Evidence-Based Interventions for Children with Challenging Behavior

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Similarly, societal stigma may increase the self-blame, remorse, and shame already felt by mothers with substance abuse disorders, pushing them further away from seeking help and contributing to the denial that is a hallmark of the disease of addiction. Mothers report feeling significant vulnerability based on fear of not being perceived as a good mother. They recognize that as a result of their condition, they can be at risk for involvement of child protective services and loss of child custody, a perception that is based in fact Berger et al. For example, using Medicaid and child welfare system data, a large study of Medicaid-eligible mothers with severe mental illness found almost three times higher odds of being involved with child welfare services and a four-fold higher risk of losing custody at some point compared with mothers without psychiatric diagnoses Park et al.

In the case of mothers with substance abuse, caseworkers may be more likely to perceive that children have experienced severe risk and harm Berger et al. And the law in many states requires that reports of domestic violence be investigated by child welfare agencies Blegen et al. Ambivalent feelings about parenting support programs may come from past experiences, as well as familial or social histories or perceptions McCurdy and Daro, Some parents report stigmatizing remarks or comments from health care or social service providers.

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Parents with substance use problems, for example, frequently report that they experience anger and blame from medical and other treatment professionals instead of being viewed as suffering from an illness and treated as such Camp and Finkelstein, ; Nicholson et al. In the case of parents with mental illness, the distrust may be part of the general attitudes associated with paranoia or delusions Healy et al. Although generating participation can be challenging, a wide range of programs are available that are designed to meet the needs of these populations, both by addressing the underlying problems and with respect to supporting and strengthening parenting.

High-quality trials of such interventions are limited, however. Although there have been randomized controlled trials, many smaller studies, observational research, and case-control studies provide some guidance on best practices. This section reviews the available evidence on interventions designed specifically to support parents facing adversities related to mental illness, substance abuse disorders, intimate partner violence, and parental developmental disabilities, since each has unique needs that should be considered in offering services to strengthen and support parenting.


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As noted, many parents face two or more of these challenges, and some face nearly all of them. There has been almost no rigorous evaluation of interventions for these very complex cases, and many of these families are referred to child welfare agencies. Later in this chapter, the committee assesses parenting interventions offered through the child welfare system. Many parents struggle with mental illness at the same time they are trying to provide a safe, nurturing environment for their family.

It is estimated that Research indicates that one-half of all lifetime cases of diagnosable mental illness occur by age 14 and three-fourths by age 24 Institute of Medicine and National Research Council, ; Kessler et al. Determining the prevalence of mental illness specifically among parents is more challenging. Depression is the most common mental illness. But many parents who experience mental illness have not been formally diagnosed, and patients with a diagnosis of mental illness often are not identified as being parents.

It is particularly challenging to estimate the number of parents with severe mental illness often defined as schizophrenia, psychosis, and bipolar disorder. The relevant research typically has assessed individuals in community settings community service agencies, mental health clinics, child welfare agencies, prisons, or hospitals , who likely do not represent the broader population Nicholson et al.

Analysis of data from the National Co-Morbidity Survey suggests that approximately one-half of mothers In another study, among adults identified with severe persistent mental illness, approximately two-thirds of women and three-quarters of men were also parents Gearing et al. Mental health disorders encompass a wide spectrum of illnesses and levels of severity, and symptoms may wax and wane over time; thus their impact on parenting and the supports these parents need can be quite variable. As with prevalence, far more is known about the impact of depression on parenting Institute of Medicine and National Research Council, than about the impact of severe mental illness Bee et al.

The IOM and NRC report describes research showing that parental depression is associated with more negative and withdrawn parenting and with worse physical health and well-being of children. But the same report describes a number of promising two-generational programs focused on prevention and emphasizes the potential for helping parents with treatment and parenting programs. For individuals with mental illness, being a parent is not only a challenge but also often one of the most rewarding parts of their lives Dolman et al.

However, mental illness also can interfere with the quality of parenting. A cross-sectional study using video observation of depressed mothers with their toddlers demonstrated that those with more severe depressive symptoms engaged in fewer positive interactions and more negative interactions with.

Children of parents with mental illness also have a higher risk of developing their own mental health issues, developmental delays, and behavioral problems Beardslee et al. There have been few high-quality large-scale evaluations of interventions designed for parents with mental illness and even fewer of those for parents with severe mental illness. However, many universal interventions have the potential to prevent or mitigate mental illness before it has serious impacts on parenting, and a number of smaller studies have shown positive or promising results of such interventions.

