Evidence Based PracticeEarly Childhood

Webcast Training

September 29, 2005

Presented by

California Institute for Mental Health

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Main Points

Defining evidence-based practices Early childhood social-emotional

development Early childhood specific practices Disorders in early childhood (DC:0-3)

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Typical Emotional Development

Established sleeping and eating patterns Demonstrates arousal and focused attention Sustained attention, concentration and

persistence Inhibition of outburst to developmentally

appropriate expectations Expression of autonomy in a socially

acceptable manner

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Typical Emotional Development

Enduring and supportive relationship with primary caregivers

Initiates play, discovery & learning Persists when discouraged or distracted Recovers from disruption, transition or

disappointment Emotional responses match social-cultural

context

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Factors that Promote Optimal Development

Physically healthy Temperamentally easy Developmentally competent Caregivers have social support and strong

parenting skills Caregivers provide emotional support, guidance

and loving supervision Safe, stable and calm home/community

environment

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Factors that Contribute to Emotional Disorders

Child is not “emotionally” available Inborn capacity to initiate and respond to

relationships, sustain attention, inhibit outbursts, and so forth

Parent is not “emotionally” available Learned capacity to read and respond to

infant/toddler’s cues, parenting model, and life circumstances

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Signs of a Problem

Problematic behaviors are intensive, extensive, or pervasive; and/or

Primary caregivers are overwhelmed

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Child’s Emotional Availability

Neurobehavioral functioning is compromised including sensory threshold, intensity of reaction, and self-regulation Low birth weight Development delays Physical disabilities Inadequate nutrition Drug or lead poisoning Maltreatment Exposure to violence

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Caregiver Emotional Availability

Care-giving is compromised by inadequate parenting models, lack of social support, health/mental health or substance use disorders, or interpersonal/external stress Mental illness Substance abuse Limited parenting skills Teen parenthood Limited social support Poverty Domestic violence

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Neurobiological Factors

Limited Caregiver Emotional Availability

Social, Economic, and Interpersonal

Factors

Neurobiological Factors

Limited Child Emotional Availability

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Evidence-Based Practices

“…the integration of the best research evidence with clinical expertise and patient values”

Based on the definition used in “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001), by the Institute of Medicine

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Levels of Science

Effective--achieves outcomes, controlled research (random assignment), with independent replication in usual care settings.

Efficacious--achieves outcomes, controlled research (random assignment), independent replication in controlled settings.

Not effective--significant evidence of a null, negative, or harmful effect.

Promising--some positive research evidence, quasi-experimental, of success and/or expert consensus.

Emerging practice--recognizable as a distinct practice with “face” validity or common sense test.

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Which Level of Science to Select

Higher levels mean more confidence that if implemented in your community (with high model adherence) similar good outcomes will be achieved

Consider lower levels of science when there is no alternative at a higher level, or interested in a practice-to-science initiative

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Treatment Approaches

Play therapy (therapist--child) Behavioral skills (practitioner--child) Parent training (practitioner--parent) Dyadic interaction (guided parent--child) Teacher trained (teacher--child) Childcare consultation (practitioner--teacher) Home visitation(practitioner--parent--child) Wraparound (interagency child and family

team)

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The Incredible Years Effective Children 2-12 Decreases child behavior problems Increases parenting competencies Decreases maternal stress Strengthens parent-teacher and parent-caregiver

relationships Carolyn Webster-Stratton, University of Washington www.incredibleyears.org

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Incredible Years Facilitated group intervention, practitioners with diverse

educational backgrounds Three sets of comprehensive developmentally based

curriculums for parents, teachers and children to promote emotional and social competence Basic parenting (early and school age) Advanced parenting Supporting your child’s education Child social skills Classroom based Teacher training

Weekly groups (12-14 sessions), 2 hours in length Uses work books, and video-vignettes to illustrate skills

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Triple P Parenting Effective Children 0-16 Improves parenting skills Decrease in parental stress and depression Improves coping skills Decrease in child behavior problems Improves partner support Improves parent anger management skills Decreases social isolation Matt Sanders, University of Queensland www1.triplep.net

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Triple P Parenting Practitioners with diverse educational backgrounds Parenting program Titrated levels of intervention Detailed support material for parents Five levels of intervention from primary prevention to

treatment Universal Triple P (primary prevention) Selected Triple P Primary Care Triple P Standard Triple P (individual or group) Enhanced Triple P

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Parent-Child Interaction Therapy

