Journal of Child and Family Studies (2018) 27:3117–3131

https://doi.org/10.1007/s10826-018-1192-3

ORIGINAL PAPER

A Case-Series of Reflective Family Play: Therapeutic Process,

Feasibility, and Referral Characteristics
Diane A Philipp1 Kristina Cordeiro2 Christie Hayos3
● ●

Published online: 8 August 2018

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Evidence-based interventions for infants and preschoolers, and their families, have largely focused on the mother-child dyad.
In response to the increasing need to diversify treatment approaches in the under six population and include the whole family
system, we have developed a new treatment approach called Reflective Family Play (RFP). A manualized, whole-family
therapy, RFP allows for the involvement of two parents and siblings when working with infants or young children. In this
case-series, we used a qualitative chart review to examine the therapeutic process, acceptability, and feasibility of RFP for 22
families with children ages 0–6, who participated in RFP. We also sought to better understand the referral characteristics of
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those families who participated in RFP by comparing them to families who were referred to and participated in an
established dyadic approach during the same time-period. Session-by-session coding of clinician chart notes revealed
evidence of positive shifts throughout the RFP process, including more whole-family play, improvements in coparenting,
and better parental mentalization. Parents reported improvements in presenting concerns in all but one case. Improvements in
coparenting, sibling relationships, and family alliance were also reported by parents after RFP. Clinical implications and
directions for future research are discussed.
Keywords Family Therapy Intervention Infant Preschool Lausanne Trilogue Play
● ● ● ●

