Abstract
Burgeoning research has documented high rates of maltreatment during the first 3 years of life. Early exposure to maltreatment is related to a host of negative physical, developmental, and mental health outcomes in childhood and adulthood. Scientists have documented the “biological embedding” of maltreatment, including alterations in the structures and processes of the young brain. Maltreatment is a complex phenomenon, which manifests in contexts of family poverty, inadequate parental knowledge and skill regarding child development and caregiving, social isolation of parents, disruptions in parent–child relationships, compromised parental psychological functioning, and concrete issues that affect parenting. Capitalizing on research on young child maltreatment, interventions have been designed to ameliorate infant/toddler maltreatment, buffer young children against the effects of maltreatment, and promote the well-being of maltreated young children. There is a growing empirical base on interventions to address early maltreatment within the context of a public health prevention framework. Primary prevention programs aim to reduce the incidence of maltreatment and related outcomes for infants, toddlers, and their families through the implementation of population-based programs, such as home visiting and early care and education programs. Secondary prevention models target families with specific risk factors associated with maltreatment, such as maternal depression. Tertiary programs generally entail involuntary services, designed to prevent maltreatment recurrence and to improve parenting skills through therapeutic approaches targeting the parent–child dyad. Empirical knowledge about maltreated young children and their families and interventions to support them can inform the design and delivery of child welfare services.
Childhood trauma, defined as witnessing or experiencing an event that poses a real or perceived threat (National Child Traumatic Stress Network, 2013), has taken center stage in public discourse around the impact of early experiences on adult outcomes. Burgeoning research has documented that early trauma exposure is related to a host of negative physical and mental health outcomes in adulthood (Anda et al., 2006; Jaffee & Christian, 2014). For example, the seminal Adverse Childhood Experiences (ACEs) study (Anda et al., 2006; Fellitti et al., 1998), which examined adult retrospective reports of adverse childhood events, such as childhood trauma (e.g., maltreatment), found that the experience of multiple ACEs was associated with a variety of adult physical illnesses and psychological disorders, including anxiety, depression, sexual problems, alcohol and substance abuse, disrupted sleep, impaired memory, obesity, cancer, and cardiovascular disease. More recently, Jaffee and Christian (2014) argued that early maltreatment is “biologically embedded” in the developing brain, thus leading to a cascade of developmental challenges for affected children across multiple domains that persist over time.
To foster public awareness of the impact of trauma and other adverse experiences on children, Shonkoff, Boyce, and McEwen (2009) have promulgated the notion of toxic stress, defined as the experience of overwhelming environmental stressors that leads to overactivation of the body’s stress response system. Toxic stress may be precipitated by “adverse childhood events” such as exposure to extreme and chronic poverty, parental mental illness, parental alcohol or substance use, intimate partner violence, and child maltreatment. The toxic stress emanating from ACEs, such as trauma, precipitates significant developmental and life-course challenges. It can disrupt brain architecture, compromise physiological and psychological responses to future stressors, limit cognitive development, and increase lifelong vulnerability to stress-related illnesses (Shonkoff, 2010). It is important to note that Shonkoff et al. underscore the pivotal role of caregiving in the experience of stress. Compromised caregiving drives stress to damaging levels, yet supportive caregiving can buffer children against the impact of toxic stress. This conceptualization undergirds many of the prevention and intervention approaches that will be discussed herein.
Although trauma negatively impacts children of all ages, in this article, we address trauma during the first 3 years of life. Compelling biological and behavioral evidence exists about the higher levels of opportunity and vulnerability during infancy (Sheridan & Nelson, 2009; Shonkoff & Phillips, 2000). Thus, there has been increased empirical interest in the epidemiology and sequelae of traumatic experiences during this developmental period, and the effectiveness of interventions to promote the well-being of affected children. Herein, we summarize the evidence about infant trauma exposure and examine the empirical basis for interventions to address this phenomenon within the context of a public health prevention framework. A major focus is how this knowledge can inform the design and delivery of child welfare and ancillary services for infants and toddlers who are victims of trauma.
Definitional and Conceptual Foundations
As noted previously, trauma has been defined as witnessing or experiencing an event that poses a real or perceived threat (National Child Traumatic Stress Network, 2013). Scholars have distinguished between various types of traumatic experiences, specifically acute trauma (i.e., single event), chronic trauma (i.e., multiple or enduring or recurring events), and complex trauma (i.e., multiple traumatic events, often of an invasive, interpersonal nature; National Child Traumatic Stress Network, 2013). A wide range of events is considered traumatic, such as serious illness (e.g., hospitalization, painful treatments), accidents (e.g., car accidents, dog bites, near drownings), separation from caregivers (e.g., foster care placement, death of parent), natural or human-caused disasters (e.g., hurricanes, droughts, famine), and poverty-related factors that compromise safety and security (e.g., lack of resources to fulfill basic needs such as hunger). These events may be especially traumatic for infants and toddlers who do not have the cognitive and language capacity to understand the temporal nature or the contextual underpinnings of such events.
Sexual abuse, physical abuse, and other violent events internal and external to the family (e.g., intimate partner violence, community violence) are also classified as traumatic experiences. Further, neglect, which affects a large proportion of maltreated infants (i.e., 62% of maltreated infants have experienced medical and/or physical neglect; U.S. Department of Health and Human Services, 2012, 2015), can be considered traumatic for infants, given its profound consequences for infant development and its potential impact on infant safety, security, and survival. Infants and toddlers in high-risk families are often exposed to chronic and complex trauma, as one traumatic experience may be related to and heightened by another (e.g., co-occurrence of intimate partner violence and child abuse).
There are several perspectives on the etiology of child maltreatment, arguably the most detrimental form of trauma exposure (Institute of Medicine, 2012; World Health Organization, 2006). Specifically, child maltreatment may emerge from one or more of the following: (1) inadequate knowledge and skills about typical child development and caregiving, (2) limited access to services that promote the physical and mental health of parents, (3) social isolation of parents, (4) disruptions to parent–infant interaction, (5) compromised parental psychological functioning, and (6) concrete issues that affect parenting (e.g., lack of housing). Further, studies have underscored a strong association between poverty and maltreatment, particularly neglect. For example, it has been documented that the availability of material supports is related to child maltreatment and the risk of foster care placement (Pelton, 2015). Shonkoff’s (2010) conceptualization of toxic stress also underscores that poverty and it concomitants can lead to adverse outcomes for affected children, which may be mitigated by stable, nurturing caregiving. The combination of these and other risk factors exponentially increase the likelihood of child maltreatment.
Clearly, child maltreatment is a complex and multifaceted phenomenon, which arises from a range of contextual factors. However, the theories around perturbed parent–infant interactions and relationships undergird many approaches for addressing trauma with infants and their families, which we will highlight in the sections to follow. Before we proceed to a conceptualization and review of prevention and intervention programs for this population, we address the epidemiology of infant/toddler maltreatment, which is critical from a public health perspective, the approach that frames this special issue. We also examine the developmental sequelae of infant maltreatment, which is important to consider for intervention design and implementation for this population, particularly in regard to whether and how such interventions can promote more positive developmental outcomes for maltreated infants and toddlers.
Epidemiology
A public health approach to prevention and intervention requires an examination of the epidemiologic data that can inform program goals, target populations, and service components. Extant data indicate that infants and toddlers are exposed to trauma at extremely high rates. For example, a recent study of young children documented that one quarter of children under the age of 4 years has experienced or witnessed a traumatic event (Briggs-Gowan, Carter, & Ford, 2012). A national study of childhood violence, abuse, and crime exposure found that 10.5% of 0- to 1-year-olds and 21.2% of children between 2 and 5 years old had witnessed violence in their lifetimes. Additionally, 7.6% of the infants and 15.8% of the 2- to 5-year-olds had witnessed an assault on a family member (Finkelhor, Turner, Ormrod, & Hamby, 2009).
Infants comprise the largest group of children victimized by maltreatment; specifically, one third (33%) of maltreated children are between 0 and 3 years of age (U.S. Department of Health and Human Services, 2012, 2015). Infants in their first year of life had the highest rate of victimization (23.1 per 1,000 children), compared to rates of 11.8, 11.4, and 11.0 out of 1,000 children for ages 1, 2, and 3, respectively (U.S. Department of Health and Human Services, 2015). Further, extant data suggest that African American infants in child welfare may drive the racial/ethnic disproportionality that has been documented in this service delivery system (Jones Harden, 2008).
