Interventions for toddlers and young children focus on enhancing the parent-child relationship, promoting children’s cognitive stimulation and development, teaching effective discipline and management of children’s behavior problems, and/or promoting positive beliefs about parenting.
Toddler-Parent Psychotherapy
Cicchetti, Toth, and Rogosch and their colleagues developed Toddler-Parent Psychotherapy (TPP) for depressed mothers and their toddlers. TPP aims to improve parenting and, thereby, promote secure attachment and healthy development in toddlers. TPP includes joint therapy sessions for mother-toddler dyads. TPP therapists use several methods to promote positive relationships between mothers and their children. First, by providing empathy, respect, and positive regard, therapists provide a corrective emotional experience that helps mothers to 1) become more accepting of themselves and their children, 2) develop a more positive views of their parenting abilities, and 3) feel supported as they try out new approaches to interacting with their children. Second, by observing and commenting on naturally occurring events (such as child tantrums and mother’s emotional responses), therapists help mothers to recognize their interpretations of their children’s behavior and the effect of these interpretations on their children. Third, the intervention helps mothers to identify and correct distorted perceptions of their children’s behavior. In the published studies of TPP, mother-toddler dyads participated in weekly sessions from the start of the intervention (when target children were approximately 18 to 20 months old) until the target children reached the age of 3.
Mothers (who had experienced a major depressive episode at some point after their child’s birth) and their toddlers were recruited through clinician referrals, newspaper advertisements, and notices placed in medical offices and on community bulletin boards. Mothers and their toddlers were randomly assigned to TPP or a no-intervention control group. The TPP and control groups were also compared to a non-depressed comparison group consisting of mothers who had not experienced depression and their toddlers.
Three papers have reported on the efficacy of TPP with overlapping samples. Two papers reported significant benefits of TPP in randomized controlled evaluations of its effects on toddler’s attachment [
10,
11]. TPP significantly reduced the proportion of toddlers with insecure attachments relative to the experimental control group. At baseline, toddlers of depressed mothers were more likely to show insecure attachment than toddlers in the non-depressed comparison group; however, these differences disappeared following TPP. Cicchetti, Rogosch and Toth [
12] found that TPP also improved toddler’s cognitive functioning relative to the controls. Similar to the attachment findings, toddlers whose mothers had a history of depression scored lower on cognitive testing than toddlers in the non-depressed comparison group at baseline; however these differences also disappeared following TPP. Thus, by fostering positive parent-child relationship, TPP may prevent the negative consequences of maternal depression on young children.
These studies of TPP used strong research designs, including random assignment to the intervention or control group, a non-depressed comparison group, and assessment of a variety of outcomes (questionnaires, observations, and standardized assessments) from multiple perspectives. One important limitation is the homogeneity of the study sample. Mothers who participated in the study had to have at least a high school education and could not be reliant on public assistance. About 90% of the mothers in the experimental conditions were married, more than 90% were of European American race/ethnicity, and most were of high SES. Thus, it will be important to determine whether the positive benefits of TPP extend to more diverse families, especially families that are coping with additional stressors linked to poverty.
Group Cognitive-Behavioral Therapy
Verduyn and colleagues [
13] developed a group cognitive-behavioral therapy (GCBT) for mothers and their young (2 1/2 to 4 year old) children with an aim to reduce maternal depression symptoms and child behavioral problems. GCBT consists of 16 weekly sessions with six to eight families. Mothers participate in a group that includes cognitive therapy for depression, psychoeducation about children’s development, parent behavior training, goal setting for focused change, and practice of skills outside the group. The cognitive therapy component focuses on cognitions that directly relate to parenting. The parent behavior training includes enhancing the mother-child relationship through child-centered play in addition to teaching reinforcement of positive behaviors, praise and attention, and dealing with negative behaviors through strategies such as time out. Children participate in the play sessions.
