Infant and Early Childhood Mental Health for Vulnerable Children

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Vulnerable children are defined here as those who are highly susceptible–or vulnerable–to poor health and well-being outcomes.[i] The presence of a variety of individual, family, and social factors are associated with this vulnerability, including children’s health needs, housing instability, caregiver substance use, domestic violence, and community violence.[ii] Some of these factors may result in trauma, which occurs when an event or ongoing situation is experienced by the child as harmful or extremely threatening, with accompanying intense fear and a feeling of helplessness. Examples of traumatic experiences include witnessing or experiencing violence or emotional abuse.[iii] Young children who experience trauma are exceptionally vulnerable to poor social-emotional and mental health outcomes both in the short and long terms.[iv] This research summary examines examples of interventions and models that promote the infant-early childhood mental health (IECMH) of children who have experienced trauma.

State Profiles that Include Infant and Early Childhood Mental Health for Vulnerable Children
Research Support for Infant and Early Childhood Mental Health for Vulnerable Children

Dyadic Treatment and Group Parenting Programs

Dyadic Treatment is a form of therapy in which the child and parent are treated together. A clinician is present with the parent-child dyad, or in a nearby room, and coaches the parent to encourage positive interactions that can help improve parenting, the parent-child relationship, and the child’s behavior [see research summary on dyadic treatment for more information]. Some evidence-based models, such as Child-Parent Psychotherapy (CPP), have been explicitly designed to treat children who have experienced trauma, while others, such as Attachment and Biobehavioral Catch-up (ABC) and Parent-Child Interaction Therapy (PCIT) have proven effective for these children.

CPP is for children from birth to five years who have experienced trauma or are at risk of insecure attachment or social-emotional problems. A number of randomized controlled trials have examined the effects of CPP on child outcomes. These studies have shown significant improvements in child behavior problems, traumatic stress symptoms, diagnostic status, and mothers’ avoidance symptoms for preschool children and mothers exposed to marital violence,[v] particularly for those children who experienced multiple traumatic and stressful life events;[vi] secure attachment[vii] and cortisol regulation[viii] for infants in maltreating families; and child avoidance, resistance, and anger, and maternal empathy and engagement for anxiously attached toddlers of Spanish-speaking immigrant mothers.[ix] CPP has been incorporated into child-serving systems in a number of states, such as mental health consultation to home visiting programs in Louisiana [see PRiSM profile] and child welfare in New Mexico [see PRiSM profile].

ABC is a 10-week in-home program designed to support parents to provide nurturing care to children from 6 to 24 months old who have experienced early adversity. ABC providers coach parents and other caregivers during in-person sessions to engage in practices that help children develop attachment, self-regulation, and coping skills. A systematic review of randomized control trials of ABC conducted with populations of children involved in child welfare or foster care found that the program had positive impacts across a number of child outcomes, including fewer problem behaviors, greater positive attachment, and less avoidance.[x]

PCIT involves observation and coaching of parent-child interactions and is designed to address externalizing behavior problems for children from two to seven years. In randomized trials an adapted version of PCIT for use with maltreating parents improved the wellbeing and behavior of young children.[xi]

Group parenting programs are multisession classes for parents and primary caregivers led by trained facilitators. They aim to increase parents’ knowledge and skills related to parenting behaviors and interactions with their children, including enhancing children’s social-emotional development, addressing their problem behavior, and supporting their mental health [see research summary on parenting programs for more information]. As with dyadic treatment, some evidence-based parenting models without an explicit focus on children who have experienced trauma have been shown to be effective for them.

The Incredible Years (IY) series consists of child, parent, and teacher programs that aim to reduce the challenging behaviors and support the social-emotional development of children from birth to age 12. The IY BASIC parenting program involves weekly 2-3-hour sessions for groups of 10-14 parents. The number of sessions varies by curricula, which are targeted at children of different ages: Parents and Babies (8-9 sessions), Toddler Basic (12 sessions), Preschool Basic (18-20 sessions), and School Age Basic (12-16 sessions). Recorded vignettes serve as the basis of discussion during the sessions. Led by two trained group leaders, IY is delivered in a number of settings, including community agencies, healthcare settings, and schools. A study of IY among parents of toddlers and preschoolers involved in the child welfare system showed clinically significant declines in parent reports of problem behavior from pre-to post-test.[xii]

Child Welfare

Because of family adversities, trauma, maltreatment, and separation from primary caregivers, young children involved in the child welfare system are at substantial risk of poor social-emotional, behavioral, and mental health outcomes.[xiii] While the child welfare system engages in collaboration with other child-serving systems to support young children’s mental health, such as referrals to Part C Early Intervention as mandated by the Child Abuse Prevention and Treatment Act (CAPTA), this section examines approaches that have incorporated trauma-informed interventions into the child welfare system itself.