Community-based studies have also confirmed high rates of maltreatment among very young children. In a national study in which mothers of infants under 1 year old and children between 2 and 5 years old were interviewed, it was documented that 2.2% of infants and 12.1% of young children had experienced maltreatment. In regard to maltreatment type, 0.6% of infants and 3.5% of young children had been neglected, and 0.6% of infants and 5.1% of young children had been physically abused (Finkelhor et al., 2009). Though there were no data on infant sexual abuse in this survey, 0.6% of 2- to 5-year-old children had been victims of sexual assault at some point in their lives (Finkelhor et al., 2009). The National Child Abuse and Neglect Data System (NCANDS) documents that the majority of infants and young children are victims of neglect (U.S. Department of Health and Human Services, 2015).
More often than not, the trauma that young children experience occurs within the home. Recent data indicate that 91.4% of all traumatized children in the NCANDS were abused or neglected by one or both of their parents (U.S. Department of Health and Human Services, 2015). Consistent with the general maltreatment data, the rate of fatalities was highest in babies; 81% of child fatalities due to abuse and neglect occur in children ages 0 to 3 (U.S. Department of Health and Human Services, 2015). Even higher rates are reported for infants younger than 1 (18.09 per 100,000 babies) as compared to other age-groups. The rate of childhood fatalities in African American populations (4.52 per 100,000 children) was 3 times higher than other racial and ethnic groups (U.S. Department of Health and Human Services, 2015).
There are multiple factors associated with infant trauma exposure. Familial and environmental risk factors, such as domestic violence, financial stress, and reliance on welfare, may increase the likelihood of childhood trauma (U.S. Department of Health and Human Services, 2012, 2015). For example, 27.4% of maltreatment victims of all ages were exposed to domestic violence. Further, 14.4% of maltreated children were living with families who struggled to obtain the sufficient financial resources to meet minimum needs and 29.9% were living with families dependent on social services. There is evidence that young children living in high-poverty communities are even more susceptible to trauma exposure than their low-poverty counterparts (Enlow, Blood, & Egeland, 2013; Ghosh Ippen, Harris, Van Horn, & Lieberman, 2011). These risk factors may exacerbate the impact of maltreatment on infants and toddlers, thus placing affected children on a downward developmental spiral.
Developmental Sequelae
Trauma has been documented to affect infants and toddlers in a particularly pernicious manner (Enlow et al., 2013; Osofsky & Osfsky, 2010; Osofsky, Osofsky, & Bocknek, 2010; Schecter & Willheim, 2009; Yoches, Beeber, Jones Harden, Malik, & Summers, 2011). Like all infants, those exposed to trauma experience developmental vulnerability, but also display developmental plasticity which fosters great potential for developmental change in response to the environment, even one marked by trauma. Thus, infants and toddlers may rebound to some extent from these traumatic experiences, particularly if they experience stable, nurturing caregiving (O’Connor & Parfitt, 2009; Osofsky & Osofsky, 2010). In the following paragraphs, we summarize the literature on trauma’s impact on young children’s brain, cognitive, language, and social-emotional development, as well as their physical and mental health.
Brain Development
Early life experiences are mapped onto the structure and functioning of the brain (Jaffee & Christian, 2014; Sheridan & Nelson, 2009). The quality of the environment and relationships in a young child’s life can either promote or inhibit healthy development of the brain and associated physical and psychological processes. During infancy, the human brain experiences more growth and refinement than at any other period of life. Infant brain development entails neuronal overproduction and pruning, rapidly developing synapses (i.e., connections between neurons), cell differentiation, myelination (i.e., fatty sheath that coats neurons allowing for efficiency of communication between neurons), and white matter development (i.e., related to coordination of communication among brain regions). Neurotransmitters and hormones direct undifferentiated neurons to their positions in brain structures in order to facilitate higher functioning (Perry, 2008; Sheridan & Nelson, 2009).
These changes in the structure and processes of the brain allow for greater connectivity and plasticity across developmental domains. Because brain development is highly context dependent, infant brains require appropriate stimulation at certain sensitive periods, which allow for optimal growth, adaptation, and the development of specific skills (National Scientific Council on the Developing Child, 2007; Schore, 2001). Exposure to trauma at sensitive periods of infant brain growth and development has significant impacts on the volume and functioning of the brain, especially the developing limbic system and cortical structures (Jaffee & Christian, 2014; National Scientific Council on the Developing Child, 2007; Perry, 2008).
With respect to brain size and volume, studies of institutionalized children suggest that overall brain size and volume are decreased, including the prefrontal cortex (i.e., implicated in abstract thinking, planning, executive functioning, behavioral regulation, etc.) and specific occipital areas (i.e., utilized for visual processing), among maltreated children (Perry, 2008; Sheridan & Nelson, 2009). Some studies have examined the size of the amygdala, a part of the limbic system implicated in memory, decision-making, and emotion processing, particularly regarding the detection of environmental threat. In a study of children who experienced physical abuse, early neglect, or low socioeconomic status, maltreated children had smaller amygdala volumes than other children who did not experience similar levels of adversity (Hanson et al., 2015). In contrast, recent studies of youth who lived in orphanages during their early years documented larger volumes in the amygdala (Ledoux, 2000; Mehta et al., 2009; Tottenham et al., 2010).
Research on maltreated and other traumatized children (e.g., those with PTSD), using imaging studies, have documented smaller size of the prefrontal cortex and hippocampus (i.e., associated with memory, spatial processing, and aspects of learning and cognition; Anderson et al., 2008; De Bellis, Hooper, & Sapia, 2005; Hanson et al., 2015). Additionally, decreased volume in the corpus callosum, the fibers that connect the two hemispheres of the brain, has been found in studies of institutionalized and maltreated children (De Bellis et al., 2005; Mehta et al., 2009; Teicher et al., 2004). Other studies have documented that maltreated children display reduction in the size of brain structures such as the anterior cingulate, frontal temporal, and lingual gyrus, and orbitofrontal cortex and reduced cortical surface area in the left middle temporal area and lingual gyrus, structures implicated in decision-making, emotional regulation, and memory (De Brito et al., 2013; Kelly et al., 2013).
There is emerging evidence that early maltreatment results in deficits in brain processing in a number of areas. The sensitive period of development of the limbic system—which includes such structures as the hippocampus, amygdala, and hypothalamus—occurs in the first three quarters of the first year of life and is modulated by early relationships, especially the infant’s relationship with the primary caregiver (National Scientific Council of the Developing Child, 2007; Schore, 2001). Prolonged activation of stress hormones (see discussion below) as a result of traumatic experiences can have significant and long-lasting effects on brain processes. For example, in a neuroimaging study comparing children between 7 and 10 years old, who experienced early institutionalization, to their noninstitutionalized counterparts, the institutionalized children evidenced dysfunction, specifically glucose hypometabolism (i.e., reduced use of glucose as an energy source), in several brain structures/areas (i.e., orbitofrontal cortex, prefrontal infralimbic cortex, lateral temporal cortex, medial temporal structures, and brainstem; Chugani et al., 2001).
The time in a child’s life between the end of the first year and start of the second year is a sensitive development period for the orbitofrontal cortex and other higher corticolimbic circuits, which are implicated in higher order and abstract thinking, emotional and behavioral regulation, executive functioning, stress responsivity, and other cognitive and emotional processes (National Scientific Council of the Developing Child, 2007; Schore, 2001; Sheridan & Nelson, 2009). Children who experience physical and sexual abuse show dysfunctional development in frontotemporal and anterior brain regions (i.e., implicated in thinking, language, and other cognitive and emotional processes; Teicher et al., 1997).
Further, neuroimaging and electrophysiological research has examined differences in the brains of maltreated children when they respond to emotion stimuli. Findings from these studies indicate that maltreated children have greater brain activation to angry cues (Curtis & Cicchetti, 2013; Shackman, Shackman, & Pollak, 2007) and greater activation of the amygdala when shown angry faces (McCrory, De Brito, & Viding, 2011).
Although more research on the infant brain is necessary to understand the nature of these early neurodevelopmental changes, there is burgeoning evidence of the pernicious impact of maltreatment on the growth and development of the brain during the early years of life. The atypical development of brain areas associated with higher order cognitive and emotional function may lead to subsequent behavioral regulation and cognitive processing issues for maltreated children, which affect their functioning across developmental domains.
Physical Health and Physiology
Childhood maltreatment and early adverse experiences have particularly detrimental consequences for an infant’s physical health and physiological regulation. There is evidence that maltreated infants and toddlers have higher rates of physical injuries and illnesses than their older and nonmaltreated counterparts, often due to parents’ lack of compliance with health recommendations around exposure to environmental toxins, oral health, and child supervision (Dubowitz & Black, 2002; U.S. Department of Health and Human Services, 2005). Early maltreatment, in particular physical neglect, can also lead to growth delays, such as failure to thrive (Block, Krebs, et al., 2005). There is also some evidence that early exposure to maltreatment, trauma, and other forms of adversity can affect the immune system, leading to chronic inflammation and heightened immune responses to stressors (Miller & Chen, 2010; Slopen, Kubzansky, McLaughlin, & Koenen, 2013). Immune system dysfunction can lead to many adverse health outcomes, such as cardiovascular disease and asthma (Miller, Chen, & Parker, 2011).