GCBT was evaluated in a trial with two comparison conditions: a) mother support group (i.e., attention placebo) and b) no-intervention [
13]. All mothers with children between two and a half to four years of age from a community registry were sent questionnaires and mothers who reported high levels of depressive symptoms and high levels of behavioral problems in their children were asked to participate in the trial. Findings revealed no significant differences between the three conditions on maternal depression severity and parent report of child behavior problems post-intervention and at 6 month and 12 month follow-ups. Analyses of within condition changes demonstrated significant improvements in child behavior for GCBT from baseline to post-intervention, which were maintained at 6- and 12-month follow-ups. Mothers in both the GCBT and support group showed reductions in depression severity from baseline to post-intervention that were maintained at 6- and 12-month follow-ups. These findings suggest that there may be some benefit for the GCBT.
One strength of GCBT is the inclusion of components that focus on parenting and psychoeducation about child development. Other strengths of this research are the inclusion of a large community sample of mothers and use of both attention placebo comparison and no treatment comparison conditions. A limitation of the study is the large refusal or withdrawal of mothers with high levels of depression symptoms from participation in the group; only 37% agreed to participate. In addition, the researchers were unable to randomize participants to the no treatment condition during the first wave of recruitment.
Cognitive-Behavioral Family Intervention
Sanders and McFarland [
14] developed a cognitive-behavioral family intervention (CBFI) that is based on efficacious treatments for child externalizing behaviors and adult depression. The focus of CBFI is to simultaneously work on the parent-child relationship and the parent’s depressed mood. CBFI aims to reduce potential family conflict, improve children’s behavior, and decrease the risk of mothers’ attrition from parent training treatment. CBFI consists of 12 sessions (8 in the clinic and 4 in the home) and includes two intervention components: behavioral family intervention (BFI) and cognitive behavioral treatment (CBT) for the parent’s depression. The BFI component includes behavioral parent training skills that promote positive parenting behaviors and effective management of child misbehavior. The CBT component focuses on increasing family activities, identifying and interrupting child related dysfunctional cognitions, using relaxation techniques, and using cognitive coping statements to address distress and negative cognitions.
CBFI was compared to the BFI component in a randomized clinical trial with mothers with MDD, their spouses, and children aged 3-9 years (mean age = 4.4 years) with Oppositional Defiant Disorder (ODD) or CD. Both interventions demonstrated a similar impact on reducing mothers’ depression and children’s behavioral problems. Specifically, in both interventions, mothers’ depressive symptoms and automatic thoughts decreased from baseline to post-intervention. Mothers’ perceptions of social support and parenting competence increased from baseline to post-intervention. The benefits on mothers’ symptoms, social support, and parenting competence were maintained at 6-month post-intervention. Similarly, in both interventions fathers’ depressive symptoms decreased and fathers’ parenting competence increased from baseline to post-intervention. However, the benefits for fathers were not maintained at 6 months post-intervention. Additionally, mothers’ reports indicated that children’s behavioral problems decreased in both interventions from baseline to post-intervention and these benefits were maintained at 6 months post-intervention. Observational measures also demonstrated that children’s negative behaviors decreased from baseline to 6 months post-intervention.
There are several strengths of the intervention including the multiple components for critical domains such as parental depression and child externalizing disorder. In addition, to address the generalizability of the skills learned, part of the intervention is conducted in the home with both parents. Inclusion of observational measures to examine outcomes is a major strength because it reduces concerns about biases that may result from relying solely on parental report measures. Because both interventions had similar effects, it is not clear whether CBFI is more beneficial than BFI alone.
Interventions for children and young adolescents focus on many of the same goals as interventions for young children such as strengthening the parent-child relationship and promoting effective discipline. In addition, interventions for children and young adolescents promote children’s own coping and resilience skills, provide psychoeducation about parental depression and its effects on children, increase communication within the family, and/or treat the depressed parent.
Preventive Intervention Project
Beardslee and colleagues developed a cognitive psychoeducational primary prevention model aimed at families with a parent diagnosed with MDD or Bipolar disorder and their children between the ages of 8 to 14. Parents are recruited from health care plans, psychiatric hospitals and general medical centers. The Preventive Intervention Project (PIP) consists of 6 to 10 sessions. The initial sessions are conducted with parents while the remaining sessions involve individual sessions with the children and family sessions. The parent sessions are designed to 1) increase parents’ knowledge about symptoms and causes of childhood and adult depression and 2) provide information about how to foster resiliency in children. The family session focused on helping the family communicate about depression and the effects on the family.
