EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
A Multi-Disciplinary Approach to Early Childhood Mental Health Intervention
Georgia Michalopoulou
Wayne State University School of Medicine
Pamela Falzarano
Wayne State University School of Medicine
Julie Hakim-Larson
University of Windsor
Daniela Wittmann
University of Michigan School of Medicine
Marshall Maldaver
The Center for Psychological Services
Jean Chambers
Wayne State University School of Medicine
Amy Vanbrussel
Wayne State University School of Medicine
David Rosenberg
Wayne State University School of Medicine
Author Note
This project was supported by grants from the Michigan Department of
Community Health and the Wayne County Interagency Coordinating Council – Early On
awarded to the first author. We are grateful to Jackie Goodwin for her contributions to
data organization and coding. We also thank Arthur Robin for his excellent review
comments.
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Correspondence concerning this article may be addressed to Georgia
Michalopoulou, Ph.D, Children’s Hospital of Michigan, 3901 Beaubien, 4th Floor,
Detroit, MI 48201, e-mail: gmichalo@med.wayne.edu, telephone: 313-745-4649; fax:
313-993-0282.
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Abstract
The purpose of this paper is to describe an Early Childhood Intervention (ECI)
model and to demonstrate its ability to improve children’s behavior and adaptive
functioning as well as improve the parent-child relationship and reduce parental stress.
The ECI program provided concurrent child and parent, intensive short-term treatment, to
increase pro-social behavior in children with negative emotional regulation and control,
to foster positive family functioning and ultimately prevent chronicity. A pilot analysis
was performed on a subset of 14 children and caregivers. The results indicate children
who participated in the ECI program showed reductions in oppositional behaviors and
externalizing problems. Parents reported an increase in their children’s adaptive social
behaviors as well as reduction in their own stress levels.
Key words: Early intervention, parent-child interaction
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Introduction
When young children (between the ages of 2 and 6) present with negative
emotional regulation and control it is often difficult to discriminate whether or not it is a
mere expression of normal development or rather the onset of a maladaptive behavioral
pattern. Parents and other caregivers in the child’s life often describe children referred for
mental health treatment as unmanageable, exhibiting frequent temper tantrums, emotional
dysregulation, oppositional and defiant behavior, hostility, hyperactivity, low attentional
regulation, and low impulse control. Usually by the time these children are referred to
treatment, the persistence and severity of these symptoms have already disrupted the
family system, daycare, or preschool environment. At this point, early intervention
becomes critically important for multi-risk families as a preventive measure to strengthen
protective factors and counteract the risks before they consolidate into a developmental
path of increasingly disruptive externalizing behaviors (Landy & Menna, 2006; WebsterStratton & Reid, 2004).
The prevalence of such behavioral patterns that significantly interfere with
developmental and social functioning in preschoolers is estimated between 5 and 14%
(Egger & Angold, 2006; Eisenberg, et al., 2001; Lavigne, et al., 1996; Moffitt, et al.,
2007). Studies have also shown that these behavioral patterns are particularly difficult to
treat, persist over the child’s development, and are related in predictable ways to
children’s long-term adjustment (Eisenberg, et al., 2001; A.E. Kazdin, 1987). Between 50
and 75% of preschool children with significant externalizing behavioral difficulties are
more likely to continue to have these difficulties up to six years later (Barkley, et al.,
2000; Campbell & Ewing, 1990; Nixon, 2002). These children are at risk for school
4
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
adjustment problems, are more likely to develop conduct disorder, to participate in more
delinquent or illegal acts as adolescents, to engage in greater substance experimentation
and abuse, and to have interpersonal problems (Campbell & Ewing, 1990; Kratzer &
Hodgins, 1997; Lynskey & Fergusson, 1995; Niec, Hemme, Yopp, & Brestan, 2005;
Webster-Stratton & Reid, 2004; Weiss & Hechtman, 1993).
The substantial risks posed for young children demonstrating this combination of
negative emotional regulation and control make early implementation of interventions
critical for the prevention or reduction of chronic maladaptive functioning. The
opportunity to teach and correct is much greater at an earlier age as the behavioral
repertoire in the early years is not yet a permanent property of the child, and the child’s
behavior and approach to the world can be shaped with greater success (Keenan &
Wakschlag, 2000). In addition, early intervention can serve a preventative role to protect
the child’s self worth and positive self-image by interrupting the chain of negative
feedback from the environment that occurs when the child is engaged in disruptive
behaviors (Lamb-Parker, LeBuffe, Powell, & Halpern, 2008; Webster-Stratton & Reid,
2004).