Effective Children ages 2-8 years Parent-child guided intervention Decrease child behavior problems Increases parenting competencies Sheila Eyberg and colleagues, University of Florida www.pcit.org http://www.ucdmc.ucdavis.edu/caare/mental/pcit_traince

nter.html

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Parent-Child Interaction Therapy

TherapistsClinic with two-way mirror, and “bug in the

ear” technologyIndividual sessions (about 12)Home models being developedParent-child guided intervention

Relationship Discipline

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Nurse Family Partnership Effective Low-income, high risk first time parents

(pregnancy-age 2) Intensive home visitation to promote health and

welfare of parents and children Improved pregnancy outcomes Improved child health and well being Increases economic self-sufficiency David Olds and his colleagues, University of

Colorado www.nursefamilypartnership.org

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Nurse Family Partnership

Registered nurseIntensive home visitation

Mother’s personal health Quality of care Life course outcomes

Visitations begin no later than 28 weeks of gestation until age 2

Visits involve mother’s support system

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Early Intervention Foster Care Promising--efficacious Preschool age foster children Increases foster parent competencies Strong support for foster parents Decrease in child behavior problems Develops age appropriate child competencies Improves parenting competencies Decreases parental stress and depression Increase in social support Promotes reunification Phil Fisher and colleagues from Oregon Social

Learning Center Pfisher@oslc.org

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Early Intervention Foster Care

Interdisciplinary team Intensive foster parent training Foster parent support groups Daily support calls 24 support to foster parent and biological family Child focused therapy Behavioral specialist for child in preschool, childcare or

home settings Parent training

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Diagnostic Classification 0-3 Provisional system Multiaxial

Axis I: Primary classification Axis II: Relationship classification Axis III: Physical, neurological, developmental or

mental health disorders Axis IV: Psychosocial stress Axis V: Functional emotional developmental level

Designed to supplement Problems not addressed Earlier manifestations

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Primary Diagnoses

Traumatic stress Disorders of affect Adjustment disorder Regulatory disorders Sleeping behavior disorder Eating behavior disorder Disorders of relating and communicating

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Traumatic Stress

Existence of a traumatic eventRe-experiencing of the traumatic eventNumbing of responsiveness in a child or

interference with developmental momentum

Symptoms of increased arousalFears or aggression

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Disorders of Affect

General feature of the child’s functioningNo severe developmental delays or

significant constitutional variationsNot specific to only a single relationship or

context

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Disorders of Affect

Anxiety Prolonged bereavement/grief reaction Depression Mixed disorder of emotional expressiveness Gender identity disorder Reactive attachment deprivation/maltreatment

disorder

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Adjustment Disorder

Mild, transient situational disturbancesNot explained by other conditionsOnset tied to a clear event or changeLasting days, up to 4 months

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Regulatory Disorders

Sensory, sensory-motor, or processing difficulty and one or more behavioral symptoms

Hypersensitive Fearful and cautious Negative and defiant

Under-reactive Withdrawn and difficult to engage Self-absorbed

Motorically disorganized, impulsive

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Sleep Behavior Disorder

Sleep disturbance is the only presenting problem for a child <3 years

Initiating or maintaining or excessive sleep Not attributable to affect or relationship

disturbances, trauma or adjustment problems

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Eating Behavior Disorder

Difficulties in establishing regular feeding patterns with adequate food intake; does not regulate eating in accordance with physiologic feelings of hunger

Not attributable to sensory reactivity or processing or motor difficulties

Not explained by relationships, trauma, or adjustments

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Disorders of Relating and Communicating (Multisystem Developmental Disorder) Significant impairment in, but not complete lack

of, the ability to engage in an emotional and social relationship with a primary caregiver

Significant impairment in forming, maintaining and developing communication

Significant dysfunction in auditory processing Significant dysfunction in the processing of other

sensations

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Differential Diagnosis

Traumatic stress disorder considered first Regulatory disorders if clear constitutionally

or maturational-based sensory, motor, processing difficulty

Adjustment disorder considered if mild and of relatively short duration

Disorders of affect considered when there is no constitutionally or maturational-based difficulty or trauma/stress, and the difficulty is not mild or of short duration

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Differential Diagnosis

Multisystem developmental disorder and reactive attachment, deprivation/maltreatment take precedence over all other categories

Relationship disorders considered when difficulty occurs only in relationship to a particular person

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Relationship Disorders

OverinvolvedUnderinvolvedAnxious/TenseAngry/HostileMixedAbusive

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Functional Emotional Developmental Level

Mutual attentionMutual engagementInteractive intentionality and reciprocityRepresentational/affective communicationRepresentational elaborationRepresentational differentiation I & II