Physical abuse of infants and toddlers can lead to more severe and observable consequences such as head trauma, physical injuries, impaired motor skills, and/or death. For example, abusive head trauma, sometimes referred to as Shaken Baby Syndrome, is particularly prevalent among children under 2 years of age. Infants who experience abusive head trauma evidence a myriad of negative outcomes. Because infants’ brains are extremely susceptible to injury, mortality rates of abusive head trauma are very high, with rates ranging from 11% to 36% (Chevignard & Lind, 2014). Short-term outcomes include, but are not limited to, retinal hemorrhaging, blindness, skull fractures, hearing loss, impaired motor skills, and/or seizures. These in turn can lead to subsequent developmental, language, and cognitive delays as well as behavior problems in children (Chevignard & Lind, 2014; Narang & Clarke, 2014; Sieswerda-Hoogendoorn, Boos, Spivack, Bilo, & van Rijn, 2012).
The function of the hypothalamus–pituitary–adrenal (HPA) axis and cortisol production, one of its end products, are especially susceptible to the effects of trauma due to their roles in young children’s stress responses. In maltreated infants, the function of the HPA axis and cortisol production patterns are damaged by prolonged exposure to stress and chronic activation of the HPA axis (Cicchetti et al., 2011). Although the literature on the specific patterns of cortisol production in infants and toddlers who have experienced trauma is mixed, the majority of studies suggest that maltreated children display dysregulated and atypical patterns and levels of cortisol production.
Two distinct patterns have been reported in the literature on stress responses and the HPA system. First, children who have suffered early trauma or other adversities may display a more blunted pattern (i.e., low levels) of diurnal cortisol production compared to typical diurnal patterns, which tend to entail high wake-up levels of cortisol production followed by a steep decline throughout the day (Bernard, Butzin-Dozier, Rittenhouse, & Dozier, 2010; Bernard, Dozier, Bick, & Gordon, 2015; Cicchetti, Rogosch, Toth, & Sturge-Apple, 2011; Dozier et al., 2006; Ivars et al., 2015). In contrast, other children may exhibit elevated cortisol production throughout the day. These diurnal patterns may emerge throughout the first year of life, sometimes as early as the infant’s first month of age (Ivars et al., 2015).
In a particularly relevant study, Bernard, Butzin-Dozier, Rittenhouse, and Dozier (2010) examined cortisol production in 2- to-31-month-old children at risk of neglect, who either lived with their birth parents or were placed in foster care. Results demonstrated that the children placed in foster care showed more typical patterns of diurnal cortisol production when compared to children living with their birth parents, who presented more blunted levels of cortisol throughout the day. Regulation of the HPA system appeared to be easier for children who were no longer exposed to their neglectful birth parents and had been placed in foster care. Consistent with other studies, however, this study also revealed that both the maltreated children living with their birth parents and those in foster care displayed lower levels of awakening cortisol and had flatter slopes during the day than the children in the low-risk comparison group (Bernard et al., 2010).
Cognition and Language
Along with deleterious neurobiological and physical effects, childhood trauma has been associated with lags in cognitive and language development. In an earlier study, infant and toddler victims of childhood neglect had smaller head size, displayed significant cognitive delay, and reached the criteria for intellectual disability (Strathearn, Gray, O’Callaghan, & Wood, 2001). Other early research revealed that maltreated 2-year-olds showed poor problem-solving skills (Erickson, Egeland, & Pianta, 1989) and neglected children had lower IQs (Gowen, 1993).
More recently, cross-sectional studies have also reported high rates of developmental delay among maltreated infants, specifically with regard to early cognition (e.g., Leslie, Gordon, Ganger, & Gist, 2002). Stahmer, Hurlburt, Horwitz, Landsverk, and Leslie (2009) conducted a study on the developmental and language skills of maltreated children between 12 and 47 months old and found that exposure to different forms of maltreatment led to distinct results. Sexually abused children demonstrated more compromised cognitive development over time than other maltreated children. Victims of physical abuse and neglect exhibited less positive changes in their language abilities over time compared to other maltreated children (Stahmer et al., 2009).
Fewer studies have specifically addressed language development in young maltreated children. An earlier study of neglected children documented delays in expressive and receptive language (Gowen, 1993). In perhaps the only study of maltreatment and language development using a refined empirical paradigm regarding language, maltreated toddlers showed a shorter mean length of utterance, a more limited expressive vocabulary, and shorter bouts of contingent discourse during play sessions than lower socioeconomic status–matched controls (Coster & Cicchetti, 1993).
Although limited, there has been some longitudinal research on early maltreatment and later developmental outcomes. In a study following children from infancy to preschool (Egeland, Sroufe, & Erickson, 1983), there were marked cognitive differences among groups of maltreated children who were physically abused or neglected, and whose mothers were psychologically unavailable. Physically abused children exhibited less focus and persistence in tasks than children experiencing other maltreatment types. Neglected children maintained less impulse control and employed less creative problem-solving tactics than other children; physically neglected children had the lowest scores on standardized tests of intellectual functioning. Children with psychologically unavailable mothers, otherwise known as victims of emotional neglect, had the lowest scores on the developmental measure—the Bayley Scales of Infant Development.
Recent examinations of children from infancy to preschool have been conducted using the National Survey of Child and Adolescent Well-Being (NSCAW), the only nationally representative study of children in the child welfare system in the United States. Specifically, more than half of children younger than age 2 were documented to be at risk for developmental delay and approximately 1/3 had language delays (U.S. Department of Health and Human Services, 2005, 2012). Children who experienced physical abuse and neglect scored lower than those who had not on tests of cognitive development (Jones Harden & Whittaker, 2011).
Extant research on child maltreatment and cognition has to a great extent involved children whose infancy was spent in institutionalized settings where they experienced serious neglect. In multiple studies, it has been documented that neglected orphans in institutions had lower levels of intellectual functioning, more compromised sustained concentration and attention, and delayed language skills when compared to children who lived with their families and those in noninstitutional foster care, including those with lower IQs (Chugani et al., 2001; Nelson et al., 2007). Although children’s motor and social skills improved substantially when placed into foster or adoptive homes, problems in language, academic performance, and attention persisted. Neurodevelopmental deficits have also been documented in language processes, memory, and executive functioning (Chugani et al., 2001). In a small study of maltreated infants in congregate care in the United States, Jones Harden (2002) found that infants in institutional settings had more compromised development than infants in foster family care and those living with their birth families.
Executive functioning encompasses skills in the areas of attention, memory, goal direction, and self-monitoring. Early childhood trauma has been associated with compromised executive functioning skills (DePrince, Weinzierl, & Combs, 2009). For example, compared to controls, neglected children showed poorer performance on spatial working memory and facial memory tasks (Pollak et al., 2010), implying that neglect impacts children’s ability to retain and manipulate information. Further, when young children were exposed to a variety of learning tasks, those with a history of neglect had lower scores on these tasks than controls and children in foster care. They also experienced greater difficulty with tasks related to visual attention and were generally more impulsive (Pollak et al., 2010). These early cognitive and language deficits have major implications for maltreated children’s later academic functioning and school success (Crozier & Barth, 2005; Stahmer et al., 2009).
Social-Emotional Functioning and Infant Mental Health
The social-emotional functioning and mental health of infants and toddlers can also be hindered if they are exposed to adverse experiences, such as abuse, neglect, or other forms of trauma. The development of a secure attachment is a major social-emotional achievement during the first few years of life (Cassidy & Shaver, 1999; Dozier & Bernard, 2015; Reite & Capitanio, 1985). A multitude of studies examining children’s attachment have demonstrated that responsive, nurturing, and sensitive parenting leads to the development of secure attachments between very young children and their caregivers (Berlin, Ziv, Amaya-Jackson, & Greenberg, 2005; Bernard et al., 2012; Stronach, Toth, Rogosch, & Cicchetti, 2013). Grounded in this secure attachment, infants are able to utilize parents as a secure base in order to explore their surroundings and utilize their caregivers for comfort and as a source of protection and nurturance when they are distressed.
However, maltreated children may experience harsh, insensitive, and inconsistent parenting, which places them at higher risk for developing insecure attachment, in particular disorganized attachment. Infants and toddlers who display disorganized attachment show a lack of a specific strategy for seeking comfort in times of distress, displaying hesitation and/or confusion when they approach their caregivers (Cyr, Euser, Bakermans-Kranenburg, & Van Ijzendoorn, 2010). Disorganized attachment in children has been linked to a number of later detrimental consequences, including behavior problems and dissociative symptoms (Bernard et al., 2012; Cyr et al., 2010).