The family is the primary socializing agent for children,
with healthy development best facilitated in the context of
families with high levels of coordination (Favez et al. 2006,
2012), warmth, acceptance, and consistent parenting stra-
tegies. Even the physical health of infants and toddlers is
influenced by the degree of family functioning (Keren et al.
2010). The family therapy literature is rich with data on the
efficacy of family-based interventions that reduce child
mental illness and improve family functioning (Sprenkle
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s10826-018-1192-3) contains supplementary
material, which is available to authorized users.
* Diane A Philipp
dphilipp@sickkidscmh.ca
1
SickKids Centre for Community Mental Health (SickKids CCMH)
and the University of Toronto, Toronto, ON, Canada
2
Department of Psychology, York University, Toronto, ON,
Canada
3
SickKids Centre for Children’s Mental Health (SickKids CCMH),
Toronto, ON, Canada
2012). The focus of these treatments, however, has tended
to be on older, verbal children who can participate in talk
therapy. In a meta-analysis of 47 randomized controlled
trials of family therapies for childhood externalizing beha-
viors, only one study included children under age five (Von
Sydow et al. 2013). While early pioneers in family therapy
reported on family treatments involving very young chil-
dren, often incorporating play (Jones et al. 2002; Lindblad-
Goldberg et al. 1998; Satir 1972), there remains a need for
data to support these efforts.
In the infant and preschool literature, the port of entry
has historically been with the infant or preschool-aged child
and their primary caregiver, typically the mother (Stern
1995). A review of interventions for early childhood found
that fathers were involved in only 3 of the 81 interventions
examined (Bakermans-Kranenburg et al. 2003). While there
are many effective dyadic treatments for mothers and their
infants or toddlers (Cohen et al. 1999; Juffer et al. 2017;
Rusconi-Serpa et al. 2009; Sadler et al. 2013), as well as
group treatments for mothers (Hoffman et al. 2006) or
mothers and babies (Meschino et al. 2015) or fathers
(Cookston et al. 2006), they are not whole family therapy
approaches.
3118
There is now sufficient evidence that difficulties in
coparenting may independently impact on infant and pre-
school functioning (McHale et al. 2000; Talbot and McHale
2002). Coparenting refers to the transactions of two people
“as they work together to rear a child or children for whom
they share responsibility” (Talbot et al. 2009, p. 2). Many
who work clinically with infants and preschoolers have now
pointed to the need for evidence-supported treatments that
conjointly work with coparents and siblings (Cornett and
Bratton 2014; Philipp 2012; Willis et al. 2016).
Fivaz-Depeursinge and Corboz-Warnery (1999) were
pioneers in exploring the impact of the mother-father-baby
triad on the developing infant. They developed a semi-
structured family play paradigm, the Lausanne Trilogue
Play (LTP), to assess the family alliance, or the degree to
which a family can accomplish a task together, such as play
(Fivaz-Depeursinge and Corboz-Warnery 1999; Favez et al.
2011). Family alliance in infancy has been found to be an
independent predictor of child well-being at age 5, includ-
ing more positive affect in story completion tasks, better
emotion regulation, and better outcomes on a theory of
mind task (Favez et al. 2012; Keren et al. 2010). The
Lausanne Family Play (LFP) was subsequently added to
incorporate siblings (Fivaz-Depeursinge and Corboz-
Warnery 1999).
With the LTP and LFP, the lens widened from the dyad,
making it possible to systematically explore the role of both
parents, the coparenting relationship, the infant’s capacity to
influence family dynamics, and the role of siblings. Using
the LTP, Fivaz-Depeursinge et al. (2004) also developed a
two-session, consultation-intervention model, the Develop-
mental Systems Consultation, for families already engaged
in some form of treatment (e.g., couples counseling or
individual therapy for one or both parents). Briefly, the
consultant uses excerpts from the LTP to provide parents
with video-feedback that highlights the family’s strengths
and difficulties. Although others have used the LTP in their
work with the very young (Keren 2010; Mazzoni and
Lubrano Lavadera 2013; McHale and Irace 2010), this work
is typically done with just the coparents, and children are
not a part of the video-feedback sessions.
McHale and Irace (2010) developed a model called
Focused Parental Consultation which aims to strengthen
communication and coordination between coparents as
leaders of the family or the “executive subsystem” (Min-
uchin 1974). This model has been successfully applied to
non-coresidential parents and “fragile families” where the
coparents have never been a couple (McHale et al. 2015).
Child Parent Relationship Therapy (CPRT) is an adaptation
of Filial Therapy (Guerney 1963) that combines psychoe-
ducation and behavioral strategies. In CPRT, parents
videotape play at home with their child and then review the
videos in a parent group format (Cornett and Bratton 2014).
Journal of Child and Family Studies (2018) 27:3117–3131
Preliminary results from a pilot of CPRT are promising,
however, only eight families, with children aged 3–10
years, were included (Cornett and Bratton 2014). Thus, it is
unclear whether CPRT can be applied to infant and pre-
school children. Furthermore, while both Focused Parental
Consultation and CPRT work with coparents conjointly,
children are not directly involved in either of these treat-
ment programs. More recently, Willis et al. (2016) adapted
Emotion Focused Family Therapy (EFFT; Johnson and Lee
2000) for a younger population, maintaining EFFT’s
attachment lens, but adding elements of play into their
model. The intervention targets families with children aged
4–6 years as it still requires a certain level of cognitive and
emotional development in the child. Thus, the approach
currently excludes infants, toddlers, and younger
preschoolers.
While the notion of the family system (Minuchin 1974)
is novel to the infant and preschool population (Fivaz-
Depeursinge and Corboz-Warnery 1999), attachment theory
and parental reflective function (pRF) have been extensively
researched in parent–child dyads, both in normative as well
as clinical families in this age group (for a review see
Katznelson 2014). Increasingly, we have come to under-
stand that a parent’s awareness of their infant or child’s
mental state, their pRF (or ability to mentalize), allows that
parent to respond in more attuned ways when the child
signals needs or distress (Fonagy et al. 1991; Grienenberger
et al. 2005; Slade et al. 2005a). Many dyadic approaches
targeting pRF, or mentalization, have demonstrated efficacy
in the infant and preschool population. Common to all is
helping parents understand their thoughts and feelings as
separate from their child’s. Most of these approaches
involve some play between a parent and child, often with
the mother-infant dyad.
Mentalization-based therapies (MBT) and the work of