There are several core components to PIP. First, all family members are assessed, thus functioning of all family members is known. Second, PIP provides psychoeducation about mood disorders and the risk and protective factors for children. Third, this psychoeducation is linked with the family members’ life experience of depression. Fourth, PIP promotes discussion of the family’s understanding of depression with an emphasis on decreasing blame and guilt. Finally, PIP helps families to develop future plans, such as increasing children’s engagement in interests and activities at school and within the community.
Beardslee and colleagues have also developed a lecture prevention program. This program also consists of psychoeducation about mood disorders and fostering resiliency in children. It is implemented in two sessions by a group format for the parents.
Several papers have reported on evaluations of the PIP compared to the lecture program; most of which include the same sample. Families were randomized to PIP or the lecture intervention. Following both interventions, parents reported increased discussion and knowledge about depression [
15,
16]. Post-intervention, families in PIP reported greater communication than families in the lecture intervention [
16,
17]. Compared with the lecture intervention, PIP improved parents’ reports of children’s behavior, family communication, and understanding of parental depression for up to 4.5 years post-intervention [
18-
21]. Similarly, children in PIP reported greater understanding of depression than children in the lecture condition post-intervention, and at 1.5 and 4.5 year follow ups [
21,
22, 37]. Improvements in children’s internalizing symptoms and understanding of parental depression endured through 4.5 years of follow-up in both conditions [
20,
21]. Findings also revealed a positive association between the change in children’s understanding of parental mood disorders and parental report of child-related behavior and attitude changes [
20-
22]. Of the 122 children without history of MDD upon entering the study, seventeen were diagnosed with MDD up to 4.5 years after implementation of the intervention and the numbers within each condition were similar suggesting that PIP and the lecture condition were equally effective in preventing the development of depression [
21].
The intervention has been adapted for a low income, ethnic minority population [
23]. The modifications included: 1) increased time and effort to build a therapeutic alliance; 2) home visitation; 3) flexibility with schedule; 4) additional meetings to address survival needs and problems; 5) advocacy; 6) use of problem-solving to cope with stress and parenting concerns; 7) emphasis on child-related issues and lack of parenting support; and 8) reconceptualization of resilience to be relevant to the families, including a focus on building self-understanding, promoting friendships, and participating in activities outside of the home.
The adapted intervention was evaluated with families recruited through health and community centers, social service agencies, and word of mouth. Families were randomly assigned to PIP or the lecture intervention. Findings showed that the adapted intervention was acceptable for the families. Both groups reported increases in family communication and understanding of parental depression, with greater improvements in PIP than in the lecture intervention [
23]. These findings are consistent with the results of previous studies with predominantly white, middle and upper class families.
PIP has several notable strengths, such as the intervention’s role as an adjunct to parent’s treatment, the inclusion of both parents and children, and the flexibility for adaptation for each family and for diverse populations. In addition, empirical evidence is available from long-term follow-ups with good retention rates and some efficacy outcomes have been replicated with a small sample of low-income, ethnic minority families. One limitation is that children’s adjustment and psychological functioning were not reported for the low-income and ethnic minority sample. Additionally, since the comparison group appears to be an active intervention, it is unclear how efficacious PIP is relative to usual care.
Cognitive-Behavioral Group Therapy Ha and Oh [
24] developed a cognitive-behavioral group therapy (CBGT) for mothers with elevated depressive symptoms whose children were in treatment for psychosocial adjustment difficulties. CBGT includes three major components covered in a total of 8 sessions. The psychoeducation component, adapted from Beardslee and colleagues’ interventions, teaches mothers about the effects of depression on themselves and their children. The cognitive component teaches cognitive restructuring techniques (identifying negative and biased interpretations, generating more reasonable interpretations of events) and helps mothers to apply these techniques to situations involving their children. The parenting skills component teaches behavioral parenting strategies (instructing children effectively, applying rewards and appropriate consequences for problematic behavior). Through these different components, the CBGT aims to 1) improve mother-child relationships and mothers’ feelings of control over their children’s behavior, 2) reduce mothers’ experience of parenting stress, negative automatic thoughts (especially negative interpretations of children’s behavior) and depressive symptoms, and 3) reduce children’s behavioral problems.