For example, the MOMS Partnership, operated by Yale University, interviewed more than 1, low-income urban mothers of young children to create a set of developmental and community-based mental health and workforce supports Smith, Early results based on a participant questionnaire reveal an increase in positive parenting and reduction in depression Smith, A number of programs are designed to prevent adverse child outcomes among families with known parental mental illness.

The evidence for treating maternal depression for mothers of infants, however, is mixed. Several reviews found that while sustained interventions may improve the cognitive development of the child, additional research is needed to determine the success of these treatments over time, particularly with regard to the benefits for the child as well as the mother Nylen et al.

Forman and colleagues. Nonetheless, most studies have demonstrated that interventions combining mental health treatment and parenting support, or at least including a component focused on parenting, often lead to better outcomes relative to programs that focus solely on the illness. A systematic review of the impact of maternal-infant dyadic interventions on postpartum depression included 19 single group pre-post and randomized controlled studies.

15 Behavior Strategies for Children on the Autism Spectrum

The author concluded that strategies focused on the dyad and maternal coaching were most effective at reducing psychiatric symptoms and demonstrated modest improvements in the mother-child relationship and maternal responsiveness Tsivos et al. Not all such approaches are successful, however. A Cochrane review assessing the impact specifically of parent-infant psychotherapy versus control or an alternative intervention found no significant effects of the psychotherapy on maternal depression or the mother-child dyad Barlow et al.

With the advent of primary care medical homes and the resultant integration of physical, mental, and behavioral health care, there has been growing interest in incorporating parenting interventions and support into primary care settings. This may be a particularly effective way of diagnosing and addressing parental mental health issues. Parents may be more willing to seek health care for their children than for themselves, but during pediatric visits, health care providers may identify a parent who would benefit from mental health treatment Nicholson and Clayfield, Screening adults for depression in primary care settings with the capacity to provide accurate diagnosis, effective treatment, and follow-up is endorsed by the U.

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The Center for Evidence-Based Practice: Young Children with Challenging Behavior

Preventive Services Task Force Models of stepped collaborative care entail screening for and identifying depression in primary care settings and providing straightforward care in those locations while referring patients with more severe or resistant illness to mental health specialists Dennis, Additional primary prevention programs for parental depression have focused on the period from conception through age 5, although most address parents with infants rather than those with toddlers Bee et al. Selective primary prevention of depression among parents has been tested most frequently in the perinatal period, with most programs targeting high-risk groups, such as mothers with preterm infants or those at increased risk for postpartum depression Ammerman et al.

The perinatal period appears to be an effective time to reach a broad population of parents. Home visiting programs discussed in detail in Chapter 4 serve parents with high rates of depression, interpersonal trauma, and PTSD, yet less than. Early studies examining the mental health benefits of home visiting interventions for parents had mixed results, but the results of more recent studies have been positive.

In recent studies, for example, home visiting that includes psychotherapy for mothers has been found to improve depression, and as depression improves, so do many measures of parenting Ammerman et al. A randomized controlled trial enrolled women in home visiting programs who were identified as being at risk for perinatal depression Tandon et al. The intervention consisted of six 2-hour group sessions focused on cognitive-behavioral therapy, with skills being reinforced during regular home visits.

At 6-month follow-up, 15 percent of mothers in the intervention group versus 32 percent of the control mothers had experienced an episode of major depression Tandon et al. In a randomized trial of the Building Healthy Children Collaborative, there was no difference in rate of referral to child protective services for mothers who received mental health services as part of home visits and women in a comparison group who did not receive such services; in both groups, almost all mothers avoided referral to child protective services Paradis et al.

There also have been efforts to help parents with children in center-based care. In a randomized controlled trial of depressed mothers who had infants and toddlers in Early Head Start, investigators tested interpersonal therapy combined with parenting enhancement training versus just treatment for the depression Beeber et al. Both groups had a significant improvement in depression scores, but only the group with parent training showed enhanced parent-child interaction skills.

Beardslee and colleagues describe a nonrandomized, multiyear, multicomponent pilot intervention with parents, staff, and administration in an Early Head Start program serving up to children a year. The intervention, Family Connections, was intended to help staff with strategies for addressing mental health problems in the families they served. The program, which was provided to all the families, not just those identified as suffering from depression, utilized widespread education of staff and parents and a parent support group. It resulted in improved parent self-reported parenting knowledge and social support and increased parent engagement with the center.

Other approaches have been tried in public health settings. Both interventions improved child mental health symptoms and behaviors.

