How much do preverbal children signal a wish to be fed? Nested case control study comparing weight faltering and healthy infants.

We aimed to 1/develop an observational tool to rate non-verbal cues infants give when being fed 2/test whether these differ between healthy children and those with weight faltering (WF) 3/describe how well these predict whether offered food is eaten. SUBJECTS: and methods: The study used videos of infants eating a standardised meal studied in a case control study nested within the Gateshead Millennium Study (GMS). Infants with weight faltering (WF) were each matched to 2 healthy controls. Half the control videos (N = 28) were used to develop the scale. Food offers were identified and the child's head, eyes, hands, and mouth position/activity rated as signalling a readiness to be fed (engaged), or not (disengaged) as well as whether food was accepted; 5 of these videos were used to assess inter-rater and test-re- test reliability. The scale was then applied to the videos of 28 WF infants (mean age 15.3 months) and 29 remaining controls (mean age 15.8 months) to identify and code all feeding events. RESULTS: test-re-test rates varied from 0.89 for events to 0.74 for head; inter-rater reliability varied from 0.78 for hands to 0.67 for mouth. From 2219 observed interactions, 48% showed at least one engaged element, and 73% at least one disengaged; 67% of interactions resulted in food eaten, with no difference between WF and control. Food was eaten after 73% interactions with any engagement, but also in 62% with disengagement. CONCLUSIONS: Infants were commonly disengaged during meals, but a majority accepted food despite this. Those with weight faltering did not differ compared to healthy controls.

Predictors of positive and negative parenting behaviours: evidence from the ALSPAC cohort.

BACKGROUND: This study aimed to establish the predictors of positive and negative parenting behaviours in a United Kingdom population. The majority of previous research has focused on specific risk factors and has used a variety of outcome measures. This study used a single assessment of parenting behaviours and started with a wide range of potential pre- and post-natal variables; such an approach might be used to identify families who might benefit from parenting interventions. METHODS: Using a case-control subsample of 160 subjects from the Avon Longitudinal Study of Parents and Children (ALSPAC), regression analysis was undertaken to model parenting behaviours at 12 months as measured by the Mellow Parenting Observational System. RESULTS: Positive parenting increased with maternal age at delivery, levels of education and with prenatal anxiety. More negative interactions were observed among younger mothers, mothers with male infants, with prenatal non-smokers and among mothers who perceived they had a poor support structure. CONCLUSIONS: This study indicates two factors which may be important in identifying families most at risk of negative parenting: younger maternal age at delivery and lack of social support during pregnancy. Such factors could be taken into account when planning provision of services such as parenting interventions. We also established that male children were significantly more likely to be negatively parented, a novel finding which may suggest an area for future research. However the findings have to be accepted cautiously and have to be replicated, as the measures used do not have established psychometric validity and reliability data.

Association between parent-infant interactions in infancy and disruptive behaviour disorders at age seven: a nested, case-control ALSPAC study.

BACKGROUND: Effective early intervention to prevent oppositional/conduct disorders requires early identification of children at risk. Patterns of parent-child interaction may predict oppositional/conduct disorders but large community-based prospective studies are needed to evaluate this possibility. METHODS: We sought to examine whether the Mellow Parenting Observational System (MPOS) used to assess parent-infant interactions at one year was associated with psychopathology at age 7. The MPOS assesses positive and negative interactions between parent and child. It examines six dimensions: anticipation of child's needs, responsiveness, autonomy, cooperation, containment of child distress, and control/conflict; these are summed to produce measures of total positive and negative interactions. We examined videos from the Avon Longitudinal Study of Parents and Children (ALSPAC) sub-cohort who attended the 'Children in Focus' clinic at one year of age. Our sample comprised 180 videos of parent-infant interaction: 60 from infants who received a psychiatric diagnostic categorisation at seven years and 120 randomly selected controls who were group-matched on sex. RESULTS: A negative association between positive interactions and oppositional/conduct disorders was found. With the exception of pervasive developmental disorders (autism), an increase of one positive interaction per minute predicted a 15% (95% CI: 4% to 26%) reduction in the odds of the infant being case diagnosed. There was no statistically significant relationship between negative parenting interactions and oppositional/conduct disorders, although negative interactions were rarely observed in this setting. CONCLUSIONS: The Mellow Parenting Observation System, specifically low scores for positive parenting interactions (such as Responsiveness which encompasses parental warmth towards the infant), predicted later psychiatric diagnostic categorisation of oppositional/conduct disorders.

