Description of the condition
The Copehenhagen Child Cohort Study (n = 6090) found a population prevalence of mental health disorders (for example, emotional and behavioural, eating and sleeping disorders) in children aged 1.5 years to be in the region of 18% (Skovgaard 2008; Skovgaard 2010). Infant regulatory disturbances such as excessive crying, feeding or sleeping difficulties and bonding/attachment problems represent the main reasons for referral to infant mental health clinics (Keren 2001).
Problems of this nature are significant predictors of longer-term difficulties. For example, infant regulatory problems have a strong association with delays in motor, language and cognitive development, and continuing parent-child relational problems (DeGangi 2000a; DeGangi 2000b). In one study, 49.9% of infants and toddlers (aged 12 to 40 months) showed a continuity of emotional and behavioural problems one year after initial presentation (Briggs-Gowan 2006). Another study showed an association between difficult temperament, non-compliance and aggression in infancy and toddlerhood (age one to three years) with internalising and externalising psychiatric disorders at five years of age (Keenan 1998). Similarly, insecure and disorganised attachment in infancy is associated with poorer outcomes in later childhood across a range of domains such as emotional, social and behavioural adjustment, scholastic achievement and peer-rated social status (Granot 2001; Sroufe 2005a; Sroufe 2005b; Berlin 2008), particularly in the case of disorganised attachment, which is a predictor of significant later psychopathology (Green 2002).
Recent research has begun to show that infant regulatory and attachment problems can best be understood in a relational context. Significant risk factors for emotional, behavioural, eating and sleeping disorders are disturbances in the parent-child relationship and parental psychosocial adversity (Skovgaard 2008; Skovgaard 2010). Early research in the field of infant mental health and developmental psychology highlighted the significant role that the infant's primary caregiver plays in regulating the infant (Beebe 1988; Tronick 1989; Sroufe 1997; Tronick 1997), and more recently, the way in which this process is influenced by the parents' own capacity for self-regulation (Beebe 2010; Beeghly 2011).
Research focusing on the factors that influence the parent-infant interaction have derived mostly from the field of developmental psychology and, in particular, infant attachment research. This rapidly developing body of literature has found only modest correlations between ‘maternal sensitivity’ and infant attachment security (De Wolff 1997), prompting a search for more specific predictive factors. Recent research has focused on:
the specific nature or quality of the attunement or contingency between parent and infant (Beebe 2010); and
Parental reflective function refers to the parent's capacity to understand the infant’s behaviour in terms of internal feeling states. Research shows that reflective function is strongly associated with maternal parenting behaviours such as flexibility and responsiveness and that low maternal reflective function is associated with emotionally unresponsive maternal behaviours (withdrawal, hostility, intrusiveness). (Slade 2001; Slade 2005; Grienenberger 2005). Maternal reflective function is also associated with beneficial infant outcomes, such as greater use of mother as a secure base (Grienenberger 2005). Research also shows a significant association between parental ‘mind-mindedness’ (the parent’s capacity to accurately interpret what their child is thinking and feeling) and later development including attachment security at 12 months (Meins 2001).
Recent research has also highlighted a number of ‘atypical’ parenting behaviours that can occur during the postnatal period, including affective communication errors (for example, mother positive while infant distressed), disorientation (frightened expression or sudden complete loss of affect) and negative-intrusive behaviours (mocking or pulling infant's body) (Lyons-Ruth 2005). A meta-analysis of 12 studies found a strong association between disorganised attachment at 12 to 18 months and parenting behaviours characterised as ‘anomalous’ (that is, frightening, threatening, looming), dissociative (haunted voice, deferential/timid) or disrupted (failure to repair, lack of response, insensitive/communication error) (Madigan 2006). These atypical parenting practices were identified in parents described as ‘unresolved’ with regard to previous trauma (Jacobvitz 1997; Cicchetti 2006; Cicchetti 2010). However, disturbances to the mother-infant relationship are common and are associated with a range of maternal problems including postnatal depression (Murray 2003; Toth 2006; Timmer 2011), personality disorder (Crandell 2003; Pawlby 2005; Newman 2008; Pawlby 2010), psychotic disorders (Chaffin 1996), substance misuse (Suchman 2005; Tronick 2005) and domestic violence (Lyons-Ruth 2003; Lyons-Ruth 2005).