Equally important to treatment of the child is early parental intervention. Parents
need to be educated regarding causes and effects of behaviors and empowered with the
skills necessary to provide a consistent and predictable environment. When consistent
limits are placed and rules are clearly defined within the family setting, the child
develops control of their environment and a sense of safety as they can predict the
consequences of their own behavior. An intervention program which encompasses both
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child treatment as well as parental training is essential in the development of socially
appropriate behaviors and relationships (Webster-Stratton & Reid, 2004).
Historically, programs that have targeted children at risk for emotional, social,
and educational problems have included Headstart and the Perry Preschool Project
(Barnett, 1985; Garces, Thomas, & Currie, 2002; Hembree-Kigin & McNeil, 1995; Zigler
& Valentine, 1979). Such programs have attempted to enhance the cognitive, social, and
emotional competence of children through quality preschool education, the stable
presence of caregivers and teachers, and the consistent utilization of mental health
professionals. However, evaluations of these programs indicate that despite the high
quality and research-based services provided, the mental health component of the
programs had been identified as an area that needed strengthening (Domitrovich, 2007;
Fantuzzo, Bulotsky, Mcdermott, Mosca, & Lutz, 2003; Webster-Stratton & Hammond,
1998). Leaders in the field suggest that in order to prevent mental health problems in
early childhood, mental health interventions need to be implemented and focus not only
on reducing children’s aggressive, disruptive and withdrawn behavior, but also on
building social-emotional competence given the protective function it serves against the
challenge of transitioning to school (Domitrovich, 2007; Lopez, Tarullo, Forness, &
Boyce, 2000; Masten & Coatsworth, 1998b).
This article describes an early childhood mental health treatment model (ECI)
designed to provide concurrent child and parent, intensive and multi-disciplinary, shortterm treatment to increase pro-social behavior in children with negative emotional
regulation and control. ECI evolved as a result of Title 1 funding from the state of
Michigan and was launched in 1975 at a state inpatient and outpatient psychiatric hospital
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for children and adolescents. With over 25 years of program refinement in conjunction
with impressive gains in the field of child development, the ECI program resulted in a
successful treatment model and prevention program (Michalopoulou, Wittman,
Chambers, Maldaver, & Hakim-Larson, 1998).
Early Childhood Intervention Program
Mission: The ECI program provided concurrent child and parent, intensive shortterm treatment, to increase pro-social behavior in children with negative emotional
regulation and control, to foster positive family functioning and ultimately prevent
chronicity.
Program Description: The ECI program served families with children 2 to 6 years
of age who presented with a variety of maladaptive externalizing and internalizing
behaviors which interfered with optimal functioning in a pre-school setting as well as at
home. Sixteen two-hour sessions, were offered two days a week and included up to 6
children. The age range of the children within each group was matched to be maximally
between 5 and 6 months apart to optimize focus on their particular developmental stage.
The program also served as a training site for psychiatry residents, psychology interns
and practicum students offering opportunities for case conferences held twice weekly.
The program utilized a multi-disciplinary approach with a treatment team consisting of a
psychiatrist, psychologist, and social worker, all with specialized experience in early
childhood development.
Referral: Children were referred to the ECI program from preschools, daycare
centers, community physicians, social service agencies as well as parents in distress.
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Children presenting with serious social, emotional and behavioral problems that disrupted
functioning at home and/or led to daycare or pre-school expulsion, were accepted into the
program with the exception of children with significant cognitive delays and pervasive
developmental disorders (i.e., autism spectrum disorders) which would disable the child
from benefiting. Also excluded were parents with untreated substance abuse and parents
unable to make commitment to attend. When communication, motor, or other nonpsychiatric disorders were identified during evaluation, the treatment team referred to and
collaborated with appropriate specialty services.
Evaluation: The evaluation consisted of comprehensive clinical interviews with
the parents and child. During the parent interview, the child was observed in free play
through a one-way mirror. The parent interview included detailed descriptions of the
presenting problem(s), developmental, medical, educational, and social histories. The
child interview aimed to assess basic cognitive, academic, language and motor skills as
well as the child’s relationship with caregivers, emotional functioning, and coping
mechanisms. When educational, learning, or cognitive problems were suspected,
psychological testing followed the outpatient evaluation. Psychological instruments were
intended to meet the unique needs of the child and were selected based on age and
referring questions.
Treatment Planning: The treatment team determined the most significant
problems on which to focus the treatment process as a variety of issues often presented
during the assessment. Effective treatment plans only dealt with a few selected problems
to avoid treatment losing its direction (Jongsma, Peterson, & McInnis, 1996). As the
problems to be selected became clear to the treatment team, opinions from the parent(s)
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
as to their prioritization of issues for which help was being sought was included. When
indicated, individual and family therapy, in addition to ECI intervention, was
recommended to address specific family and child concerns. In cases of abuse and
removal from the home, the primary caregivers were involved in the treatment. In those
cases where social services had determined that the child would be returning to the
biological family, biological parents were involved in the ECI treatment as well.