Infant-Toddler Courts (ITC) is an approach that aims to reduce time spent in foster care and improve child well-being and safety. ITCs’ multidisciplinary approach builds connections between the court system and other systems—including mental health, early care and education, and home visiting—to support the needs of families. Zero To Three’s Safe Babies Court Team (SBCT) is perhaps the best-known example of this approach, but ITCs share core components across models. These include a multidisciplinary team that implements the program (e.g., a local judge committed to the ITC approach, a community coordinator, and mental health service providers); trauma screening and services; a range of other behavioral health, family support, parenting, developmental and early education services; concurrent planning for a permanent placement for the child; and training and workforce development for team members. Based on the results of a parent-child relationship assessment, families are referred as indicated to evidence-based dyadic treatment, with CPP being the model recommended for SBCTs.

ITC approaches have been studied in a number of multisite evaluations. A study of Zero to Three’s SBCT in three jurisdictions (Little Rock, Arkansas; Des Moines, Iowa; and Tulsa, Oklahoma) found that 88 percent of SBCT cases received CPP, and that 86 percent of SBCT children had typical or strong attachment relationships according to primary caregiver responses on the DECA Infant and Toddler Caregiver Form; children in the interventions also showed stronger attachment to caregivers compared to samples drawn from the general population.[xiv] Other evaluations of ITCs have shown positive changes in parenting including greater empathy toward child’s needs, increased sensitivity in responding to children, and reductions in physical discipline.[xv]

Home Visiting

Home visiting programs connect “expectant parents and parents of young children with a designated support person who guides them through the early stages of raising a family.”[xvi] Several home visiting programs have been found to deliver effective supports for the well-being of young children who have experienced trauma. Child First targets families with young children from the prenatal period through age five who have social-emotional or developmental problems and are experiencing multiple adverse circumstances, including extreme poverty, homelessness, domestic violence, parent incarceration, maternal depression, and abuse and neglect [see PRiSM profile for more information on Child First in Connecticut]. The model incorporates CPP in its home-based services, as well as care coordination to connect families to community-based resources. After initial twice-weekly visits, families receive weekly visits for six to 12 months. A randomized controlled trial of Child First in Bridgeport, Connecticut, showed significant positive outcomes for participating children and families, including fewer externalizing problems for children, improved child language skills, fewer mental health symptoms for mothers, and decreased child abuse and neglect.[xvii] A second evaluation in Bridgeport found that 82 children exposed to violence who participated in Child First showed significant decreases in parent reports of their children’s post-traumatic stress symptoms.[xviii]

In Michigan, Infant Mental Health (IMH) is a statewide Medicaid-funded home visiting program for families facing multiple risks, including maternal depression, that threaten the parent-infant attachment and development of the infant [see PRiSM profile of Michigan home visiting for more information]. Visits are conducted weekly, or more often as needed, by a Masters-level early childhood mental health professional who must be endorsed at Level 2 by the Michigan Association of Infant Mental Health, with Level 3 preferred. A major feature of the model is the delivery of dyadic Infant-Parent Psychotherapy (a precursor to CPP), with other components including support for the family’s material needs, offering emotional support, and providing developmental guidance. IMH is currently undergoing a comprehensive evaluation, including two community-based, quasi-experimental studies and a university-based randomized control trial, to establish it as an evidence-based model.

Part C Early Intervention

Part C Early Intervention services are intended for infants and toddlers with disabilities, including those with a developmental delay in the social-emotional domain or a diagnosed mental health condition that has a high probability of resulting in a developmental delay [see research summary on Part C Early Intervention for more information]. Children who have been exposed to trauma, such as maltreatment, are at high risk of social-emotional delays and mental health problems,[xix] and CAPTA requires states to develop plans that include referrals for infants and toddlers in substantiated cases of abuse or neglect to Part C Early Intervention.[xx] Part C Early Intervention programs have implemented a number of strategies to support IECMH, including adopting a trauma-informed approach, and can refer families to more intensive treatment such as CPP.[xxi] However, there are fewer examples of interventions designed specifically for use by Early Intervention providers working the children who have experienced trauma.