Fonagy and colleagues (Asen and Fonagy 2012; Midgley
and Vrouva 2012) have shaped our thinking around men-
talization and reflective function. In Minding the Baby,
clinicians work directly with high-risk mothers and infants
during home visits (Sadler et al. 2013; Slade et al. 2005a, b).
Play and discussion are integrated, and clinicians work to
validate the mother’s experience to create space for her to
consider her infant’s experience as separate yet connected to
her own. An MBT approach has also been used with high-
risk fathers in the UK (Motz 2016). Other approaches, such
as Watch Wait and Wonder (WWW; Muir et al. 1999),
begin with child-led play. The play then serves as a starting
point to understand the parent-child relationship as the
clinician next follows the parent’s lead in exploring their
observations of their child during the play. By way of
reflective questioning (Philipp 2012), the WWW clinician
helps parents understand their own and their infant’s
experiences as mutually influential, but ultimately distinct
Journal of Child and Family Studies (2018) 27:3117–3131
from one another (Muir et al. 1999). This approach was
found to reduce presenting symptoms, improve the parent-
infant relationship, and shift the child’s attachment to the
parent towards greater security (Cohen et al. 1999, 2002).
While mentalization and attachment-based approaches
focus on the parent-infant dyad, this perspective holds great
value in the context of the family. Some have proposed
models for combining attachment and systems theories
(Byng-Hall 2002; Kozlowska and Hanney 2002; Mikulincer
et al. 2002; Talbot and McHale 2002; Talbot et al. 2009).
Clinically, MBT and Systems Theory have been combined
for work with older, verbal children (Asen and Fonagy
2012; Keaveny et al. 2012; Seifer and Dickstein 2000).
These approaches rely heavily on verbal skills, and so were
not a fit for the infant and preschool population.
Our goal in developing RFP was to provide a brief
intervention where we could invite two parents into the
treatment setting along with their child and any siblings. We
borrowed the structure of the LTP, adding concepts from
the mentalization and attachment-based work we were
already doing. Each session has two components—play
followed by a discussion about the play that day. The play
sequence in RFP mirrors that of the LTP, however, the
instructions were expanded to include “following the child’s
lead” to guide parents to focus on the infant or child’s cues
(see WWW; Cohen et al. 1999). Briefly, in parts 1 and 2,
each parent has the opportunity to play, but is specifically
instructed to follow the child or children’s lead while the
other parent is asked to be simply present. In part 3, the
family is to play together in a shared task, with both parents
following the child or children’s lead. Finally, in part 4,
while the child or children manage on their own, the parents
are asked to begin reflecting on the play. Families with
infants are given 12 min to play, and for toddlers and
beyond, ~20 min. If they do not end the play after
25–30 min, the therapist may interrupt and ask if they have
completed the 4 parts. Parents are not told who should play
first or when the transitions should happen, as these allow
for practicing moments for coparenting decisions. While the
family plays, the therapist remains unobtrusively in the
room, or behind a one-way mirror, and the play is video-
taped. The intervention is structured as an experiential place
for the family to practice being together in new ways,
reinforcing the importance of playing together on a con-
sistent basis.
Early in the treatment, the therapist reviews with parents
what “following the child’s lead” means—to be observers,
while remaining active, and available to play, allowing the
children to direct the activities and themes. Parents are
encouraged to be curious about their child’s thoughts and
feelings during the play, and to pay attention to what comes
up for themselves as well. In subsequent sessions, the
instructions are briefer and elements from previous sessions
3119
may be highlighted. As well, what it means to be “simply
present” is left vague, just as it is in the LTP. In families
with a strong alliance, parents seem to intuitively under-
stand “simply present” as meaning attending to and reso-
nating with the play, without intruding or excluding oneself
completely (Fivaz-Depeursinge and Corboz-Warnery
1999).
The second half of each RFP session is for discussion.
The therapist asks the parents to reflect on the interactions
during the play—their own experiences, and those of their
coparent and child (or children, if there are siblings) as
unique and separate from their own. The therapist helps the
parents generate hypotheses about their child’s thoughts,
feelings, and/or intentions (for further detail and examples,
see Philipp and Hayos 2015). Together, the family and
therapist select and watch specific parts of the play. Parents
(and therapists) often see things they forgot or missed. In
this way, video from the play component of the session is
used to support the discussion. The therapist still follows the
family’s lead; the timing of when to stop viewing the video
is based on the family’s reactions to watching themselves.
The clinician works hard to attend to the various family
members, to mentalize and validate their experiences, and to
help them expand upon their hypotheses about themselves
and each other. With increased flexibility to consider what
might be going on in their child’s mind, parents are better
able to anticipate the needs of their child and understand the
complexities that may impact on behavior and relationships
in the family. With increased skills in mentalization, parents
develop greater sensitivity and attunement to their child, to
their coparent, and to themselves.
While anecdotally our clinicians and the families we
worked with saw the need for and the value of a treatment
that addressed coparenting and sibling issues in the infant
and preschool population, we had not yet done any sys-
tematic review of the cases treated. We chose a retro-
spective chart review design to begin exploring some of the
questions we had around our referral practices, the treatment
process, and outcomes. First, we were interested in under-
standing how families who participate in RFP differ from
families who receive another modality. We set out to
explore whether there were differences in family composi-
tion, or presenting issues, that influenced our recommen-
dation of whole family treatment. We expected that having
two parents engaged in the assessment process would be a
strong indication for RFP, but that the demographic alone
would not suffice for a referral. Rather, we hypothesized
that there would be documented concerns about the copar-
enting and/or the sibling relationships. We also qualitatively
explored session-by-session clinician notes to get a better
sense of the change process through the course of treatment,
looking for common themes and families’ responses to the
modality. We hypothesized that parents would report
3120 Journal of Child and Family Studies (2018) 27:3117–3131