ECI Treatment: The initial session was attended by parents without children. The
multi-disciplinary team members introduced themselves and explained their roles as well
as the purpose and structure of the program. Similarly, parents were asked to introduce
themselves, talk about their child, and discuss reasons for enrolling in the program.
Parents were provided with the group’s schedule and an outline of the structure. Parents
were asked to sign a form committing themselves to regular attendance. To ensure safety
for the child’s participation in the group, a health form was also given to the parents to be
filled out by the child’s pediatrician. This form served to alert the treatment team of any
medical condition(s) that required special attention and promoted coordination with
primary care.
Both parent and child groups had a primary therapist who represented a consistent
and predictable figure. Parent and child groups met concurrently (See Figure 1 Group
Process and Table 1 Group Session Schedule and Topics). Group topics were based on
the problems presented by the population served and materials were matched to promote
topic discussion and to support individualized behavioral treatment goals. Materials
utilized for the children’s groups were based on age appropriateness and developmental
level. A behavioral chart was developed for each child stating two-to-three behavioral
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
goals. The goals were reviewed at the beginning of each session and children were given
feedback and rewards at the end of the session. The children’s group provided a warm,
accepting psycho-educational environment designed to increase social competence, selfunderstanding, self-regulation, and facilitate healthy coping strategies.
In each group session, routines were designed to provide positive anticipation of
reliable sequences (Flores, Tomany-Korman, & Olson, 2005). Social skills for daily
living were embedded in the routines. Self regulation, impulse control, and cooperation
with peers and adults was taught through modeling, self monitoring, positive
reinforcement, re-direction, behavioral contracts, and time-outs (Hoagwood, Burns,
Kiser, Ringeisen, & Schoenwald, 2001; Ochsner & Gross, 2005). Promotion of selfesteem, self-worth and competence was encouraged through successful accomplishment
of tasks and in the frequent positive interaction with peers, parents, and other adults
(Jacobs, Lanza, Osgood, Eccles, & Wigfield, 2002). Self-understanding was promoted
through guided recognition and expression of feelings as well as by providing education
about coping strategies. Social and emotional development was facilitated through
modeling, feedback, and empathy in structured group activities (Greenberg, et al., 2003).
The parent group provided a supportive psycho-educational environment
consisting of therapeutic materials on child development, parenting skills, and behavior
management techniques (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). A
developmental understanding guiding the application of parenting skills and behavior
management techniques was further facilitated through the opportunity to observe the
therapist/child interaction modeling through an observation mirror. The goal was to
increase the parents’ ability to respond constructively while fulfilling the child’s needs
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
for daily structure and routine. The group further provided parents with insight into the
influence of their own experiences, temperament, and personality on the development
and psychological functioning of their child. The parent group further provided an
opportunity for parents to talk together and share ideas about parenting and learn new
ways of interacting with their children during this critical period of development.
Cohesion and group support among the parents was promoted by sharing experiences and
brainstorming about solutions to manage identified problems.
Attempts to Measure Treatment Effectiveness
Since its inception in 1975, the ECI program consistently reported positive
clinical outcomes such as decreased child symptomatology and behavioral difficulties
and increased caregiver confidence and competence to promote and enhance young
children’s competencies, optimizing their learning and development of adaptive
functioning. In an effort to evaluate the ECI program and to provide objective and
measurable evidence of clinical outcomes, the clinical team manualized the approach in
1998 and added pre- and post-treatment measures (Michalopoulou, et al., 1998).
Development of the manual, outlining a step-by-step plan, helped ensure maintenance of
program fidelity and successful adaptation of the program. The multi-disciplinary team
was trained using the materials and curriculum, and met at the end of every session to
review clinical material as well as adherence to treatment procedures.
The pre- and post-treatment measures, both qualitative and quantitative, were collected
from 1999-2000 on 59 families and included measures that provided objective criteria to
evaluate effects of treatment and attainment of goals (These measures are described in
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Table 2 and demographic characteristics and DSM diagnoses are described in Table 3).
Following treatment, the measures were used to demonstrate improvement in child’s
behavior and adaptive functioning as well as improvement in the parent-child relationship
and a reduction in parental stress. This new focus was a first step towards bridging the
gap between practice and research in early childhood intervention and developing a
model that assesses the effectiveness of the intervention (Anderson, et al., 2003).
Preliminary analyses on the effectiveness of the program were performed posthoc on a subset of 14 families served by the program as those families had sufficient data
including attendance in at least 10 sessions with the majority completing pre- and posttest measures. The study was approved by the Wayne State University Institutional
Review Board. A multi-method and multi-measure design was used. Analyses were
conducted using SPSS version 17 (SPSS Inc, Chicago, Illinois).