One example is Trauma-Informed Behavioral Parenting (TIBP; subsequently renamed Smart Start), a parent coaching intervention designed to meet the social-emotional needs of toddlers enrolled in both Part C services and involved in child welfare. The model is an adaptation of PCIT. In a study of TIBP, five early intervention (EI) providers participated in an initial nine-hour online and in-person training. Throughout the study, the EI providers also participated in in-person, hour-long monthly supervision trainings that included coaching and discussion of cases. TIBP was delivered in the homes of eight parent-child dyads over eight sessions before other EI services were begun by the same providers. Posttest findings included “gains in positive parenting skills, decreases in parenting stress, and decreases in child post-traumatic stress symptoms.”[xxii]

Early Care and Education (ECE)

With approximately 60 percent of U.S. children age 5 and younger in a regular ECE arrangement in 2016,[xxiii] ECE programs are likely to encounter children who have been exposed to trauma. Professional development or curricula focused on trauma-informed practice can help ECE teachers identify and support children who have experienced trauma and can complement treatment they may be receiving. In addition, a number of interventions and approaches have been designed explicitly for use by ECE programs to address trauma.

TraumaSmart (TS) is a mental health-ECE cross-system partnership designed to “decrease the stress of chronic trauma, foster age-appropriate social and cognitive development, and create an integrated, trauma-informed culture for young children, parents, and staff.”[xxiv] TS includes training for ECE staff and child caregivers, intensive evidence-based trauma-focused cognitive behavioral therapy, classroom mental health consultation, and peer mentoring. A study of TS in three Head Start programs serving 81 children identified as needing a therapeutic intervention found significant improvements in children’s parent-reported internalizing behaviors, externalizing behaviors, and inattention/hyperactivity and in teacher-reported externalizing behaviors, oppositional/defiant behaviors, and attention deficit/hyperactivity.[xxv]

IECMH consultation is “a service that pairs a mental health consultant with families and adults who work with infants and young children in the different settings where they learn and grow, such as child care, preschool, and their home. The aim is to build adults’ capacity to strengthen and support the healthy social and emotional development of children…. Mental health consultation equips caregivers to facilitate children’s healthy growth and development.”[xxvi] Research on IECMH consultation in ECE settings has shown its effectiveness as an approach to improving teacher attitudes and knowledge, overall classroom quality, teacher-child interactions, expulsion outcomes, and child social-emotional development and behavior outcomes. In 2020, the Center of Excellence for Infant and Early Childhood Mental Health Consultation published a comprehensive synthesis of the research evidence for IECMH consultation, with an accompanying annotated bibliography of all known published studies on IECMH consultation.[xxvii] A number of additional literature reviews have synthesized the research across a broad range of outcomes.[xxviii] And while most IECMH consultation models do not explicitly focus on trauma, “teachers report that a high percentage of children with challenging behavior in ECE settings experience adverse family circumstances associated with trauma,”[xxix] which suggests that IECMH consultation may have a key role to play in supporting ECE professionals’ work with children who have experienced trauma.

In Arkansas, Project PLAY has a long-standing partnership with Arkansas’ child welfare system and continues to provide training and supports to encourage placement of children in foster care in high quality ECE settings and promote collaboration between ECE providers and child welfare staff for the benefit of children in foster care. Educational materials and a partnership toolkit developed to support this partnership are available online [see PRiSM profile of Arkansas for more information]. Annual evaluation reports that examine teacher reports of children’s behavior pre- and post-consultation have found significant decreases in children’s disruptive behaviors, hyperactivity, and conduct problems, increases in prosocial behaviors, and decreases in the extent to which the disruptive behaviors were problematic for the teacher.[xxx] An earlier evaluation of Project PLAY’s pilot predecessor found significant positive effects for teacher reports of children’s attachment and decreases in behavior problems in 14 intervention sites compared to four control sites.[xxxi]

Several additional supports, while not covered in this research summary, can play a role in preventing trauma and identifying and supporting young children who have experienced trauma. The federal Family First Prevention Services Act (FFPSA) authorizes states to use Title IV-E funding for evidence-based prevention services for mental health and parenting programs for children who are candidates for foster care. Screening and developmentally appropriate assessment and diagnosis (for instance using the DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood), also play a critical role in helping ensure that children who have experienced trauma receive appropriate treatment. Young trauma-exposed children also benefit from professional development focused on trauma-informed practice for early childhood service providers who do not offer treatment for trauma exposure, such as home visitors, early intervention providers, and early care and education teachers. The work of these professionals will complement that of treatment providers and so it is critical they have been trained to bring a trauma-informed lens to their caregiving practice. It is also important to note that while many trauma-informed interventions have been tested with racially and culturally diverse groups of families (e.g., CPP[xxxii]), there is still limited knowledge about the efficacy of culturally tailored supports for infants and young children exposed to trauma. Notably, there are increasing efforts to design and deliver culturally tailored parenting programs to groups of families who have experienced both historic and current trauma.[xxxiii] In the future, evaluations of the efficacy of these models can suggest a much wider range of approaches to supporting diverse groups of infants and young children who have experienced trauma and other serious, adverse circumstances.