Description of the intervention
Over the past two decades, a range of interventions have been developed to address developmental problems in the infant, and problems in the parent-infant relationship, with a view to promoting optimal infant development. Parent-infant psychotherapy is rooted in findings from developmental and clinical research, and involves a parent-infant psychotherapist working directly with individual parent-infant dyads (or triads if two parents are involved) in the home, clinic or hospital setting, to address a wide range of problems that can arise during the antenatal and postnatal periods. Parent-infant psychotherapy comprises a theoretically guided dyadic intervention (that is, delivered concurrently to the parent and infant) that focuses on improving infant attachment security by targeting parental internal working models. The approach is essentially psychodynamic in that it involves identifying unconscious patterns of relating and seeing the parent-infant relationship itself as the focus of the intervention.
The earliest approach, developed by Selma Fraiberg (Fraiberg 1980) focused primarily on the mother’s ‘representational’ world (‘representation-focused’ approach) or the way in which the mother’s current view of her infant is affected by interfering representations from her own history, the aim of therapy being to help the mother to recognise the ‘ghosts in the nursery’ (that is, the unremembered influences from her own past) and to link them to her current functioning, thereby facilitating new paths for growth and development for both mother and infant (Cramer 1988). Fraiberg's model has been further developed and evaluated by others (for example, Lieberman 1991; Toth 2006), and, more recently, representational and behavioural approaches have been combined (Cohen 1999). For example, 'Watch, Wait and Wonder’ is an ‘infant-led’ parent-infant psychotherapy that involves the mother spending time observing her infant’s self-initiated activity, accepting the infant’s spontaneous and undirected behaviour, and being physically accessible to the infant (behavioural component). The mother then discusses her experiences of the infant-led play with the therapist with a view to examining the mother’s internal working models of herself in relation to her infant (representational component) (Cohen 1999). Parent-infant psychotherapy may also work with the father, or with both parents together.
The duration of delivery of the intervention depends on the presenting problems but typically ranges from 5 to 20 weeks, usually involving weekly sessions. Parents may be referred to this service by a clinician (for example, GP or health visitor in the UK) or may self-refer to privately run services. Parent-infant psychotherapy services typically target infants less than two years of age at the time of referral. This reflects the importance of the first two years of life in terms of children's later development (as described above).
How the intervention might work
The logic model underpinning representational forms of parent-infant psychotherapy is that changes to the mother’s representations (internal working models) will improve the mother’s sensitivity and behaviour towards her infant (for example, Lieberman 1991) and make it more possible for her to see the infant as someone with a 'mind of their own'. Maternal sensitivity is strongly associated with more optimal parent-infant interaction, which is in turn associated with infant attachment security (De Wolff 1997). Secure attachment is associated with resilience and optimal social functioning (Lecce 2008), while both insecure (for example, Granot 2001; Sroufe 2005a; Sroufe 2005b; Berlin 2008) and disorganised attachment (Green 2002) are associated with a range of compromised outcomes. The addition of behavioural components provides opportunities for parent and infant to interact, which then become the focus of exploratory discussions between therapist and parent, aimed once again at changing maternal representations about the infant (Cohen 1999).The empathic relationship between the therapist and parent plays a key role in helping parents to revise their internal working models (Toth 2006).
Why it is important to do this review
Parent-infant interaction is a significant factor in infant mental health (for example, Fonagy 2002a), and problems with the parent-infant relationship are common (Keren 2001). Government policy is increasingly emphasising the importance of early intervention and the need to develop evidence-based models that can support vulnerable parents and their children, and this reflects an increased recognition at a policy level that both health and social inequalities have their origins in early parent-infant interaction (Field 2010), and that the social gradient in children’s access to positive early experiences needs to be addressed (Marmot 2010).
There is a growing body of evidence pointing to the effectiveness of parent-infant psychotherapy in terms of improving both parental functioning (Cohen 1999; Cohen 2002) and fostering secure attachment relationships in young children (Toth 2006), and some evidence to suggest that different forms of the therapy may be differentially effective for parents with different types of attachment insecurity (Bakermans-Kranenburg 1998).
However, there has to date been only one ‘thematic’ summary of the evidence about the effectiveness of parent-infant psychotherapy (Kennedy 2007), which did not involve a systematic search for evidence. As such, there is an urgent need for a systematic review to identify whether this unique method of working has benefits for parents and infants, and whether the outcome is affected by duration or the use of additional components, so as to inform and improve the delivery of early intervention programmes.