The CBGT was evaluated in a small study using a non-randomized wait-list control design. Recruitment was conducted through hospital child psychiatry departments and outpatient clinics. Mothers’ and children’s adjustment was measured before the intervention and post-intervention, at which point the wait-list group received referrals for parent education. A follow-up assessment was conducted 3 months post-intervention with participants in the CBGT condition only. Analyses comparing the two conditions through post-intervention indicated that the CBGT significantly reduced mothers’ reports of parenting stress, negative automatic thoughts, and depressive symptoms relative to the control group. The CBGT also improved mother-child interactions and mothers’ (but not fathers’) reports of children’s behavioral problems. The follow-up assessment indicated that (in the CBGT group), mothers’ depressive symptoms, mothers’ parenting anxiety, and children’s behavioral problems continued to be lower than at baseline.
A major strength of CBGT is the inclusion of several promising intervention components. Study limitations include the lack of random assignment and the very small sample size; there were only 17 families in each condition. Thus, it will be important to replicate these findings with a larger sample using a randomized controlled design.
Parent Education Group
Sanford and colleagues [
25] developed a parent education group for parents with MDD and their partners. The parent education group incorporates family psychoeducation and parent training models. It aims to increase: 1) knowledge about depression and its impact on the family, 2) spousal support, 3) positive family communication and 4) positive parenting strategies. The intervention consists of eight weekly two-hour sessions with parents alone or with a partner. Each session focuses on a particular issue of families with parental depression and includes socialization, didactic teaching, viewing videotapes of parenting situations, and homework tasks.
The parent education group was compared to a wait list comparison. In addition, effects were assessed on one child between the ages of 6-13 from each family. At post-intervention, parents with MDD who were in the parent education group reported higher levels of family functioning than parents with MDD in the comparison group. There was a marginally significant benefit of parent education relative to control on reports of family conflict, parenting disagreements, and parenting competence among parents with MDD. There was also a marginally significant benefit of parent education relative to control on partners’ depressive symptoms. Surprisingly there were no differences found in depression knowledge between groups. Child outcomes (i.e., depressive symptoms, peer relationships, participation in activities, school problems) also did not differ by condition.
The strengths of this intervention include the integration of psychoeducation and parenting interventions and the potentially increased feasibility of implementing a parent group compared with interventions that include both parents and children. The major limitation of the study is the lack of retention; 27% participants did not complete the post-intervention assessment and 43% were lost by the 8 weeks post-intervention. There was a selective bias in which parents with greater depression severity were more likely to drop out of the intervention than the wait list comparison. Overall, parents with greater depression and single parents failed to complete the study. As a result, the generalizability of the findings is limited especially considering the small sample size.
Interpersonal Psychotherapy for Depressed Mothers
Swartz and colleagues [
26,
27] developed an individual interpersonal psychotherapy for depressed mothers whose school-age children are in treatment for psychiatric disorders. The therapy (IPT-MOMs) uses three overlapping intervention approaches. The first session focuses on building engagement. The session includes motivational interviewing techniques. These techniques are designed to enhance the client’s motivation for change and to identify and resolve barriers to treatment. The session also includes ethnographic interviewing techniques designed to increase the therapist’s understanding of the client’s cultural background. The remaining eight sessions are based on brief interpersonal therapy, adapted to focus on parenting a child with psychiatric difficulties. The program acknowledges the mothers’ love for her child and validates her for bringing her child in for appropriate treatment. Major goals of the program include helping mothers to understand the difficulties of parenting a child with a psychiatric illness, to understand the importance of taking care of themselves, to develop new parenting strategies, and to interact with their child’s mental health team effectively. In addition, the therapists are in contact with the child’s mental health team in order to facilitate an alliance with the child’s therapist and to help address family issues [
26].
