Two-Generation Psychiatric Intervention in the Prevention of Early Childhood Maltreatment Recidivism

"Adam" is a 4-year-old boy who was placed in foster care under the guardianship of his maternal aunt after an emergency department visit for listlessness, where it was discovered that, after a series of coercive disciplinary practices, his mother had overdosed him with clonidine in an attempt to manage his disruptive behavior. After 6 months in the child welfare system, his case was moving toward termination of parental rights, and he and his family were referred by the Family Court for psychiatric support via the SYNCHRONY Project. At this juncture, his mother was a frequent intruder into the home of the foster mother, his maternal aunt (far exceeding the mother's authorized weekly supervised visits), where she (the mother) would desperately attempt to assert her own disciplinary practices over her sister's caregiving of Adam, at times resulting in authorities escorting her from the home. The father was at a loss as to how best to support the mother and had distanced himself from the escalating domestic struggles between mother and aunt. A two-generation evaluation indicated that untreated maternal borderline personality disorder traits were compromising the mother's responses to the circumstances of domestic custody, and untreated attention deficit hyperactivity disorder symptoms in the boy were intensifying the mother's worries about whether her sister was competently caring for him. The clinical team first recommended temporary suspension of maternal visits to the household of the maternal aunt (creating an important boundary that constituted an initial step in an intervention strategy to manage her borderline traits). She was enrolled in dialectical behavior therapy, which she successfully completed. She also benefited from the addition of a low-dose antipsychotic, and her borderline symptoms improved substantially. Simultaneously, a detailed behavior modification protocol was implemented for Adam, to which he responded well. This was followed by family therapy beginning with the couple, then extending to the maternal aunt and the child. The father became increasingly re-engaged, supporting the mother, and he became the supervisor of visits between mother and child. The mother and father next successfully completed group-based parenting education (the Incredible Years curriculum). The family made steady progress, the court disposition was converted to reunification, the child is with his birth parents, and the mother has remained engaged in monthly supportive psychotherapy with continued healthy outcomes and no maltreatment recidivism in the 3 years since reunification.