Paired t-test analyses of pre- and post-group involvement data were conducted
and significant differences were found on the measures of Delinquent Behavior (t=3.084,
df=8, p=.015), Externalizing Problems (t=2.146, df=13, p=.05), and Social Development
(t=-3.292, df=5, p=.01) with reports of delinquent and externalizing behaviors decreasing
in frequency and an increase in adaptive behaviors as evidenced in higher scores in social
development. Initial and last ECBI testing also showed a reduction in the Intensity of
Symptoms (t=2.99, df=11, p<.01) and Number of Problems (t=2.14, df=11, p=<.05). PSI
Total Stress scores, were lower at post-test but not significant (t=.876, df=5, p=.44)
(Table 4). Parental feedback affirmed the ECI goals. Eleven of the fourteen parents
surveyed (79%) felt they had a better understanding of children's ways of learning
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EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
following the ECI program with most (71%) indicating they could use the information to
interact better with their children.
Discussion
The primary purpose of this article was to provide a detailed description of ECI, a
mental health treatment model designed to decrease disruptive behaviors and promote
pro-social behavior in children with negative emotional regulation and control. Children
that participated in the ECI program showed reductions in oppositional behaviors and
externalizing problems, and parents reported an increase in their child’s adaptive social
behaviors and reduction in their own stress levels. Parental satisfaction with the group
process helped assure its usefulness and applicability outside the group structure. Our
findings are consistent with outcome studies of similar treatment programs such as Parent
Management Training (PMT) and Parent-Child Interaction Therapy (PCIT) that focus on
families with behaviorally disturbed children (Hembree-Kigin & McNeil, 1995; Alan E.
Kazdin, 1997; Nixon, Sweeney, Erickson, & Touyz, 2003). There are recent studies of
PCIT’s and PMT's benefits as preventive interventions that not only improve children's
conduct but also positively affect parent-child relationships, mood, social competence,
and school adjustment or performance (Herschell, Calzada, Eyberg, & McNeil, 2002;
Mabe, Turner, & Josephson, 2001).
As corroborated by clinical observation and parental feedback, the frequency and
intensity of treatment fostered mastery of developmentally appropriate skills. Treatment
structure that provided consistency, predictability, and follow-through helped children
learn how to make adjustments. The unique format of the parent groups engaged the
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extended network of individuals involved in the child’s life including foster parents,
grandparents and other caretaker who otherwise might have been missed with programs
focused solely on the parent-child dyad. When all of these individuals were taught the
fundamental components in managing children with internalizing and externalizing
behavioral patterns, the opportunity for successful implementation was greater. The
multi-disciplinary team approach facilitated free communication without barriers and
fostered family discussion, collaborative decision-making, and efficient implementation
of recommendations. Recent recommendations by Landy and Menna (2006) for how best
to structure early intervention programs include the necessity of a collaborative team with
supportive and proper supervision of the staff members who implement the program. In
the current ECI program, the regular de-briefing that took place following each session
allowed the multi-disciplinary team to monitor family progress and accordingly adjust
treatment.
Although clinical observation, parental reports, and results from objective
measures showed improvement in children’s adaptive social behaviors and reduction in
parental stress levels, there were many difficulties encountered with the effort to properly
evaluate the effectiveness of the ECI program. As ECI was a clinical service program, it
was limited in controlling for factors such as patients receiving individual and family
therapies during the course of their participation, missed sessions, sample size, pre- and
post-test reliability, and comparison to a control group. Such difficulties are not unusual
in attempts to garner evidence for treatment effectiveness in clinical practice settings, as
compared to attempts to more rigorously establish treatment efficacy in university or
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hospital-based clinical research settings where randomized controlled trials are possible
(e.g., Summerfelt & Meltzer, 1998).
Generally, attendance was poor due to lack of access related resources such as
child care and transportation. The preliminary analysis conducted was on the subset of
families that had completed a minimum of 10 sessions. Thus, positive outcomes reported
may have been influenced, in part, by unique individual and family attributes that those
families brought to the treatment encounter. These attributes were not isolated nor
evaluated in this analysis. Analysis was also limited in its ability to isolate the various
treatment components (i.e., modeling, in vivo observation of parent-child interactions,
immediate and direct feedback, use of educational material, multi-disciplinary approach,
etc), and evaluate their association with clinical outcomes. Using a practice-based
research synthesis approach, Bakermans-Kranenburg, van IJzendoorn, and Juffer (2003),
were able to isolate those characteristics of their intervention that mattered most in terms
of influencing parents’ adoption and use of a sensitive and responsive interactional style.
These researchers identified behaviorally based interventions specifically targeting
parental awareness, interpretation, and responsiveness to their children’s behavior as
being most effective, with the effectiveness optimized through the use of videotapes and
in vivo observations (Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Dunst &
Trivette, 2009).