Prediction of 7-year psychopathology from mother-infant joint attention behaviours: a nested case-control study.

BACKGROUND: To investigate whether later diagnosis of psychiatric disorder can be predicted from analysis of mother-infant joint attention (JA) behaviours in social-communicative interaction at 12 months. METHOD: Using data from a large contemporary birth cohort, we examined 159 videos of a mother-infant interaction for joint attention behaviour when children were aged one year, sampled from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Fifty-three of the videos involved infants who were later considered to have a psychiatric disorder at seven years and 106 were same aged controls. Psychopathologies included in the case group were disruptive behaviour disorders, oppositional-conduct disorder, attention-deficit/hyperactivity disorder, pervasive development disorder, anxiety and depressive disorders. Psychiatric diagnoses were obtained using the Development and Wellbeing Assessment when the children were seven years old. RESULTS: None of the three JA behaviours (shared look rate, shared attention rate and shared attention intensity) showed a significant association with the primary outcome of case-control status. Only shared look rate predicted any of the exploratory sub-diagnosis outcomes and was found to be positively associated with later oppositional-conduct disorders (OR [95% CI]: 1.5 [1.0, 2.3]; p = 0.041). CONCLUSIONS: JA behaviours did not, in general, predict later psychopathology. However, shared look was positively associated with later oppositional-conduct disorders. This suggests that some features of JA may be early markers of later psychopathology. Further investigation will be required to determine whether any JA behaviours can be used to screen for families in need of intervention.

How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P.

BACKGROUND: Interventions to promote positive parenting are often reported to offer good outcomes for children but they can consume substantial resources and they require rigorous appraisal. METHODS: Evaluations of the Triple P parenting program were subjected to systematic review and meta-analysis with analysis of biases. PsychInfo, Embase and Ovid Medline were used as data sources. We selected published articles reporting any child-based outcome in which any variant of Triple P was evaluated in relation to a comparison condition. Unpublished data, papers in languages other than English and some book chapters were not examined. Studies reporting Eyberg Child Behavior Inventory or Child Behavior Checklist scores as outcomes were used in the meta-analysis. RESULTS: A total of 33 eligible studies was identified, most involving media-recruited families. Thirty-one of these 33 studies compared Triple P interventions with waiting list or no-treatment comparison groups. Most papers only reported maternal assessments of child behavior. Twenty-three papers were incorporated in the meta-analysis. No studies involved children younger than two-years old and comparisons of intervention and control groups beyond the duration of the intervention were only possible in five studies. For maternally-reported outcomes the summary effect size was 0.61 (95%CI 0.42, 0.79). Paternally-reported outcomes following Triple P intervention were smaller and did not differ significantly from the control condition (effect size 0.42 (95%CI -0.02, 0.87)). The two studies involving an active control group showed no between-group differences. There was limited evidence of publication bias, but there was substantial selective reporting bias, and preferential reporting of positive results in article abstracts. Thirty-two of the 33 eligible studies were authored by Triple-P affiliated personnel. No trials were registered and only two papers contained conflict of interest statements. CONCLUSIONS: In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions. See related commentary: http://www.biomedcentral.com/1741-7015/10/145.

Mother-child feeding interactions in children with and without weight faltering; nested case control study.