[i] Public Health England. (2020). No child left behind: Understanding and quantifying vulnerability.

[ii] Public Health England. (2020). No child left behind: Understanding and quantifying vulnerability.

[iii] Substance Abuse and Mental Health Services Administration. (2018). Helping children and youth who have traumatic experiences.

[iv] Bartlett, J. D., & Smith, S. (2019). The role of early care and education in addressing early childhood trauma. American Journal of Community Psychology, 64(3-4), 359-372.

[v] Lieberman, A. F., van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child-Parent Psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44(12), 1241-1248.

[vi] Ippen, C. G., Harris, W. W., van Horn, P., & Lieberman, A. F. (2011). Traumatic and stressful events in early childhood: Can treatment help those at highest risk? Child Abuse & Neglect, 35(7), 504-513.

[vii] Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18(3), 623-649.

[viii] Cicchetti, D., Rogosch, F. A., Toth, S. L., & Sturge-Apple, M. L. (2011). Normalizing the development of cortisol regulation in maltreated infants through preventive interventions. Development and Psychopathology, 23(3), 789-800.

[ix] Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62(1), 199-209.

[x] Grube, W. A., & Liming, K. W. (2018). Attachment and Biobehavioral Catch-up: A systematic review. Infant Mental Health Journal, 39(6), 656-673.

[xi] Wilsi, C., Campbell, C., Chaffin, M., & Funderburk, B. (2017). Parent-Child Interaction Therapy in child welfare. In D. M. Teti (Ed.), Parenting and family processes in child maltreatment and intervention (pp. 107-125). Springer.

[xii] Webster-Stratton, C. (2014). Incredible Years parent and child programs for maltreating families. In S. Timmer & A. Urquiza (Eds.), Evidence-based approaches for the treatment of maltreated children (pp. 81-104). Springer.

[xiii] McLeigh, J. D., Tunnell, K., & Lazcano, C. (2021). Developmental status of young children in foster care. Journal of Developmental and Behavioral Pediatrics: JDBP, 42(5), 389-400.

Olson, A. E., Kim, H. K., Bruce, J., & Fisher, P. A. (2019). General cognitive ability as an early indicator of problem behavior among toddlers in foster care. Journal of Developmental and Behavioral Pediatrics: JDBP, 40(2), 144-149.

[xiv] Faria, A., Bowdon, J., Conway-Turner, J., Pan, J., Ryznar, T., Michaelson, L., Derrington, T., & Walston, J. (2020). The Safe Babies Court Team evaluation: Changing the trajectories of children in foster care. American Insitutes for Research.

[xv] Casanueva, C., Fraser, J. G., Gilbert, A., Maze, C., Katz, L., Ullery, M. A., Stacks, A. M., & Lederman, C., (2013). Evaluation of the Miami Child Well-Being Court Model: Safety, permanency, and well-being findings. Child Welfare, 92(3), 73-96.

Chinitz, S., Guzman, H., Amstutz, E., Kohchi, J., & Alkon, M. (2017). Improving outcomes for babies and toddlers in child welfare: A model for infant mental health intervention and collaboration. Child Abuse & Neglect, 70, 190-198.

Stacks, A. M., Barron, C. C., & Wong, K. (2019). Infant mental health home visiting in the context of an infant-toddler court team: Changes in parental responsiveness and reflective functioning. Infant Mental Health Journal, 40(4), 523-540.

[xvi] National Home Visiting Resource Center (2019). 2019 home visiting yearbook: An overview. Retrieved from

[xvii] Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs-Gowan, M. J. (2011). A randomized controlled trial of Child FIRST: A comprehensive home-based intervention translating research into early childhood practice. Child Development, 82(1), 193-208.

[xviii] Crusto, C. A. Lowell, D. I., Paulicin, B., Reynolds, J., Feinn, R., Friedman, S. R., & Kaufman, J. S. (2008). Evaluation of a wraparound process for children exposed to family violence. Best Practices in Mental Health: An International Journal, 4(1), 1-18.

[xix]McCue Horwitz, S., Hurlburt, M. S., Heneghan, A., Zhang, J., Rolls-Reutz, J., Fisher, E., Landsverk, J., & Stein, R. E. (2012). Mental health problems in young children investigated by U.S. child welfare agencies. Journal of the American Academy of Child and Adolescent Psychiatry, 51(6), 572-581.

[xx] Early Childhood Technical Assistance Center. (n. d.). Child maltreatment: Referral requirements under CAPTA and IDEA.