The association between child maltreatment and disorganized attachment was investigated in a meta-analysis in which 55 studies of high-risk and maltreated children were reviewed. Results of this meta-analysis revealed that maltreated children are more likely to display disorganized attachment and less likely to present secure attachment when compared to nonmaltreated high-risk children (Cyr et al., 2010). Based on these findings, it was hypothesized that maltreated children could not be securely attached to their maltreating caregivers because their caregivers, instead of being the source of comfort and reassurance, were the cause of fear and harm (Hesse & Main, 2006).
Another core developmental process affected by infant maltreatment is emotion expression and understanding. As noted in the section on the brain, findings from studies conducted by Pollak and his colleagues (e.g., Goldsmith, Pollak, & Davidson, 2008; Romens & Pollak, 2012) suggest that maltreated children may exhibit emotion understanding capacities that are different from their nonmaltreated counterparts. Findings from these studies suggest that abused children may be more attuned to the expression of negative emotions, such as anger, and that neglected children may be less able to discern distinctions between emotions. However, in a small study of young children in foster care, language was the most important predictor of emotion understanding, rather than factors such as maltreatment type and the stability of foster care placement (Jones Harden, Morrison, & Clyman, 2014).
Research on infant maltreatment has also investigated emotion regulation, defined as a biologically based and environmentally mediated process through which children adapt and cope with their emotions when responding to stimuli (Cole, Martin, & Dennis, 2004; Thompson, 1994). Infants and toddlers depend on their caregivers to initially orchestrate and later facilitate their emotion regulation and use their caregivers’ regulatory behaviors as a model and scaffold for their own (Cole et al., 2004). Exposure to maltreating parents’ harsh, inconsistent parenting and negative, dysregulated affect does not facilitate young children’s goal-directed emotion regulation (Kim-Spoon, Cicchetti, & Rogosch, 2013; Maughan & Cicchetti, 2002; Robinson et al., 2009). Because emotion regulation is a developmental process that spans the early childhood years (ages birth to 5), most of the studies focus on preschool age children and older. However, one study that examined 1- to 3-year-olds found that maltreated children displayed lower positive affect and more anger toward their mothers, which in turn was associated with more internalizing symptoms (Robinson et al., 2009).
Certain developmental factors, such as memory, affective expression, perceptual abilities, and motor skills, impede the diagnosis of post-traumatic stress disorder (PTSD) and other psychopathology in infants and toddlers, as these are just starting to develop and mature during this early phase of a child’s life (De Young, Kenardy, & Cobham, 2011). However, individual symptoms of PTSD can appear in younger children, including a child’s reexperiencing the traumatic event often through play, avoidance of triggers that remind them of the traumatic experience, as well as hyperarousal, commonly exhibited through a child’s disturbed sleep, increased irritability, aggression and alertness, temper tantrums, and startled and extreme responses to stimuli (De Young et al., 2011; Scheeringa, Myers, Putnam, & Zeahah, 2015).
Providing evidence of PTSD in very young children, a study with 1- to 5-year-old Israeli children found that nearly a third of the children suffered from PTSD as a result of being exposed to war. However, this study also demonstrated that preschoolers (3- to 5-year-olds) were twice as likely as toddlers to develop PTSD (Feldman & Vengrober, 2011). Finally, infants and toddlers who have experienced adversity, such as maltreatment, are also at higher risk for developing psychological disorders in later childhood, such as depression, anxiety, dissociation, and PTSD (De Young et al., 2011; Hagan, Hulette, & Lieberman, 2015; Kaplow, & Widom, 2007; Scheeringa et al., 2015; Yoches et al., 2011).
In sum, early trauma, specifically maltreatment, affects young children across all domains of functioning. Because the brain is still “under construction” during the first 3 years of life, maltreatment affects the structure and process of the developing brain. Specifically, brain regions that are implicated in higher order thinking and emotion/behavioral regulation are compromised. Additionally, maltreatment can lead to physiological and physical health impairments that begin in infancy and potentially extend to adulthood, including growth delays, compromised immune systems, altered HPA/stress-response system function, and the sequelae of head trauma.
Further, maltreated young children have high rates of cognitive and language delays and display compromised executive functioning, memory, and problem-solving skills. Regarding social-emotional functioning, maltreated infants experience insecure attachment to their caregivers; have impairments in their emotion understanding, expression, and regulation; and display symptoms of posttraumatic stress. The evidence regarding the adverse outcomes of early trauma exposure argues for the design and delivery of prevention and intervention programs that could potentially alter the developmental trajectories for these young children and their families. Because infant development primarily occurs in the context of relationships with caregivers, it is critical for development-promoting interventions to target infants’ caregiving environments.
Prevention and Intervention
The field of public health has contributed substantially to the ways in which service delivery systems develop programs to benefit vulnerable children and families. Specifically, the Institute of Medicine (2009, 2014) reports on prevention build on earlier recommendations to employ a three-tiered approach to the prevention of mental, emotional, and behavioral disorders in children. Primary, or universal, prevention programs target entire populations or vulnerable subgroups of a population (e.g., impoverished families) with a goal of preventing the onset of a problem. Secondary, or selective, prevention strategies are designed to benefit individuals who display risk for the development of a particular problem.
Finally, tertiary, or indicated, prevention programs have a goal of preventing the recurrence of a problem and adverse outcomes that emanate from the experience of a particular phenomenon. Tertiary programs target individuals who have already experienced a particular problem and address individual-level challenges and sequelae. The National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research (1998) argued for an expanded definition of tertiary prevention to include individuals who may already have a “full-blown” disorder. Following on this expanded definition, scholars advocated that prevention intervention should incorporate elements of treatment and that treatment interventions should be considered within a broader prevention framework (Weisz, Sandler, Durlak, & Anton, 2005). Thus, some of the tertiary prevention programs described in this review may also be considered treatment interventions.
The last few decades have witnessed a proliferation of prevention programs at all levels, which are designed to address trauma in children, adults, and families, many of which are empirically grounded (Institute of Medicine, 2009, 2014). Scholars and practitioners alike have advocated for the integration of these evidence-based programs into the child welfare service delivery system. However, some scholars have cautioned against a “one-size-fits-all” approach to this integration, arguing for a developmental approach to linking families with appropriate programs (Wulczyn, Barth, Yuan, Jones Harden, & Landsverk, 2007). Specific to the early years, Jones Harden (2007) advocates for an infant-centered approach to intervention, as a way to address the mechanisms by which the consequences of trauma during this developmental period can be abated.
In the following paragraphs, we use a three-tiered prevention, developmentally grounded approach to review the extant evidence on intervention programs to address trauma with children under 3 years of age and their families. The goal of this section is not to present a systematic review of prevention and intervention programs to address trauma but to highlight programs that have been documented via rigorous research studies to be effective in reducing the negative impacts of young children’s experience of trauma and its concomitants. Thus, specific programs that have been delineated in other systematic reviews (e.g., California Clearinghouse, Maternal Infant Early Childhood Home Visiting), as effective in reducing the incidence of maltreatment, in decreasing risk factors associated with maltreatment, or in promoting positive outcomes for maltreated children are explored. All the programs described have a goal of preventing maltreatment, have been tested with children and families experiencing maltreatment, or have examined its impacts on parental characteristics and parenting processes associated with maltreatment.
Specifically, we review primary prevention programs which are provided to the populations that are at highest risk for child maltreatment (e.g., impoverished populations), secondary prevention programs targeted to subgroups with specific risk factors associated with child maltreatment (e.g., maternal depression, toxic stress), and tertiary prevention programs for families in whom maltreatment has been indicated. In particular, we focus on programs that promote the stable, nurturing caregiving that may buffer children against the effects of trauma, such as early maltreatment (Shonkoff et al., 2010). We include a brief summary of each program and a review of the evidence on its benefits for maltreated infants and their families.
Primary/Universal Prevention
Primary prevention programs for infants, toddlers, and their families aim to reduce the incidence of maltreatment and related outcomes (e.g., infant mortality) through the implementation of population-based programs. Universal home visiting, community-based prevention programs, and early care and education programs have been developed to improve child outcomes by engaging new mothers, especially those of lower socioeconomic status, and addressing identified risks for trauma, abuse, and neglect that are specific to the prenatal, infancy, and toddler periods. Some of these early intervention efforts have been modestly effective at preventing maltreatment of infants and toddlers as well. Herein, we review primary prevention programs that are targeted to low-income families, are focused on infants and toddlers, and have been found to be effective in improving behaviors associated with child maltreatment.
Nurse Family Partnership (NFP)
Perhaps the most well-researched of the early childhood home visitation programs, NFP is designed to support first-time mothers who are teenaged, single, or of low socioeconomic status, through intensive prenatal and postnatal home visits with a registered nurse until the child’s second birthday. Nurse home visitors focus on improving pregnancy outcomes, child health and development, and maternal life course through providing support to mothers around their care of their children, pregnancy planning, education and work, as well as conditions in the home that affect mother and child well-being.