Given the evidence that children with negative emotional regulation and control
are at risk for developing school adjustment problems, disruptive, and antisocial
behaviors, there is a societal stake to create policy to support specialized early
intervention mental health programs to interrupt the progression of these serious
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maladaptive behaviors (Masten & Coatsworth, 1998a). As it becomes increasingly
evident that emotional development and academic learning are far more closely
intertwined in the early years than has been previously understood, legislative advocates
and government officials who understand the importance of early childhood mental
health need to be identified and petitioned to provide leadership, to set appropriate policy,
and to obtain funding (Raver & Knitzer, 2002). Professionals who work within the
domain of child development and policymakers have an ethical responsibility to promote
early mental health interventions that can lead to healthier outcomes.
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17
Figure 1
ECI Group Process
Gathering
Parents and children gather in the waiting room
5 Minutes
Interactive play for children with parents
Focus on positive interaction
20 minutes
5 Minutes
10 minutes
15 minutes
Parents separate and
move to the
observation room.
Therapists observe and facilitate play. A
bell is rung to signal parents and children
that is time to put the toys away as a
cooperative activity. Children say good-bye
to parents.
Parental Observation
Parents take seats in front of the
observation mirror. The parents
observe the greeting, story reading
and art project. At this time,
parents are encouraged to
spontaneously initiate discussion
which may include the child's state
upon arrival to the clinic or vious
internal and external factors in the
child's life. Therapeutic support is
given as indicated immediately
and/or later during a scheduled
parent counseling session.
Children are greeted individually through the use of animal puppets
who invite them to tell everybody about interesting events.
Story
Children are reminded of their behavioral goals that had been
established in collaboration with parents during the early
stages of the group. A story with a therapeutic theme is read
and children are invited to comment on the meaning.
Art Project
Children move to the semi-circular activity table for an art
project related to the story theme. The project focuses on
cognitive and developmental skills at each child's
developmental level. Verbal negotiation of sharing materials
is encouraged.
Unstructured Interactive Play
Parent Group
20 Minutes
10 Minutes
Vertical blinds on the
observation mirror are
closed and parents gather in
a circle. The therapist
introduces a scheduled
topic. Parents are
encouraged to ask
questions and make
comments to integrate the
session content. In addition,
specific examples and
applications of the material
presented are discussed.
Children and members of the
treatment team arrange
child-sized chairs into
a semi-circle in front
of the observation mirror.
Unstructured interactive play is designed to
encourage developmentally appropriate peer
interactions. When possible, gross motor activity
is included to facilitate release of tension,
pleasure in physical competence, reciprocal
interaction and body regulation.
Snack Time
Children wash their hands and have a snack. They are
encouraged to be independent in caring for their body needs
under supervision. Behavioral goals are reviewed and
stickers are awarded on a chart. The daily theme is reviewed.
Efforts at communication are reinforced.
Good-Bye
10 Minutes
Children invite parents to participate in a good-bye song, sung to each child individually. To
reinforce and generalize social learning, children are given feedback about the thngs they did
well and receive a sticker in the presence of their peers, parents, and the treatment team.
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
18
Table 1
ECI Group Session Schedule and Topics
Child Group
Topic
Making friends
Sharing
Story
The Friendship Book (Hubbard, 1993)
Franklin is Bossy (Bourgeois, 1993)
I Was So Mad! (Simon, 1991)
Anger
Worries
Individuality
Irritability
Sharing
Development
Moods
Making
mistakes
Self-esteem
Franklin in the Dark (Bourgeois, 1987)
Titch (Hutchins, 1993)
The Grouchy Ladybug (Carle, 1996)
The Rainbow Fish (Pfister, 1999)
When I Was Little: A Four Year Old’s
Memoir of Her Youth (Curtis, 1995)
Alexander and the Terrible, Horrible, No
Good, Very Bad Day (Viorst, 1987)
Oops! A Diaper David Book (Shannon,
2005)
I Like Me! (Carlson, 1990)
The Tenth Good Thing about Barney
(Viorst, 1971)
Open session to meet needs of the group
Good-bye
The Kissing Hand (Penn, 2006)
Loss
Art Project
Paper bag
puppets
Making a
turtle
Naming &
coloring
feeling faces
Draw worry
bag
Make flowers
Create
ladybugs
Rainbow fish
with glitter
PlayDoh
Parent Group
Topic
Observation
Introduction of
play techniques
Behavior
contracts
Discipline
Development
Feedback
What makes me
snap
Problem solving
skills
Coloring
feeling into
bodies
Depression in
children
Making
bracelets
How do parents
get support
Color myself
Self-esteem as
parents
Decorating a
cat
Loss
Power struggles
Decorating
Siblings
hearts
Parents attended the first session without children to introduce themselves, talk about their
child, and discuss reasons for enrolling in the program. ECI purpose and program structure was
discussed. Parents attend the last session without children to address termination planning.