AIMS: To explore whether the Mellow Parenting assessment system can detect any difference in parent-child meal time interaction between children with weight faltering (failure to thrive) and normally growing children. SUBJECTS AND METHODS: Thirty mother-infant dyads with weight faltering and 29 healthy controls nested within the Gateshead Millennium prospective cohort study were assessed at mean age 15.6 months (range 13-20). Video-tapes of two standardized meals per child by a researcher blind to infant health status were analysed using a simplified version of the Mellow Parenting Coding System (MPCS), an all events measure of maternal-child interactivity. These were linked to questionnaire data on eating behaviour and growth held on the children. RESULTS: The MPCS had good inter-rater reliability (0.82) and coherent inter-relationships between coding domains. During case meals there were significantly fewer positive interactions overall: cases median 81.5 (IQR 4-496); controls 169.5 (40-372) and within all the commonly observed domains (Anticipation (p=0.013), autonomy (p=0.003), responsiveness (p=0.005) and cooperation (p=0.016)). There were only low levels of distress and control or negative behaviours and no significant differences were found in these between the groups. The case infants had significantly lower reported appetite by the age of 4 months and higher reported avoidance of feeding at the age of 8 months than controls. CONCLUSIONS: Mothers of weight faltering infants generally showed fewer interactions with their infants at mealtimes. It is not clear whether this is causal or simply a maternal adaptive response to their child's eating behaviour.

Secure mother-infant attachment and the ABC programme: a case history.

This case history describes the first application of the Attachment and Bio-behavioural Catch-up (ABC) programme in the UK. It illustrates the key role and value of primary care clinicians in early infancy. The health visitor's careful and reflective observations, and her close links with a GP who shared her understanding of why these were significant, were the only means for this family to access help. The need for interventions in attachment is only likely to be identified by health visitors, with their unique opportunities to see families in their own homes.

What have birth cohort studies asked about genetic, pre- and perinatal exposures and child and adolescent onset mental health outcomes? A systematic review.

Increased understanding of early neurobehavioural development is needed to prevent, identify, and treat childhood psychopathology most effectively at the earliest possible stage. Prospective birth cohorts can elucidate the association of genes, environment, and their interactions with neurobehavioural development. We conducted a systematic review of the birth cohort literature. On the basis of internet searches and 6,248 peer-reviewed references, 105 longitudinal epidemiological studies were identified. Twenty studies met inclusion criteria (prospectively recruited, population-based cohort studies, including at least one assessment before the end of the perinatal period and at least one assessment of behaviour, temperament/personality, neuropsychiatric or psychiatric status before 19 years of age), and their methodologies were reviewed in full. Whilst the birth cohort studies did examine some aspects of behaviour and neurodevelopment, observations in the early months and years were rare. Furthermore, aspects of sampling method, sample size, data collection, design, and breadth and depth of measurement in some studies made research questions about neurodevelopment difficult to answer. Existing birth cohort studies have yielded limited information on how pre- and perinatal factors and early neurodevelopment relate to child psychopathology. Further epidemiological research is required with a specific focus on early neurodevelopment. Studies are needed which include the measures of early childhood psychopathology and involve long-term follow-up.

Parent-child relationships: are health visitors' judgements reliable?

The quality of the parent-child relationship is a strong predictor of outcomes for children, and its assessment is a key element of the work of health visitors. The Glasgow Parenting Support Framework emphasises the importance of relationship assessment, and a feasibility study using a semi-structured approach is being carried out in one area of the city. This paper explores how well health visitors agree in observational assessments of problems in video-recorded mother-child interactions and considers the impact of specific training in observational skills. Variable levels of agreement in judgement were demonstrated by 25 health visitors attending a training day. With little negative interaction between parent and child, agreement was high whether rates of positive interaction were high or low. Less agreement was found where high frequencies of negative behaviours were seen alongside positive behaviours. Assessment training may increase the abilities of health visitors to identify these problems, but more research is required into how this might be done most effectively.

Health visitors' assessments of parent-child relationships: a focus group study.