Randomized controlled trials among ethnically diverse samples have been conducted to test the efficacy of NFP. Among other benefits to children and families, NFP has been found to reduce rates of infant death and childhood injury through age 2 years (Kitzman et al., 1997; Miller, 2015; Olds et al., 2014). Additionally, NFP participating mothers were less likely to be reported to Child Protective Services (CPS) than controls (Mejdoubi et al., 2015; Olds et al., 1997). Reductions in risk factors for child maltreatment have also been documented, in areas such as intimate partner violence, drug use and arrests, as well as dependence on food stamps, Temporary Assistance for Needy Families, and Medicaid (Miller, 2015; Olds et al., 1997). Notably, some attempts at replicating NFP in other communities have not yielded positive results (e.g., Robling et al., 2016).
Durham Connects
Extending the NFP model, Durham Connects is a nurse home visiting program, which is implemented at the population level. A brief, highly structured intervention is provided through one to three home visits delivered between 3 and 12 weeks of birth to new mothers and fathers enrolled at a birthing hospital in Durham, NC. During the home visits, the nurses conduct evaluations to identify the families’ unique risks and connect them with appropriate community resources.
In a randomized controlled trial, Durham Connects was documented to improve parenting behavior, facilitate connections with community service providers, and reduce the incidence of emergency room visits (Dodge et al., 2014). Further, intervention mothers exhibited more positive parenting behaviors, such as comforting and reading to their children, and lived in higher quality home environments than their control group peers (Dodge et al., 2014).
Healthy Families America (HFA)
Developed by Prevent Child Abuse America, HFA is perhaps the largest, national child maltreatment prevention program. Interventionists conduct population-based risk screening at birthing hospitals and provide voluntary, intensive home visits to at-risk mothers from children’s birth to up to their fifth birthday. The program’s goals are to promote positive parenting and ameliorate trauma-related, adverse public health outcomes. HFA was inspired by the Hawaii Healthy Start Program (HSP), a home visiting intervention that demonstrated improved maternal care, increased family connection to medical services, and decreased maternal stress and partner violence (Duggan et al., 1999).
When implemented at the statewide level, HSP showed a modest decrease in childhood neglect and parental threats of physical discipline (Duggan et al., 2007). In an experimental study of Healthy Families Alaska (HFAK), the intervention mothers were less likely to employ mild levels of physical discipline than those who did not receive HFAK home visits. Rates of CPS reports for abuse and neglect were unaffected (Duggan et al., 2007). A randomized controlled trial of Healthy Families New York (HFNY) found the strongest effects; intervention mothers were less likely to seriously abuse their children than controls and employed nonviolent discipline strategies more frequently (Dumont et al., 2008). Those who participated in HFNY had fewer total CPS reports, abuse-related CPS reports, and CPS reports when the perpetrator was the study mother (Dumont et al., 2010).
Safe Environment for Every Kid (SEEK)
The SEEK model aims to reduce maltreatment by engaging mothers at their community pediatric primary care facilities and connecting them with appropriate community services (Dubowitz, 2014). Health-care professionals are trained to address families’ risk factors related to child trauma exposure. The intervention protocol includes administering a Parent Screening Questionnaire, providing additional resources in the form of handouts, and working with a social worker when requested by health-care professionals and parents (Dubowitz, Feigelman, Lane, & Kim, 2009).
In a study with low-risk families, SEEK participants had lower rates of minor physical assault and maternal psychological aggression (i.e., screaming, yelling, and insulting the child) than families receiving standard primary care (Dubowitz, Lane, Semiatin, & Magder, 2012). When implemented in urban primary care settings with very low-income families, SEEK resulted in fewer cases of abuse and neglect reported to CPS, fewer neglect-related medical issues, and reduced rates of severe or very severe physical assaults (Dubowitz et al., 2009).
Family Check-up (FCU)
The FCU intervention is designed to increase supportive parenting in low-income families with children aged 2–3 years (Dishion & Kavanagh, 2003; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006). It entails three home visits delivered annually to families who are receiving services from the Supplemental Program for Women, Infants, and Children (WIC). The three home visits include (1) an observation of parent–child interaction and other ecological factors; (2) an intake session that addresses family strengths, family concerns, and child well-being; and (3) an individualized feedback session that encourages families to obtain services tailored to their particular needs. Families who display the need for parenting support are linked to an evidence-based parenting intervention focusing on positive behavior support strategies (i.e., Everyday Parenting; Dishion, Stormshak, & Kavanagh, 2011).
FCU has been the subject of rigorous evaluation since its inception. An early evaluation documented that the intervention decreased child behavior problems from 2 to 4 years of age, as well as sustained more engagement of caregivers with their children (Shaw et al., 2006). A subsequent study revealed that parents’ positive behavior support mediated the impact of FCU on the decrease in children’s behavior problems from 2 to 4 years of age (Dishion et al., 2008). In follow-up studies of this sample, children whose families had received FCU were rated as less oppositional by their teachers when they were 7.5 (Dishion et al., 2014) and were found to be more “school ready” based on measures of self-regulation and academic achievement (Brennan et al., 2013; Lunkenheimer et al., 2008). Relevant to the maltreatment outcome of interest herein, a recent evaluation of FCU documented that duration of positive engagement between caregivers and their 3-year-old children yielded decreased child neglect at age 4, controlling for family adversity (Dishion et al., 2015). Additionally, important moderating and mediating effects were found: (1) FCU was most beneficial for families with higher levels of family adversity and (2) the strongest relations between positive caregiver engagement and decrease in child neglect were found for families with the highest levels of adversity (Dishion et al., 2015).
Early Head Start (EHS)
EHS is a large federally funded early care and education program for low-income families with infants and toddlers, which provides two-generational support for parents and children through home-based or center-based programs. By assisting families in a wide variety of areas, including parenting, education, health, child development, and social services, EHS has proven to positively impact parent–child relationships and reduce the incidence of spanking and substance abuse in the household (Green et al., 2014; Vogel, Brooks-Gunn, Martin, & Klute, 2013).
The first investigation of the intervention’s impact on maltreatment revealed that children in EHS families were less likely to be victims of substantiated child maltreatment reports or out-of-home placement transfers between the ages of 5 and 9 years old, the phase of childhood with the most child welfare encounters. Additionally, EHS children were less frequently reported to CPS for physical and sexual abuse, and in the case of multiple reports, children of EHS families were less likely to experience subsequent abuse (Green et al., 2014).
Positive Parenting Program (Triple P)
Although Triple P is not exclusively for infants and toddlers, it is worth discussing here given that research has examined its impact on young children. This preventive intervention is designed to reduce the incidence of child maltreatment using a multilevel approach. At the community level, a strategic universal media campaign is mounted, which provides positive parenting information to all parents. The intervention proceeds to levels of escalating intensification of support, based on family need (Sanders, 1999). Triple P offers brief individual consultations and group parenting seminars for parents contending with minor behavioral problems in their children and provides increasing quantities of individual, active skill-practicing sessions through home visits or group sessions for parents needing more intensive support. Community-based health-care professionals, social workers, school employees, and other groups who work with children and families are trained to promote the program’s principles: a stimulating environment, assertive disciplinary parenting strategies, keeping appropriate expectations, and parental self-care (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009; Sanders, 1999).
In an effort to examine how Triple P impacts child abuse and neglect, the U.S. Triple P System Population Trial was conducted. Triple P was implemented in 18 randomly selected counties of similar size in a southeastern state. This study tested the effects on child maltreatment in families with at least one child between 0 and 8 years old. Families in Triple P counties experienced lower rates of CPS reports, out-of-home foster care placements, and abuse- and neglect-related medical injuries (Prinz et al., 2009) than non-Triple P counties.
Strong Communities for Children (SCC)
SCC was a comprehensive, community mobilization initiative to prevent child maltreatment via connecting families to their communities, implementing activities to foster social support networks, and providing direct support for families with identified needs. SCC’s two-pronged approach entailed (1) community monitoring of children to keep them safe, promoted by outreach workers; and (2) services for young children and families, provided mainly by volunteers in established community settings (Kimbrough-Melton & Melton, 2015).
The SCC initiative was evaluated through a survey of parents who had children under 10 years of age and an examination of CPS reports. Benefits of SCC were found in the areas of social support, collective efficacy, child safety, observed and self-reported parenting practices, parental stress, parental efficacy, rates of substantiated child maltreatment, and rates of child injuries that reflected maltreatment (McDonell, Ben-Arieh, & Melton, 2015).