[xxi] Early Childhood Technical Assistance Center. (2022). Briefing paper: Infant and early childhood mental health and early intervention (Part C): Policies and practices for supporting the social and emotional development and mental health of infants and toddlers in the context of parent-child relationships. University of North Carolina, FPG Child Development Institute.

Smith, S., Ferguson, D., Burak, E. W., Granja, M. R., & Ortuzar, C. (2020). Supporting social-emotional and mental health needs of young children through Part C Early Intervention: Results of a 50-state survey. National Center for Children in Poverty.

[xxii] Agazzi, H., Adams, C., Ferron, E., Ferron, J., Shaffer-Hudkins, E., & Salloum, A. (2019). Trauma-Informed Behavioral Parenting for early intervention. Journal of Child and Family Studies, 28(8), 2172-2186.

[xxiii] Corcoran, L., & Steinley, K. (2019). Early childhood program participation, results from the National Household Education Surveys Program of 2016: First look (NCES 2017-101.REV). National Center for Education Statistics.

[xxiv] Holmes, C., Levy, M., Smith, A., Pinne, S., & Neese, P. (2015). A model for creating a supportive trauma-informed culture for children in preschool settings. Journal of Child and Family Studies, 24(6), 1650-165.

[xxv] Holmes, C., Levy, M., Smith, A., Pinne, S., & Neese, P. (2015). A model for creating a supportive trauma-informed culture for children in preschool settings. Journal of Child and Family Studies, 24(6), 1650-165.

[xxvi] Center of Excellence for Infant and Early Childhood Mental Health Consultation. (n. d.). About infant and early childhood mental health consultation.

[xxvii] Davis, A., Perry, D., F., & Tildus, K. (2020). Annotated bibliography: The evidence base for infant and early childhood mental health consultation (IECMHC). Center of Excellence for Infant & Early Childhood Mental Health Consultation.

Davis, A., Perry, D. F., & Tidus, K. (2020). Status of the evidence for infant and early childhood mental health consultation. Center of Excellence for Infant & Early Childhood Mental Health Consultation.

[xxviii] Albritton, K., Mathews, R., E., & Anhalt, K. (2019) Systematic review of early childhood mental health consultation: Implications for improving preschool discipline disproportionality. Journal of Educational and Psychological Consultation, 29(4), 444-472.

Brennan, E. M., Bradley, J. R., Allen, M., & Perry, D. F. (2008). The evidence base for mental health consultation in early childhood settings: Research synthesis addressing staff and program outcomes. Early Education and Development, 19(6), 982-1022.

Perry, D. F., Allen, M., Brennan, E. M., & Bradley, J. R. (2010). The evidence base for mental health consultation in early childhood settings: A research synthesis addressing children’s behavioral outcomes. Early Education and Development, 21(6), 795-824.

[xxix] Bartlett, J. D., & Smith, S. (2019). The role of early care and education in addressing early childhood trauma. American Journal of Community Psychology, 64(3-4), 359-372.

[xxx] Conners-Edge, N., & Kyzer, A. (n.d.). Project PLAY: Annual evaluation report FY18-19. University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine.

Conners Edge, N. A., Kyzer, A., Abney, A., Freshwater, A., Sutton, M., & Whitman, K. (2021). Evaluation of a statewide initiative to reduce expulsion of young children. Infant Mental Health Journal, 42(1), 124-139.

Conners-Edge, N., Kyzer, A., & Williams, M. (n. d.). Project PLAY: Annual evaluation report FY20-21. University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine.

Kyzer, A., Williams, M., & Conners-Edge, N. (n. d.). Project PLAY: Annual evaluation report FY21-22. University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine.

(n.d.). Project PLAY: Annual report FY17-18. University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine.

University of Arkansas for Medical Sciences, Department of Family and Preventive Medicine. (n.d.). Evaluation update 2014: Project PLAY: Positive Learning for Arkansas’ Youngest.

[xxxi] Conners-Burrow, N. A., Whiteside-Mansell, L., McKelvey, L., Virmani, E., & Sockwell, L. (2012). Improved classroom quality and child behavior in an Arkansas early childhood mental health consultation pilot project. Infant Mental Health Journal, 33(3), 256-264.

[xxxii] Child-Parent Psychotherapy. (2018). Child-Parent Psychotherapy: Research fact sheet.

[xxxiii] Richardson, M., Big Eagle, T., & Waters, S. F. (2022). A systematic review of trauma intervention adaptations for indigenous caregivers and children: Insights and implications for reciprocal collaboration. Psychological Trauma: Theory, Research, Practice, and Policy, 14(6), 972-982.