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Family Talk utilizes manual-based psychoeducation prevention strategies. One study of 93 families with. While parents with brief or time-limited mental health problems can benefit from brief interventions, those with severe mental illness or more complex mental health disorders are likely to need ongoing support and crisis intervention services. Unfortunately, interventions to support and strengthen parenting for parents with severe mental illness have typically not been rigorously evaluated using the types of well-designed randomized controlled trials used to test other parenting interventions described in this report, and this is an identified area of need Schrank et al.

Shrank and colleagues conducted a systematic review of parenting studies involving parents who had severe mental illness psychosis or bipolar disorder and at least one child between the ages of The review included a heterogeneous range of interventions, and child outcomes were evaluated. Four of six randomized controlled trials included in the review showed significant benefits from the interventions, which included intensive home visits, parenting lectures, clinician counseling, and Online Triple P; the lower-quality studies showed mixed results. A 3-year observational study of mothers with severe mental illness with children ages demonstrated that over time, as serious symptoms remitted, parents became more nurturing, raising the hope that treatment could lead to improved child outcomes Kahng et al.

A meta-analysis of a variety of parenting interventions found a medium to large effect size in improving short-term parent mental health but noted that these benefits may wane over time, again emphasizing the need for longer and more enduring programs Bee et al. One approach for parents with severe mental illness that appears to be promising is to provide parenting interventions during intensive outpatient treatment or inpatient treatment for mental health crises Krumm et al.

A few hospitals in the United States many more in Europe and Australia have mother-baby mental health units where the baby can stay with the mother while she is hospitalized. A newer observational study in the United Kingdom using a video feedback intervention found that between the time of admission and discharge, mothers with schizophrenia, severe depression, and mania became more sensitive and less unresponsive, and their infants became more cooperative and less passive Kenny et al. Notably, mothers at discharge had better outcomes on all parenting measures than both a comparison group of nonhospitalized mothers with mental illness of comparable severity and a group of mothers without mental illness in the community.

Interventions and treatment for parents with mental illness have been found to significantly reduce the risk of children developing the same mental health problems as well as behavior challenges.


  • Evidence-Based Interventions for Children with Challenging Behavior?
  • theory, research and practice in educational psychology.
  • Addressing Challenging Behavior - Introduction.

A meta-analysis included 1, children in 13 randomized controlled trials of interventions with cognitive, behavioral, or psychoeducational elements for parents with a variety of mental illnesses and substance use problems Siegenthaler et al. Given the enormous complexity of comorbidities and varieties of presentation in mental illness, sorting out which risks to children derive from parental mental illness and which should be attributed to other stressors is challenging.

Doing so is critical, however, for identifying the best strategies for helping families and in considering interventions at both the micro and macro levels. For example, many parents living with severe mental illness will need support in learning parenting knowledge, attitudes, and practices, specifically in understanding normal child development and milestones and how to provide emotional support for their children. They, like all parents, may also benefit from training in such skills as getting children to have a consistent bedtime routine, feeding them, administering nonphysical discipline, and providing emotional support Nicholson and Henry, ; Stepp et al.

Mothers living with severe mental illness themselves have identified generic parenting issues for which they may need help—both in accessing essential resources and in developing critical parenting skills Nicholson and Henry, Mental illnesses include a wide range of conditions. One mother may have severe depression and struggle with lifelong, recurrent episodes, while another may have a single episode of mild postpartum depression.

One disorder may cause symptoms that make it difficult to recognize the emo-. Even a single diagnosis can manifest with different symptoms and severity at different stages of the illness, and the illness itself can lead to complications. Parents with severe or recurrent illness also may face separation from their children due to hospitalization or temporary or permanent loss of custody, which can impact parental self-efficacy as well as attachment Gearing et al.

Thus it is important for programs to tailor services to the individual needs of parents. Programs that offer service coordination are likely to be effective for parents with mental illness who face other adversities as well, such as poverty, family violence, housing instability, and substance abuse.

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Providers and policy makers also need to be mindful of the multiple layers of risk these co-occurring conditions pose to families, since childhood outcomes will be affected by far more than the parenting behaviors or knowledge targeted by many programs. Like mental health conditions, substance use and abuse can affect parenting attitudes and practices, as well as engagement and retention in parenting programs.

It has been estimated that nearly 22 million Americans have a substance use disorder Center for Behavioral Health Statistics and Quality, Yet in , only 4. Moreover, both research and clinical practice have seen little integration of child development and parenting with addiction prevention and treatment. Most studies on substance abuse to date have measured mainly retention in treatment and reduction in maternal substance use as the primary outcomes, with less attention to parenting and work with children Finkelstein, , ; Nicholson et al.