A recent efficacy study evaluated IPT-MOMs as an adjunct to child therapy. Families were recruited through pediatric mental health clinics. Mothers of children (ages 6-18) who were in therapy were screened for depressive disorders. Mothers with MDD were then randomly assigned to the IPT-MOMs intervention or to a usual care control. Mothers and children were assessed at baseline, post-intervention, and a follow-up approximately 3 months following the intervention. IPT-MOMs improved mothers’ depression and anxiety symptoms and global functioning (relative to usual care) at post-intervention. Improvements in mothers’ depressive symptoms and global functioning were maintained at follow-up. Although there was no intervention effect on children’s symptoms at post-intervention, children in the IPT-MOMs condition showed greater improvement than controls on depressive symptoms and overall functioning at follow up [
27]. The pattern of findings suggests that IPT-MOMs improves mothers’ functioning which, in turn, promotes children’s well-being.
This study used a strong research design, including random assignment to condition, assessment of mothers’ and children’s well-being, and evaluation of effects through 6 months of follow up. Limits to the study include the small sample size and high levels of attrition and missing data; the authors note that 40% of children are missing for some measures at some assessments.
Interventions for older adolescents focus on promoting adolescents’ coping skills and reducing depressive cognitions and symptoms, as the risk for MDD increases dramatically during this period. One intervention
Coping with Depression
Clarke and colleagues developed a group cognitive-behavioral intervention, the Adolescent Coping with Depression Course (CWD), for adolescents (13-18 years old) with depressive disorders. They also developed an adaptation of this program, the Coping with Stress Course (CWS), for adolescents with high depressive symptoms but sub-threshold for MDD diagnoses. Although these interventions were originally designed for general use with adolescents with depressive disorders and elevated symptoms, they have recently been evaluated with adolescents with depressed parents.
CWD teaches a variety of cognitive-behavioral skills designed to reduce and prevent depression, such as cognitive-restructuring, relaxation, increasing engagement in pleasant activities, and communication and conflict resolution. CWD consists of 16 two-hour group sessions for adolescents and three informational meetings for parents. The CWS consists of 15 one-hour group sessions for adolescents and three informational meetings for parents. The CWD and CWS parent meetings teach parents about the topics and skills covered in the adolescent course so that parents can understand and support their adolescents’ use of the skills. Clarke and colleagues evaluated the CWD with depressed adolescents whose parents had received treatment for depression within the past year [
28]. Parents were recruited through their Health Maintenance Organization (HMO) and their adolescents were invited to complete a screening assessment. Families with a depressed adolescent were randomized to CWD or to a usual care control that, for most participants, included outpatient mental health visits and medication. CWD did not lead to significantly greater improvement than usual care in this study. However, the majority of adolescents in both conditions recovered from depression following the intervention phase, suggesting both conditions did well and there may have been little room for an added benefit of CWD.
Clarke and colleagues conducted a parallel study of the CWS with adolescents with high sub-threshold depressive symptoms [
29]. Recruitment and screening procedures were similar to the CWD study except that adolescents with sub-threshold depressive symptoms (rather than depressive disorders) were invited to participate. Families were randomized to CWS or usual care control condition. This study revealed significant benefits of CWS. Adolescents who participated in CWS were significantly less likely to develop depressive disorders for two years following the intervention. The CWD and CWS intervention studies used strong designs, including random assignment to condition and diagnostic interviews to assess effects on psychiatric disorder. A large, multi-site evaluation of the CWS intervention is underway.
The CWD and CWS programs have many strengths, including targeting adolescents’ cognitions and coping styles that may increase risk for depression. Nonetheless, the parent intervention component is very brief and does not focus specifically on parental depression or the effects of parental depression on the family. Similarly, the adolescent and parent interventions do not address parental depression explicitly. Even greater benefits may be obtained by combining CWD/CWS with intervention components that focus more specifically on the effects of parental depression on the family.
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