibility and effectiveness. The outcomes for Juvenile Justice youth in MTFC have been examined for males and females, with the results indicating higher rates of program completion, fewer days in locked settings, and significant decreases in criminal or delinquent activity compared to children in group care settings (Chamberlain & Reid, 1998; Eddy, Whaley, & Chamberlain, 2004; Leve, Chamberlain, & Reid, 2005). Furthermore, Juvenile Justice girls in MTFC have been shown to have higher rates of homework completion and school attendance during treatment (Leve & Chamberlain, 2006) and fewer pregnancies (Kerr, Leve, & Chamberlain, 2009).
The results from the MTFC-P randomized control trial demonstrate increased effective parenting practices in the foster home, reduced child behavior problems, improved physiological regulation, and improved attachment behaviors among MTFC-P children (Fisher, Gunnar, Chamberlain, & Reid, 2000; Fisher & Kim, 2007; Fisher et al., 2007). In addition, the MTFC-P intervention has been shown to significantly decrease risk for subsequent placement failures irrespective placement history (Fisher et al., 2000), thus increasing the odds of a successful permanent placement.
Project KEEP is a group-based, 16-week, manualized intervention of training, supervision, and support for foster and kinship caregivers (ages 5–12 years; Price, Chamberlain, Landsverk, & Reid, 2009). It integrates training content from MTFC and PMTO and emphasizes the use of positive reinforcement, effective discipline, and monitoring. The foster parents attend a training/support group session for one hour weekly to learn strategies for reducing child problem behavior and stabilizing the current foster placements. The session topics include contingency and reinforcement systems, limit-setting, power struggles, school success, and self-care. Home practice assignments are assigned each week and are reviewed the subsequent week.
The effectiveness of the original Project KEEP intervention was tested using a randomized control trial design with 700 families (Price et al., 2008). The authors examined the impact of the Project KEEP intervention on the likelihood of (p. 502) positive or negative placement changes among foster children and whether the intervention moderated the relationship between the number of prior placements and permanent placement failure. The families were randomized to treatment and control groups. For the control participants, the number of prior placements predicted negative exits from the current placement. Specifically, children with higher numbers of placement disruptions were more likely to experience a negative exit. The Project KEEP intervention, however, was shown to mitigate the risk of negative exits despite a history of multiple placements, and to increase the likelihood of a positive exit (e.g., reunification). The KEEP children also demonstrated significantly fewer behavior problems than the control group (Chamberlain, Price, Reid, & Landsverk, 2008).
Current and Future Directions
Children with PSE exhibit extremely high levels of risk given their co-occurring individual and contextual factors that interfere with healthy development. Without effective intervention, the trajectories for these children are fraught with difficulties. Many of the interventions discussed above, although not initially designed for children with PSE, may be effective with this population. However, the theoretical underpinnings of most family-based interventions posit that the crux of child behavior change lies within the parent–child interaction dynamic, wherein behaviors are maintained or discouraged. By contrast, children with PSE evidence behavioral difficulties that result in part from the neurological damage caused by PSE. Although the parent–child interaction pattern is an important influencing factor, it does not explain the entirety of the behavioral phenomenon demonstrated in this population. This highlights the importance of population-specific interventions or adaptations.
Interventions designed to address the unique and specific needs of this population are necessary. These interventions must be thoughtfully developed with consideration of the scope and diversity of factors salient to the treatment of children with PSE, their caregivers, and the relevant settings. A universal approach will not be capable of addressing all issues, but there are several key features that should be included in intervention development. First, treatment approaches that recognize the need for individualizing methods based on the ever-changing developmental and social-behavioral needs of the child are imperative to improving treatment outcomes. Treatment models must emphasize using developmentally appropriate instructional methods for the child-directed components of an intervention that support skill acquisition and generalization. Similarly, family-based interventions should address a caregiver’s understanding of the child’s unique developmental needs. Equipping a caregiver with the tools necessary to be proactive and responsive to the rapidly changing developmental and behavioral needs of the child is more likely to engender long-term success. Second, reducing environmental risk factors (e.g., substance use, lack of safety, and placement instability) is vital for overall success. Third, increasing protective factors (e.g., positive parent–child interactions, peer networks, academic success, and social support for parents and caregivers) is an important counterpoint to risk reduction. Fourth, providing parents and (p. 503) caregivers with strategies to mitigate stress, parenting-related and otherwise, is integral to effectively utilizing therapeutic parenting strategies and maintaining a positive and responsive approach. Without the necessary coping skills for dealing with the contextual risk factors germane to this population, parents struggle to make good use of even the most well-designed and effective methods.