Secondary/Selective Prevention
Secondary prevention models target families with specific risk factors that are associated with maltreatment and related adverse outcomes. Interventions have been created to prevent maltreatment through embedded treatment of mental health disorders. Although we recognize that substance abuse is a major risk factor for infant maltreatment (Wulczyn et al., 2011), a review of programs targeting these families is beyond the scope of this article, given the incorporation of substance abuse treatment and related services. We do explore interventions that address maternal depression, a major risk factor for child maltreatment (Conron, Beardslee, Koenen, Buka, & Gortmaker, 2009; Lovejoy, Graczyk, O’Hare, & Neuman, 2000).
We also discuss interventions that, on the surface, could be categorized as tertiary-level interventions. However, because they were not originally designed to reduce child maltreatment, are voluntary, and are not considered “therapeutic” interventions, we discuss them herein. Finally, because the toxic stress experienced by young children exposed to trauma may be somewhat abated if they also experience nurturing, stable caregiving (Shonkoff, 2010), we review programs that are part of the Buffering Toxic Stress Consortium (Buffering Toxic Stress Consortium, Meyer, & Fortunato, 2013), which have a conceptual goal of enhancing parental responsiveness to young children as a mechanism to “mediate the impact of adversity on child well-being” (Supplee & Meyer, 2015).
Moving Beyond Depression (MBD)
MBD is a comprehensive program that integrates depression treatment in primary home visiting programs. Mothers enrolled in home visiting programs are screened for depression at enrollment. Master’s level therapists provide in-home cognitive behavioral therapy (IH-CBT) over 15 weeks to depressed mothers as a supplement to home visiting services. Home visitors and therapists collaborate throughout the intervention and are supported by a team leader.
Ammerman and colleagues (Ammerman, Putnam, Altaye, Stevens, et al., 2013; Ammerman, Putnam, Altaye, Teeters, et al., 2013) conducted a clinical trial in which they compared families of young children who received home visitation with IH-CBT to those who received only home visitation. At the end of the intervention, mothers with home visitation enhanced with depression treatment were less likely to have a diagnosis of major depressive disorder; reported increased social support; and experienced decreased psychological distress, improved coping, and fewer relationship difficulties. Those who recovered from depression experienced improved coping and increased nurturing and stimulation of their children at the end of the intervention and 3 months later.
Using a similar approach (i.e., home visiting supplemented by IH-CBT), two other programs have been found beneficial for depressed mothers. Tandon, Perry, Mendelson, Kemp, and Leis (2011) provided preliminary data that documented the efficacy of a cognitive-behavioral intervention to prevent perinatal depression among pregnant and new mothers in a home visitation program. In a pilot study with mothers enrolled in EHS, Beeber, Holditch-Davis, Belvea, Funk, and Canuso (2004) documented that depression treatment delivered by psychiatric mental health nurses, in the context of EHS home visits, resulted in decreased depressive symptom severity and improved mother–child interactions.
Attachment and Biobehavioral Catch-up (ABC)
Grounded in attachment theory and research, ABC is a brief manualized intervention for children 0 to 24 months of age and their parents who are at risk for maltreating their children. It is delivered in ten 1-hr sessions, typically in the parents’ homes, and focuses on providing nurturance to infants; following the child’s lead; avoiding frightening behaviors; and overcoming aspects of the parents’ own history that might interfere with providing nurturing, nonfrightening care (Dozier et al., 2006). Continuous “in-the-moment” commenting by a trained ABC parenting coach, as well as extensive video feedback following particular activities, is provided to facilitate parents’ understanding of the content of each session (Bernard et al., 2012; Dozier et al., 2009).
The promise of the ABC intervention for infants and toddlers at risk for maltreatment has been strongly supported by two recent randomized control trials, one focused on infants and toddlers in foster care (Dozier et al., 2009) and the other on children living with their biological parents at risk for child neglect who were participants in a CPS diversion program (Bernard et al., 2012). Both ABC children in foster care and those living with their biological parents had significantly higher rates of secure attachment postintervention when compared to children in the control group (Bernard et al., 2012; Dozier et al., 2009). Foster children who received ABC were reported to have fewer behavior problems than control children in foster care (Dozier, Peloso, et al., 2006) and greater cognitive flexibility and theory of mind (perspective taking) skills between the ages of 4 and 6 compared to comparison children who were not in foster care (Lewis-Morrarty, Dozier, Bernard, Terracciano, & Moore, 2012). Additionally, ABC toddlers living with their birth families displayed less negative affect (i.e., sadness, anger) in a challenging, problem-solving task with their mothers than controls (Lind, Bernard, Ross, & Dozier, 2014). There is also evidence that ABC helps regulate the cortisol production of high-risk infants and toddlers to levels and patterns similar to those of children who have not experienced early trauma (Bernard et al., 2015; Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008; Dozier, Manni, et al., 2006).
Promoting First Relationships (PFR)
PFR is another manualized intervention aimed at preventing the risk of maltreatment in infants and toddlers. Originally designed for homeless mothers, PFR consists of 10 home visits for caregivers and their children, 0 to 3 years old. The aim of the intervention is to promote positive parent-–child relationships through helping caregivers to understand the needs and emotions of their children, and how these are connected to the challenges of their relationships with their children. The home visitor videorecords about 20 min of mother–child interactions every other session. During alternate weeks, home visitors and parents review the entire video clip together in order to identify parents’ strengths and enable the interpretation of children’s cues that parents might have missed. Parents also learn how to respond more sensitively to their children in order to provide them with a safe and predictable environment (Maher, Kelly, & Scarpa, 2008).
There is currently one randomized control trial of the effectiveness of PFR with infants and toddlers at risk of maltreatment. In a study with 10- to 24-month-old children and their caregivers in the child welfare system, PFR caregivers showed greater improvements in their sensitivity and understanding of their toddlers’ social and emotional needs compared to the caregivers in the educational control group. However, no changes were observed in the attachment security of dyads immediately after the intervention or in the 6-month follow-up (Spieker, Oxford, Kelly, Nelson, & Fleming, 2012). In a 2-year follow-up study, PFR was not found to have an effect on the stability and permanency of the child’s placement 2 years after the conclusion of the intervention (Spieker, Oxford, & Fleming, 2014). Although PFR did not impact stability for children living with their biological parents, children living with foster and close relative caregivers experienced more stability and permanency when their caregivers received PFR compared to the children in the control intervention. Another investigation of a subset of participants from the Spieker, Oxford, Kelly, Nelson, and Fleming (2012) study revealed that PFR had an indirect effect on the reduction of sleep problems of 11- to 36-month-old maltreated toddlers who had been recently reunified with their birth parents, by decreasing their separation distress (Oxford, Fleming, Nelson, Kelly, & Speiker, 2013).
Circle of Security (COS)
COS is another intervention for families who present with risk factors commonly associated with trauma. Although originally designed as a group intervention for parents of preschool children, a modified and shorter home visiting version of the intervention for parents of infants and toddlers exists. The intervention has a direct focus on the caregiver, as opposed to the parent–child dyad. It provides parents with user-friendly visual aids and educational tools to help them learn about attachment theory, emphasizing reading and responding to their children’s cues and encouraging parents to have empathy and understanding for their children. Parents review segments of their own videorecorded interactions with their children in order to highlight the parents’ emotional presence and the children’s behaviors when exploring and seeking comfort from their parents (Cassidy et al., 2010; Cassidy, Woodhouse, Sherman, Stupica, & Lejuez, 2011).
Although research on the efficacy of COS on young children at risk for maltreatment does not yet exist, there are studies of the intervention conducted with high-risk families. For example, a nonrandomized study with pregnant, nonviolent offenders, with a substance abuse history, revealed that infants whose mothers had received the COS Perinatal Program showed high levels of secure attachment and low levels disorganized attachment. Mothers who received COS also had levels of maternal sensitivity similar to mothers in an existing community comparison group (Cassidy et al., 2010). In another nonrandomized study with Head Start and EHS families, children 11 to 58 months of age showed an increase in rates of organized attachment and a decrease in the rates of disorganized attachment postintervention (Hoffman, Marvin, Cooper, & Powell, 2006).
Incredible Years (IY)
The goal of IY’s Basic Parenting Program is to promote positive parenting in high-risk populations in order to buffer the detrimental effects of multiple risk factors on the normative development of children. It is a group-based intervention that focuses on enhancing parenting skills and the parent–child relationship. Designed for families with children from ages 2 to 12 years, with conduct problems, the program is divided into different subsets depending on the child’s age. Through reviewing video samples and role plays, caregivers can learn to improve their parenting as a way to promote their children’s emotion regulation, academic success, and social interactions (Hughes & Gottlieb, 2004; Hurlburt, Nguyen, Reid, Webster-Stratton, & Zhang, 2013; Linares, Montalto, Li, & Oza, 2006).