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Table 2
Psychological Assessment Instruments –Adaptive Functioning and Behavior
Scale
Description of Measure
Child Behavior Checklist 2/3 and
Widely used measures that identify specific
4/18 [CBCL-2/3 & CBCL-4/18]
emotional and behavioral problems in children
based on a questionnaire completed by the
caregiver (Achenbach, 1991, 1992).
Minnesota Child Development
Identifies specific domains of child development
Inventory [CDI]
and whether or not the caregiver perceives the
child to be within the norm for his or her age
(Ireton, 1992; Kovacs, 1985).
Parenting Stress Index [PSI]
Identifies caregivers who have experienced
unusual stress and who therefore are at risk for
having difficulties with parenting (Abidin, 1983).
Eyberg Child Behavior Inventory
Assesses the frequency or intensity of symptom
[ECBI]
occurrence and the number of conduct problems
using caregiver report (Eyberg & Ross, 1978).
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20
Table 3
Description of ECI Program Participants from 1999-2000 (N=59)
Participant Characteristics / DSM – IV Diagnoses
n (%)
Gender
Male
46 (78)
Female
13 (22)
Race
European American
32 (54)
African American
17 (28)
Multi-Racial
2 (3)
Not reported
8 (14)
DSM-IV Diagnoses
Adjustment Disorder with mixed disturbance of emotions and conduct
33 (56)
Oppositional Defiant Disorder
13 (22)
Disruptive Behavior NOS
6 (11)
Physical Abuse of Child
6 (11)
Co-Morbid ADHD
13 (22)
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
21
Table 4
Pre-Test and Post-Test Means and Standard Deviations for Delinquent Behavior,
Externalizing Problems, Social Development, Intensity of Symptoms, Number of
Problems, and Total Stress (N=14)
Scale
CBCL Delinquent Behavior
n
Pre-Test M(SD)
Post-Test M(SD)
9
68.33 (8.81)
61.22 (9.33)
14
68.93 (9.68)
64.86 (9.64)
9
26.50 (9.40)
30.22 (7.56)
ECBI Intensity of Symptoms
12
160.00 (45.68)
133.18 (35.92)
ECBI Number of Problems
12
15.36 (9.86)
11.27 (9.13)
6
270.16 (6.71)
260.33 (11.96)
CBCL Externalizing Problems
CDI Social Development
PSI Total Stress
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Abidin, R. R. (1983). Parenting Stress Index. Charlottesville, VA: Pediatric Psychology
Press.
Achenbach, T. M. (1991). Manual for Child Behavior Checklist / 4-18 and 1991 Profile.
Burlington, VT: University of Vermont, Department of Psychiatry.
Achenbach, T. M. (1992). Manual for Child Behavior Checklist / 2-3 and 1992 Profile.
Burlington, VT: University of Vermont, Department of Psychiatry.
Anderson, L. M., Shinn, C., Fullilove, M. T., Scrimshaw, S. C., Fielding, J. E., Normand,
J., et al. (2003). The effectiveness of early childhood development programs: A
systematic review. American Journal of Preventive Medicine, 24(3, Supplement
1), 32-46.
Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2003). Less Is More:
Meta-Analyses of Sensitivity and Attachment Interventions in Early Childhood.
Psychological Bulletin, 129(2), 195-215.
Barkley, R. A., Shelton, T. L., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., et
al. (2000). Multi-method psycho-educational intervention for preschool children
with disruptive behavior: preliminary results at post-treatment. Journal of Child
Psychology and Psychiatry, 41(3), 319-332.
Barnett, W. S. (1985). The Perry Preschool Program and Its Long-Term Effects: A
Benefit-Cost Analysis. High/Scope Early Childhood Policy Papers, No. 2.
Ypsilanti, Michigan: High/Scope Educational Research Foundation.
Bourgeois, P. (1987). Franklin in the Dark. New York, NY: Scholastic, Inc.
Bourgeois, P. (1993). Franklin Is Bossy. Tonawanda, NY: Kids Can Press, Limited.
22
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Campbell, S. B., & Ewing, L. J. (1990). Follow-up of Hard-to-Manage Preschoolers:
Adjustment at Age 9 and Predictors of Continuing Symptoms. Journal of Child
Psychology and Psychiatry, 31(6), 871-889.
Carle, E. (1996). The Grouchy Ladybug. New York, NY: HarperCollins Publishers.
Carlson, N. (1990). I Like Me! New York, NY: Penguin Group.
Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E. (2004).
Enhancements to the Behavioral Parent Training Paradigm for Families of
Children with ADHD: Review and Future Directions. Clinical Child and Family
Psychology Review, 7(1), 1-27.