These interventions must then be tested using rigorous methodological designs to establish a clear evidence base for their use. Randomized trials are also needed to examine existing interventions that are likely to be effective but were not originally intended for this population. Interventions such as MTFC-P, which have been shown to impact underlying neural systems affected by PSE such as the HPA axis, may be especially promising. Furthermore, it is likely that some of children with PSE were included in the studies noted above. In many cases, however, this has not been explicated in the literature; and a small number of children with PSE in a larger mixed sample would not prove sufficient. When possible (and in cases where the samples included a sizeable portion of this population), secondary analyses of the data are needed to examine the unique effects of the intervention on children with PSE. Specifically, for treatment utility and external validity, it is integral to examine whether children with PSE made differential gains and whether relevant meditating and moderating factors can explain the resulting variance in treatment outcomes.
As discussed above, therapeutic techniques and interventions that can be highly individualized might be most appropriate, given the heterogeneity and varying intensity of behavioral and developmental concerns among this population. One such technique is called Marte Meo (which translates as “on one’s own strength”), which has been field-tested worldwide. Given its limited empirical basis, Marte Meo was not included in the review of family-based interventions above. However, it has the potential to be highly efficacious with this population.
Developed in the Netherlands by Maria Aarts and colleagues, Marte Meo focuses on the observed strengths of a child and his/her parent or caregiver as a means of potentiating development (Aarts, 2008). In Marte Meo, a trained therapist works with a parent or caregiver, whose child may be of any age, to identify an aspect of the child or parent–child dynamic that needs improvement. Child social, emotional, linguistic, and cognitive developments are potential targets. The therapist then takes a short film of the child in a naturally occurring setting or activity and proceeds to carefully edit the film to illuminate the strengths observed in the child or parent–child interactions relevant to the identified need. These brief, edited films are then shown to the client with a microanalytic narration from the therapist, highlighting the frame-by-frame sequence of events that foster the child’s development. In this way, the Marte Meo therapist facilitates a shift in the parent’s perceptions of self and of their child and enables the parent to be more engaged and responsive to the child’s developmental processes. In total, the Marte Meo therapist might record five or six films for a treatment time of approximately three months.
Marte Meo has been field-tested with infants and children who struggle with attachment, irritable temperament, ADHD, autism, intellectual disability, communication delay, and mental health problems. It has been used with biological (p. 504) parents, foster caregivers, teachers, and other professionals and has been in practice in 30 countries for over 20 years. In a non-randomized control trial, Marte Meo was used for the early detection and intervention of externalizing behavior problems in a school setting with children (ages 4–12 years; Axberg, Hansson, Broberg, & Wirtberg, 2006). The Marte Meo children demonstrated significant decreases in problem behavior at home and school compared to the control children. These results were found to have been maintained at a two-year follow-up assessment.
Lastly, innovative techniques that might facilitate enhanced neurological functioning or promote plasticity also warrant examination. Therapies such as attention training (Amir et al., 2009; Rueda, Rothbart, McCandliss, Saccomanno, & Posner, 2005; Wells, 2007) or mindfulness training (Heywood, Fisher, & Tang, 2011) might help remediate deficits in self-regulation, attention, and cognitive flexibility. In addition, there are promising new approaches for using nutritional supplementation to facilitate neural plasticity and neurogenesis that might help improve outcomes (Thomas, Abou, & Dominguez, 2009). All of these approaches could prove to be appropriate adjunct therapies for enhancing the effectiveness of more comprehensive treatments for children with PSE and their parents and caregivers. Again, relevant scientific investigations into these approaches are needed.
At present, attempting to determine the best ways to address the needs of children with PSE leads to a multitude of unanswered questions. However, we should be encouraged by the numerous avenues opened for exploration, including risk-prevention efforts with women in high-risk groups, prenatal and postnatal treatment options, school- and home-based contexts for care and treatment, and long-term support systems for adolescents and adults with PSE. As we move forward, it is paramount that scientists conscientiously examine these approaches with methodological rigor and that practitioners refer children and families to treatments that are ecologically informed, developmentally sensitive, and focused on outcomes relevant to their unique needs.
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