BACKGROUND: Health visitors (HVs), also known as public health nurses, in the UK provide a universal community-based service to preschool children and their parents. Since they have ongoing supportive contact with almost all mothers and young children they have opportunities to identify problems in the parent-infant relationship: for example during developmental screening, home visits and immunisation clinics. Research into the role of screening for problems in the parent-child relationship in early childhood is sparse and little is known about how such problems are currently identified in the community. OBJECTIVE: To explore the approaches taken by health visitors (HVs) to identifying problems in the parent-child relationship. DESIGN: Focus group study. SETTING: Glasgow, Scotland. PARTICIPANTS: 24 health visitors sampled purposively. RESULTS: Multiple sources of information were used by health visitors in assessing parent-child relationships. These include use of known risk factors, knowledge of local norms, direct observations of behaviour, reflection on the relationship between the parent and health visitor, as well as more intuitive reactions. In many cases understanding difficulties in parent-child relationships involved piecing together a jigsaw over a considerable time span. Continuity of relationships appeared to be crucial in this task. Home visits were described as the most informative setting in which to develop an understanding of the parent-child relationship. PARTICIPANTS reported a lack of formal training in the assessment of parent-child relationships and were keen to obtain more training. CONCLUSIONS: Health visitors use complex strategies to integrate information about parent-child relationships. These strategies are acquired in a variety of ways, but receive little emphasis during basic professional training.

'Me and my bump': an interpretative phenomenological analysis of the experiences of pregnancy for vulnerable women.

Eight pregnant women, considered to be 'vulnerable' due to exposure to a number of underlying risk factors, participated in semi-structured interviews regarding their experiences of pregnancy and of Mellow Bumps, a 6-week targeted antenatal intervention. Interview transcripts were explored using interpretative phenomenological analysis. The analysis revealed five superordinate themes: pregnancy as a time of reflection; the body being taken over; pregnancy as an emotional rollercoaster; relationships as important; separating identities. Pre- and post-natal attachment theories were found to be useful in interpreting the data. Findings suggest that pregnancy may be 'normalising' and provide an important opportunity for building more positive representations of the self. Findings also provide clinical support for the assertion that the attachment relationship begins before birth. The Mellow Bumps intervention was uniformly seen as helpful. It appeared to nurture prenatal attachment relationships, playing a potentially protective role, by helping to establish the foundations for secure mother-infant relationships in the future. Meeting similar women and engaging in ordinary, supportive conversation during Mellow Bumps seemed to reduce feelings of isolation and stigma. Implications for clinical practice are considered.

Motor activity at age one year does not predict ADHD at seven years.

We have examined the predictive utility of motor activity in infancy towards diagnosis of attention deficit hyperactivity disorder (ADHD) in later childhood. We conducted a nested case-control study using videos of infants in the Avon Longitudinal Study of Parents and Children (ALSPAC). Sixty videos of children who received any Development and Well-being Assessment (DAWBA) psychiatric diagnosis at age 91 months (including 16 with ADHD) plus two controls per case were selected for data analysis. Body movements were measured at age one year: associations between motor activity-derived variables using factor analysis, and later ADHD diagnoses were sought. No significant association was found between infant motor activity and later ADHD. A positive association between motor activity and inattentive ADHD was found in males. Motor activity at age one year did not predict ADHD at age seven years. The positive association with inattentive ADHD in males requires further investigation.

Can behaviour during immunisation be used to identify attachment patterns? A feasibility study.

BACKGROUND: Infant attachment is a strong predictor of mental health, and current measures involve placing children into a stressful situation in order to observe how the child uses their primary caregiver to assuage their distress. OBJECTIVES: This study aimed to explore observational correlates of attachment patterns during immunisation. PARTICIPANTS AND SETTING: 18 parent-child pairs were included in the study. They were all recruited through a single general medical practice. METHODS: Infant immunisation videos were observed and coded for parenting behaviours as well as pain promoting and pain reducing strategies. Results were compared between different attachment groups, as measured with the Manchester Child Attachment Story Task. RESULTS: Parents of securely attached children scored higher on positive Mellow Parenting Observational System behaviours, but not at a statistically significant level. Parents of securely attached children were also significantly more likely to engage in pain reducing behaviours (p<0.01) than parents of insecurely attached children. CONCLUSIONS: Robust composite measures for attachment informative behaviours in the immunisation situation should be developed and tested in a fully powered study.