Although IY was designed for use with families of children as young as 2 years of age, most of the research on this intervention has been conducted with families of children older than 3 years of age. For example, in a study on the effectiveness of IY for the families of maltreated 3- to 8-year-old children, mothers who participated in the intervention showed significant improvements in their parenting and marginally significant improvements in the support of their children’s autonomy (Hughes & Gottlieb, 2004). Another study with biological and foster parents of children who had been neglected documented improvements in parenting capabilities as well as fewer externalizing problems in children as reported by parents who had received the intervention (Linares et al., 2006). Additionally, research on IY has demonstrated significant improvements in parents’ nurturance and positive affect with Head Start families who reported a history of child maltreatment (Hurlburt et al., 2013). Despite the positive outcomes of the intervention with children who have experienced trauma, research needs to be conducted to observe the efficacy of IY specifically on toddlers at risk of experiencing maltreatment.
Tertiary/Indicated Prevention
Tertiary programs generally entail involuntary services, designed to prevent maltreatment recurrence. Given that about a third of all reported maltreatment cases occur in children under age 3 (U.S. Department of Health and Human Services, 2015), the development and implementation of tertiary prevention models, designed to impact families with indicated maltreatment of infants and toddlers, is essential. Although the evidence on effective tertiary programs is sparse, a few interventions have been found to be effective for this highest risk group of families.
Child Parent Psychotherapy (CPP)
CPP is an evidence-based intervention designed to address trauma in families, specifically those with a history of child maltreatment and/or intimate partner violence. The intervention’s central goal is to enhance the relationship between parents and their traumatized children from birth to 5 years old. Unlike many other models, CPP is nondirective and nondidactic, allowing parents to lead the visits based on their own concerns, while still receiving constant empathic comments from the therapist on their interactions with their children. The intervention consists of weekly 1-hr home visits over the course of a year, which focus on increasing parents’ responsiveness, sensitivity, and attunement to their children while providing a safe environment in order to promote a more secure parent–child attachment. CPP also directly addresses maltreatment and trauma by supporting parents and children to “normalize” trauma-related responses and to create a shared interpretation of their traumatic experiences (Cicchetti, Rogosch, & Toth, 2006; Lieberman, Van Horn, & Ghosh Ippen, 2005; Stronach et al., 2013).
There is extensive research on the effectiveness of CPP with maltreated children in diverse populations. A study with 13-month-old maltreated infants found that children both in the CPP and the Psychoeducational Parenting Intervention (PPI) groups demonstrated significant increases in the rates of secure attachment and decreases in disorganized attachment after the interventions (Cicchetti et al., 2006). These rates of secure attachment postintervention were comparable to the rates of attachment in the normative comparison group of infants from nonmaltreating families. Further, the rates of disorganized attachment of the maltreated infants in the control community standard (CS) group postintervention were substantially higher. Although Cicchetti et al. found no differences in the attachment security of children who received CPP and PPI, a follow-up study conducted 1 year later demonstrated the sustainability of CPP in promoting secure attachment in infants and toddlers who have experienced trauma. Children who had received CPP had significantly lower levels of disorganized attachment and higher rates of secure attachment compared to children who had received PPI or the CS (Stronach et al., 2013). Other research on the efficacy of CPP has been conducted primarily on maltreated preschoolers. Studies with this population have found that CPP significantly improves children’s positive self-representations and mother–child relationship expectations (Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002), as well as reduces preschoolers’ behavior problems and trauma-related symptoms (Lieberman, Ghosh Ippen, & Van Horn, 2006).
Child First
Building on the CPP approach, Child First aims to intercede, prevent, or amend serious emotional trauma; improve child development and learning problems; and safeguard children from abuse and neglect (Lowell, Carter, Godoy, Paulicin, & Briggs-Gowan, 2011). The intervention identifies children 0 to 6 years old and their families who have multiple risk factors, in order to prevent child maltreatment or the harmful consequences of abuse and neglect. A team, consisting of a clinician and a community care coordinator, is assigned to each family as a way of providing these high-risk families with a well-rounded and comprehensive approach. Clinicians focus on therapeutic assessments and interventions of the child and the parent, using the CPP approach, while care coordinators serve as liaisons to the community and its services. As there is no set curriculum, families guide the visits depending on their current needs and concerns (Lowell et al., 2011).
Currently, there is only one randomized controlled trial that examined the effectiveness of Child First. The study, consisting of multirisk children aged 6–36 months and their mothers, found that Child First significantly improved language and reduced externalizing symptoms in enrolled children. These findings were sustained a year after the conclusion of the program. Further, intervention parents displayed and reported significantly lower parenting stress and psychopathology symptoms and had less involvement with CPS 3 years after the beginning of the program (Lowell et al., 2011).
Parent Child Interaction Therapy (PCIT)
Although primarily designed for children aged 2–12 years, PCIT is notable due to its empirically supported impact on the prevention of child abuse (Ware, Fortson, & McNeil, 2003). PCIT consists of 12–14 home visiting sessions that concentrate on improving the quality of the parent–child relationship, as well as teaching and encouraging parents to use new skills, such as alternative methods to physical discipline (Chaffin et al., 2004). Studies have shown PCIT to have significant effects on increasing maternal sensitivity (Thomas & Zimmer-Gembeck, 2011), preventing new reports of physical abuse 2 years after the conclusion of the intervention (Chaffin et al., 2004), and reducing child welfare recidivism (Chaffin, Funderburk, Bard, Valle, & Gurwitch, 2011). In a study with 2- to 8-year-old children with a history of maltreatment, investigators found reductions of behavior problems in the children after completing the PCIT intervention (Timmer, Urquiza, Zebell, & McGrath, 2005).
To date, there are two different adaptations of PCIT that have been designed to be more developmentally appropriate for younger children: Parent–Child Attunement Therapy (PCAT) and Parent–Child Interaction Therapy for Toddlers (PCIT-T; Dombroski, Timmer, Blacker, & Urquiza, 2005; Kohlhoff & Morgan, 2014). Based on the same goals and strategies as PCIT, PCAT was designed for 12- to 30-month-old children and aims to promote a strong parent–child relationship by increasing parents’ attention to children’s positive behavior and teaching parents to support their children’s play rather than to direct it. In a case study of a 23-month-old maltreated infant, PCAT led to an increase in positive parent–child interactions and improvements in the emotional availability scores of the dyad (Dombroski et al., 2005). A recent pilot study examined the effectiveness of and adaptation of PCIT for children under 2 years of age (PCIT-T). Results revealed that PCIT-T was associated with decreased disruptive behaviors in children, reduced parental depressive symptoms, and increased parental use of parenting skills learned in the intervention (Kohlhoff & Morgan, 2014).
Cognitively Enhanced Home Intervention
Unlike the other interventions rooted in attachment theory, this tertiary intervention aims to improve parenting skills through cognitively enhanced home visitation (Bugental et al., 2002). This model was originally designed to prevent the risk of abuse in young children and consists of 20 sessions given throughout a period of a year to high-risk parents. Unlike traditional home visitation programs in which the home visitors provide parents with solutions to their problems, Bugental’s cognitive behavioral therapy focuses on teaching parents ways to seek support and information as well as problem-solving tactics to achieve solutions to challenges they are facing, which may be hampering their parenting (Bugental et al., 2002).
Randomized controlled trials on this cognitively enhanced home visiting intervention have confirmed its effectiveness in improving parenting skills with high-risk mothers. In a study with newborn children that were born prematurely, experienced birth complications, and/or had illnesses, results demonstrated that mothers in the cognitively enhanced home visitation program used less physical punishment, reported fewer child injuries, and maintained higher safety standards in their homes compared to mothers who received the traditional home visiting program (Bugental & Schwartz, 2009). In the 3-year follow-up with the same participants, intervention effects revealed less aggression in children whose mothers had higher social-emotional availability (Bugental, Corpuz, & Schwartz, 2012). Mothers in the cognitively enhanced intervention were also less avoidant and withdrawn than comparison mothers. The intervention has also demonstrated improvement in cortisol regulation in high-risk children. Infants with mothers who had received the intervention showed lower levels of basal cortisol production when compared to children in the traditional home visitation program (Bugental, Schwartz, & Lynch, 2010). In the follow-up study completed a year after the conclusion of the program, when children were 3 years old, findings showed that the children with lower levels of cortisol in infancy had better verbal short-term memory than the children in the control intervention (Bugental et al., 2010).