Curtis, J. L. (1995). When I Was Little: A Four-Year-Old's Memoir of Her Youth. New
York, NY: HarperCollins Publishers.
Domitrovich, C. E. (2007). Improving Young Children’s Social and Emotional
Competence: A Randomized Trial of the Preschool “PATHS” Curriculum. . The
Journal of primary prevention 28 (2), p. 67., 28(2), 67-91.
Dunst, C. J., & Trivette, C. M. (2009). Using Research Evidence to Inform and Evaluate
Early Childhood Intervention Practices. Topics in Early Childhood Special
Education, 29(1), 40-52.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in
preschool children: presentation, nosology, and epidemiology. Journal of Child
Psychology and Psychiatry, 47(3-4), 313-337.
Eisenberg, N., Cumberland, A., Spinrad, T. L., Fabes, R. A., Shepard, S. A., Reiser, M.,
et al. (2001). The Relations of Regulation and Emotionality to Children's
23
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Externalizing and Internalizing Problem Behavior. Child Development, 72(4),
1112-1134.
Eyberg, S. M., & Ross, A. W. (1978). Assessment of Child Behavior Problems: The
Validation of a New Inventory. Journal of Clinical Child Psychology, 16, 113116.
Fantuzzo, J., Bulotsky, R., Mcdermott, P., Mosca, S., & Lutz, M. N. (2003). A
Multivariate Analysis of Emotional and Behavioral Adjustment and Preschool
Educational Outcomes. School Psychology Review, 32(2), 185-203.
Flores, G., Tomany-Korman, S. C., & Olson, L. (2005). Does Disadvantage Start at
Home?: Racial and Ethnic Disparities in Health-Related Early Childhood Home
Routines and Safety Practices. Archives of Pediatric Adolescent Medicine, 159(2),
158-165.
Garces, E., Thomas, D., & Currie, J. (2002). Longer-Term Effects of Head Start.
American Economic Review, 92 (4), 999-1012.
Greenberg, M. T., Weissberg, R. P., O'Brien, M. U., Zins, J. E., Fredericks, L., Resnik,
H., et al. (2003). Enhancing School-Based Prevention and Youth Development
Through Coordinated Social, Emotional, and Academic Learning. American
Psychologist, 58(6-7), 466-474.
Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent-child Interaction Therapy: A
Step-by-Step Guide for Clinicians. New York and London: Plenum Press.
Herschell, A. D., Calzada, E. J., Eyberg, S. M., & McNeil, C. B. (2002). Parent-child
interaction therapy: New directions in research. Cognitive and Behavioral
Practice, 9(1), 9-16.
24
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Hoagwood, K., Burns, B. J., Kiser, L., Ringeisen, H., & Schoenwald, S. K. (2001).
Evidence-Based Practice in Child and Adolescent Mental Health Services.
Psychiatric Services, 52(9), 1179-1189.
Hubbard, W. (1993). The Friendship Book. New York, NY: Chronicle Books.
Hutchins, P. (1993). Titch. Chicago, IL: Simon & Schuster Children's Publishing.
Ireton, H. (1992). Child Development Inventories. Minneapolis, MN: Behavior Science
Systems.
Jacobs, J. E., Lanza, S., Osgood, D. W., Eccles, J. S., & Wigfield, A. (2002). Changes in
Children's Self-Competence and Values: Gender and Domain Differences across
Grades One through Twelve. Child Development, 73(2), 509-527.
Jongsma, A. E., Peterson, L. M., & McInnis, W. P. (1996). The Child and Adolescent
Psychotherapy Treatment Planner. New York: John Wiley & Sons.
Kazdin, A. E. (1987). Treatment of antisocial behavior in children: Current status and
future directions. Psychological Bulletin, 102(2), 187-203.
Kazdin, A. E. (1997). Parent Management Training: Evidence, Outcomes, and Issues.
Journal of the American Academy of Child & Adolescent Psychiatry, 36(10),
1349-1356.
Keenan, K., & Wakschlag, L. S. (2000). More than the Terrible Twos: The Nature and
Severity of Behavior Problems in Clinic-Referred Preschool Children. Journal of
Abnormal Child Psychology, 28(1), 33-46.
Kovacs, M. (1985). The Children's Depression Inventory (CDI). Psychopharmacology
Bulletin, 21(4), 995-998.
25
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Kratzer, L., & Hodgins, S. (1997). Adult Outcomes of Child Conduct Problems: A
Cohort Study. Journal of Abnormal Child Psychology, 25(1), 65-81.
Lamb-Parker, F., LeBuffe, P., Powell, G., & Halpern, E. (2008). A Strength-Based,
Systemic Mental Health Approach to Support Children's Social and Emotional
Development. Infants & Young Children, 21(1), 45-55.