Cortisol secretion in children with symptoms of reactive attachment disorder.

Maltreated children with reactive attachment disorder (RAD) have severe problems with social relationships and affect regulation. An association between early maltreatment and changes in the daily rhythm of cortisol secretion has already been reported for maltreated toddlers. We sought to find out whether such changes were apparent in school-age children with symptoms of RAD, who had experienced early maltreatment but were currently adopted in well-functioning families. We recruited 66 children: 34 adopted children, aged 5-12 years, with an early history of maltreatment and with social difficulties such as indiscriminate friendliness; and 32 age- and sex-matched comparison children with no history of maltreatment or social difficulties. Daily rhythms of cortisol production were determined from saliva samples collected over 2 days. The adopted group had significantly lower absolute levels of cortisol compared to the control group, but a typical profile of cortisol secretion. There was no association between cortisol secretion and symptom scores for psychopathology.

Neurodevelopmental problems in maltreated children referred with indiscriminate friendliness.

We aimed to explore the extent of neurodevelopmental difficulties in severely maltreated adopted children. We recruited 34 adopted children, referred with symptoms of indiscriminate friendliness and a history of severe maltreatment in their early childhood and 32 typically developing comparison children without such a history, living in biological families. All 66 children, aged 5-12 years, underwent a detailed neuropsychiatric assessment. The overwhelming majority of the adopted/indiscriminately friendly group had a range of psychiatric diagnoses, including Attention Deficit Hyperactivity Disorder (ADHD), Post-Traumatic Stress Disorder (PTSD) and Reactive Attachment Disorder (RAD) and one third exhibited the disorganised pattern of attachment. The mean IQ was 15 points lower than the comparison group and the majority of the adopted group had suspected language disorder and/or delay. Our findings show that school-aged adopted children with a history of severe maltreatment can have very complex and sometimes disabling neuropsychiatric problems.

Inexpensive video cameras used by parents to record social communication in epidemiological investigations in early childhood-A feasibility study.

We tested the feasibility of parents recording social interactions with their infants using inexpensive camcorders, as a potential method of effective, convenient, and economical large scale data gathering on social communication. Participants were asked to record two short video clips during either play or a mealtime, and return the data. Sixty-five video clips (32 pairs) were returned by 33 families, comprising 8.5% of families contacted, 44.6% of respondents and 51.6% of those sent a camcorder, and the general visual and sound quality of the data was assessed. Audio and video quality were adequate for analysis in 85% of clips and several social behaviours, including social engagement and contingent responsiveness, could be assessed in 97% of clips. We examined two quantifiable social behaviours quantitatively in both adults and infants: gaze direction and duration, and vocalization occurrence and duration. It proved difficult for most observers to obtain a simultaneous clear view of the parents and infant's face. Video clips obtained by parents are informative and usable for analysis. Further work is required to establish the acceptability of this technique in longitudinal studies of child development and to maximize the return of usable data.

Rebuilding relationships: a pilot study of the effectiveness of the Mellow Parenting Programme for children with Reactive Attachment Disorder.

Mellow Parenting is an intensive parenting programme which has been shown to be effective in improving the psychosocial functioning of very vulnerable babies and preschool children. We used a complex interventions model to evaluate its use with school-age children with Reactive Attachment Disorder (RAD), a serious disorder of social functioning associated with maltreatment. The programme had a positive effect on mothers' mental health, but had no measurable effects on symptoms of RAD or on parent-child interaction, although the variation between families after the group suggested that some had responded more than others. Mellow Parenting is an effective programme for vulnerable families with younger children and may be a useful adjunct in the treatment of school-age children with RAD, but it cannot be considered a definite treatment for RAD in this age group. The search continues for safe and effective treatments for RAD in school-age children.