Implications for Practice in the Child Maltreatment Arena
The burgeoning evidence on trauma and its sequelae, as well as on the effects of interventions designed to address trauma, has to a limited extent informed policy and practice in the child maltreatment arena. However, as many scholars assert, child welfare practice has not kept pace with the corpus of research on maltreatment prevention and intervention (Institute of Medicine, 2012). Consistent with the three-tiered prevention approach presented previously, the Institute of Medicine (2012) asserts that the field has access to a range of universal, selective, and indicated prevention programs that have been documented to attenuate the effects of maltreatment on children. For example, there is evidence that early intervention programs (e.g., home visitation, EHS), which typically encompass universal prevention strategies, especially when focused on new parents, can improve parenting and child outcomes. Selected interventions, such as home visiting for depressed mothers and interventions to buffer toxic stress, have been documented to improve parental psychological functioning, enhance parenting skills, and thus reduce maltreatment. Finally, tertiary interventions, that are brief, focused, and intensive (e.g., attachment-oriented and cognitive-behavioral parenting skill interventions), have been found to reduce maltreatment recurrence. Although the evidence base is growing for these programs, they have not been widely disseminated to and evaluated in community-based settings (Institute of Medicine, 2012). Thus, we are encouraging efforts to integrate such programs into child welfare and other child service delivery systems and to conduct evaluations of their effectiveness in these settings.
Further, the National Child Traumatic Stress Network (2013) has advocated for the development of trauma-informed service delivery systems for children. Trauma-informed systems instill the knowledge about the impact of traumatic stress on children, caregivers, and service providers into their organizational cultures, policies, and practices (e.g., Gilkerson et al., 2013). A trauma-informed service delivery system would aim to (1) maximize physical and psychological safety for children and families; (2) identify trauma-related needs of children and families; (3) enhance the well-being and resilience of children, families, and providers; and (4) partner with children, families, agencies, and systems that interact with children and families (National Child Traumatic Stress Network, 2013). Additionally, these service delivery systems would prioritize screening and assessment for trauma, trauma-based interventions for children and parents, staff support around addressing families’ and their own trauma, and collaboration with other programs to alleviate the impact of trauma on children.
Child welfare is arguably the major service delivery system contending with child and family trauma. Many of the trauma-informed objectives are already addressed within this system; however, there is a need to enhance specific strategies. For example, as has been noted previously, child welfare systems should implement empirically grounded trauma interventions for children and parents, at all levels (Institute of Medicine, 2012). It is also critical that child welfare systems attend to the secondary trauma of the child welfare workforce, through staff well-being promotion strategies and strong, supportive supervision (Chen & Scannapieco, 2010; Denmark & Jones Harden, 2011; Sprang, Craig, & Clark, 2011). In addition, Osofsky and Lieberman (2011) have recommended that principles and intervention strategies from the field of infant mental health be integrated into child welfare practice. Specifically, child welfare systems should incorporate parent–child interaction into all interventions and should consider the trauma experienced by the caregiver as a child in the context of service delivery.
Additionally, there should be efforts to move toward an infant-centered approach to child welfare practice (Jones Harden, 2007). Such an approach would incorporate efforts to address safety and permanency for infants and toddlers, such as risk and child protection assessments that address issues unique to very young children (e.g., symptomatology of Shaken Baby Syndrome), and case decisions that attempt to limit to one the number of placements that young children have to experience. In addition, interventions would capitalize on the interventions that exist in other service delivery systems that would promote the well-being of maltreated infants and toddlers. For example, home visiting programs have the potential to improve health and developmental outcomes, infant care centers and early intervention may promote optimal cognitive and language outcomes, and infant mental health programs can support positive social-emotional functioning in very young children. Child abuse prevention programs have capitalized on each of these approaches (e.g., Holmes, Levy, Smith, Pinne, & Neese, 2015; Howard & Brooks-Gunn, 2009).
Germane to this article, prevention efforts should focus on the knowledge derived from epidemiologic, developmental, and intervention research on infants and toddlers in the child welfare system. For example, epidemiologic data suggest that infants are more likely to be neglected, to die from maltreatment, and to have a recurrence of maltreatment (U.S. Department of Health and Human Services, 2015; Wulczyn, Ernst, & Fisher, 2011). Thus, tertiary prevention efforts should be implemented and evaluated that address child neglect, that focus on the factors predictive of fatalities (e.g., infant crying and shaking, lack of supervision during “near-miss” events), and that are designed to support families during the reunification phase (e.g., when children are returned to their birth parents after foster care placement).
Developmental evidence abounds relative to the adverse consequences of maltreatment for infants and toddlers. Interventions to prevent developmental delay in maltreated children are scarce but should incorporate strategies to promote birth and foster parent stimulation of children’s cognitive and language skills, as well as linking children to early care and education programs, such as EHS. Although there are many interventions designed to reduce mental health and behavior problems in older children, infant/toddler mental health is a lower priority in the child welfare system despite the evidence that early identification of mental health risk can attenuate later mental health difficulties. Consistent with the recommendations of Osofsky and Lieberman (2011), it is critical that young children and their families receive therapeutic services congruent with an infant mental health approach (e.g., parent–child interaction therapy).
Specific to intervention research, there is substantial evidence that strategies to promote positive parent–child interaction are critical for prevention programs serving infants, toddlers, and their families. As Thompson (2015) asserts, attention to parenting practices is essential in such programs but should occur in the context of providing emotional support to parents and concrete resources to families. Such interventions should be incorporated into prevention efforts at the primary level (e.g., early care and education programs, home visiting programs), at the secondary level (interventions to reduce depression and to improve parenting), and at the tertiary level (e.g., interventions to enhance birth parent–child visitation, to reduce instances of physical abuse and neglect, and to support reunification). Evidence-based programs that have been found to benefit infants, toddlers, and parents in controlled studies should be disseminated more widely, with a focus on how they can be utilized across the range of child welfare settings that exist in the United States. Importantly, the child welfare field would benefit from efforts to implement and evaluate programs to respond to the question of which programs work for which families, with respect to geography, culture, risk level, and maltreatment type.
Wald (2015) argues for moving beyond the child welfare sector for providing a system of support services for parents at risk for maltreating their young children. His approach would include broad outreach to families, capitalize on current service delivery systems, and incorporate evidence-based parenting interventions. Consistent with this approach and building on the intervention evidence, we offer the following specific recommendations for improving practices relative to this vulnerable population of young children and their families.
Primary Prevention
Implement broad community engagement and outreach efforts that encourage and incentivize parents to participate in parenting activities and remove the stigma of receiving parent support (e.g., Durham Connects).
Provide universal support (e.g., parenting information, newborn home visits; NFP) for pregnant women and parents of newborns through existing service sectors (e.g., health clinics, WIC) and in settings where families with young children frequent (e.g., community centers, grocery stores).
Expand availability of EHS, given its dual-generation focus of promoting child development, positive parenting, and functioning of parents (e.g., self-sufficiency).
Secondary Prevention
Screen parents in primary prevention settings for risks associated with maltreatment (e.g., depression, parental stress, childhood trauma exposure) and engage these families in more targeted services.
Integrate evidence-based home visiting and other parenting programs (e.g., ABC; PFR), into primary prevention settings (e.g., EHS, family support programs).
Develop, implement, evaluate, and expand the availability and use of interventions that target specific risk factors for infant maltreatment (e.g., substance abuse, depression, intimate partner violence; MBD) and also provide services designed to improve parenting.
Tertiary Prevention
Expand availability of and increase engagement of high-risk families in evidence-based parenting programs that have documented effectiveness in reducing infant/toddler maltreatment (e.g., CPP, Child First, PCIT, Cognitively Enhanced Home Visitation).
Incorporate such evidence-based interventions into child welfare service delivery, including family preservation programs, visitation/family time programs, and reunification services.
Conduct ongoing screening of young children whose families are enrolled in tertiary prevention programs for developmental and mental health concerns.
Increase workforce of interventionists trained to provide infant mental health and other intervention services for families of infants/toddlers who have experienced maltreatment.
Conclusions
Infants and toddlers are disproportionately exposed to trauma and show severe and long-lasting developmental consequences of this exposure. Extant data suggest that this population is most likely to experience maltreatment and is most vulnerable to the adverse sequelae of maltreatment. Given this evidence, it is critical to design effective interventions that prevent the maltreatment of very young children and that prevent the cascade of negative outcomes that they may endure as a result of maltreatment.
There is a growing number of evidence-based interventions designed to mitigate the effects of trauma on very young children. Although few interventions targeting infants and toddlers have been subjected to rigorous evaluation regarding their effectiveness in community settings, current data suggest that prevention and intervention approaches focused on enhancing parent–child relationships and interactions are effective with this population. Programs serving infants and toddlers exposed to trauma, in particular maltreatment, should integrate such interventions into their services for families with very young children at the primary, secondary, and tertiary levels of prevention. Working in tandem with other infant/toddler service delivery systems, such as early childhood care and education, early intervention, and infant mental health, child welfare has the potential to be a major resource for preventive services for maltreated infants and toddlers, and ultimately change the long-term developmental trajectories of this vulnerable population of children.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.