Landy, & Menna, R. (2006). An evaluation of a group intervention for parents with
aggressive young children: improvements in child functioning, maternal
confidence, parenting knowledge and attitudes. Early Child Development and
Care, 176(6), 605-620.
Lavigne, J. V., Gibbons, R. D., Christoffel, K. K., Arend, R., Rosenbaum, D., Binns, H.,
et al. (1996). Prevalence Rates and Correlates of Psychiatric Disorders among
Preschool Children. Journal of the American Academy of Child & Adolescent
Psychiatry, 35(2), 204-214.
Lopez, M. L., Tarullo, L. B., Forness, S. R., & Boyce, C. A. (2000). Early Identification
and Intervention: Head Start's Response to Mental Health Challenges. Early
Education & Development, 11(3), 265 - 282.
Lynskey, M. T., & Fergusson, D. M. (1995). Childhood conduct problems, attention
deficit behaviors, and adolescent alcohol, tobacco, and illicit drug use. Journal of
Abnormal Child Psychology, 23(3), 281-302.
Mabe, P., Turner, M., & Josephson, A. (2001). Parent management training. Child
Adolescent Psychiatry Clinics of North America, 10(3), 451-464.
26
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Masten, A. S., & Coatsworth, J. D. (1998a). The Development of Competence in
Favorable and Unfavorable Environments: Lessons from Research on Successful
Children. American Psychologist, 53(2), 205-220.
Masten, A. S., & Coatsworth, J. D. (1998b). The development of competence in
favorable and unfavorable environments: Lessons from research on successful
children. The American Psychologist, 53(2), 205-220.
Michalopoulou, G., Wittman, D., Chambers, J., Maldaver, M., & Hakim-Larson, J. A.
(1998). Child/Adolescent Training and Service Programs Early Childhood
Intervention Handbook. Detroit, Michigan: Wayne State University Department
of Psychiatry Office of Program Development.
Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., et
al. (2007). Depression and Generalized Anxiety Disorder: Cumulative and
Sequential Comorbidity in a Birth Cohort Followed Prospectively to Age 32
Years. Archives of General Psychiatry, 64(6), 651-660.
Niec, L. N., Hemme, J. M., Yopp, J. M., & Brestan, E. V. (2005). Parent-child interaction
therapy: The rewards and challenges of a group format. Cognitive and Behavioral
Practice, 12(1), 113-125.
Nixon, R. D. V. (2002). Treatment of behavior problems in preschoolers: A review of
parent training programs. Clinical Psychology Review, 22(4), 525-546.
Nixon, R. D. V., Sweeney, L., Erickson, D. B., & Touyz, S. W. (2003). Parent-child
interaction therapy: A comparison of standard and abbreviated treatments for
oppositional defiant preschoolers. Journal of Consulting and Clinical Psychology,
71(2), 251-260.
27
EARLY CHILDHOOD MENTAL HEALTH INTERVENTION
Ochsner, K. N., & Gross, J. J. (2005). The cognitive control of emotion. [doi: DOI:
10.1016/j.tics.2005.03.010]. Trends in Cognitive Sciences, 9(5), 242-249.
Penn, A. (2006). The Kissing Hand. Terre Haute, IN: Tanglewood Press.
Pfister, M. (1999). The Rainbow Fish. New York, NY: North-South Books.
Shannon, D. (2005). Oops!: A Diaper David Book. New York, NY: Scholastic, Inc.
Simon, N. (1991). I Was So Mad! Park Ridge, IL: Albert Whitman.
Viorst, J. (1971). The Tenth Good Thing About Barney. Chicago, IL: Simon & Schuster
Children's Publishing.
Viorst, J. (1987). Alexander and the Terrible, Horrible, No Good, Very Bad Day.
Chicago, IL: Simon & Schuster Children's Publishing.
Webster-Stratton, C., & Hammond, M. (1998). Conduct Problems and Level of Social
Competence in Head Start Children: Prevalence, Pervasiveness, and Associated
Risk Factors. [10.1023/A:1021835728803]. Clinical Child and Family
Psychology Review, 1(2), 101-124.
Webster-Stratton, C., & Reid, M. J. (2004). Strengthening Social and Emotional
Competence in Young Children-The Foundation for Early School Readiness and
Success: Incredible Years Classroom Social Skills and Problem-Solving
Curriculum. Infants & Young Children, 17(2), 96-113.
Weiss, G., & Hechtman, L. T. (1993). Hyperactive children grown up: ADHD in
children, adolescents, and adults. New York: Guilford Publications.
Zigler, E., & Valentine, J. (1979). Project Head Start: A Legacy of the War on Poverty.
New York: The Free Press, A Division of Macmillan Publishing Co., Inc.
28