Fig. 1 Visual overview of the Analyses Set 1: Referral Characteristics

selection of cases
Referrals to Infancy &
Preschool Teams Families not assessed
(n=114) (excluded)
(n=26)

Referrals to other 2
Referrals to team teams (excluded)
consistently using RFP (n=72)
(n=42)

Sample for
Analyses Set 1
(n=42)

Analyses Set 2: RFP Session Coding

Referrals to Infancy
& Preschool Teams
(n=114)

Families that did not Referrals to team Referrals to other 2 Families that did not
receive RFP, excluded consistently using RFP teams (n=72) receive RFP, excluded
(n=25) (n=42) (n=67)

Families that received Families that received

RFP RFP
(n=17) (n=5)

Sample for Analyses

set 2
(n=22)

improvements in their child’s presenting symptoms fol-
lowing the completion of RFP. Additionally, because RFP
targets both mentalization and coparenting, we expected to
find evidence of these elements shifting in the chart notes.
Thus, we hypothesized that clinicians would note parents’
increasing flexibility and ability to understand their child
with less pathology and greater connection to dynamics
within the family. We also anticipated that the couple would
be working more as a team to guide the family through the
play and using part 4 to create a clear but flexible boundary
around their subsystem to discuss their observations.
Finally, we expected to find evidence in the chart notes of
the feasibility and effectiveness of RFP as a new approach
to working with the infant and preschool population.
Method
Participants
Families referred to the infant and preschool teams at our
center between 1 January 2010 and 30 June 2014 were
screened for inclusion in the study (n = 114). Families were
assigned to one of three teams, based on their availability
for a new case. Each team was made up of psychology,
psychiatry, and social work trainees and supervising clin-
icians from one of those three professions who treat children
from 0–6 years of age. Two sub-samples (described below)
were selected and used in our study—one for our initial
investigation of referral characteristics and treatment
recommendations, referred to as analyses set 1 (n = 42), and
another for our session-by-session look at RFP, comprising
analyses set 2 (n = 22; see Fig. 1).
Analyses set 1
Only one of the three infant and preschool teams (trained
and supervised by the first and third authors) was con-
sistently recommending RFP. For our analyses examining
referral characteristics, we included only those families seen
by that team (n = 42 completed full clinical assessments;
see results section for sample demographics). Not all of
these families went on to RFP. Some went on to do an
alternative therapy (e.g., dyadic therapy), while others were
Journal of Child and Family Studies (2018) 27:3117–3131
referred for a specialized assessment or service outside of
the center. Decisions about which intervention(s) a family
would receive were made collaboratively with parents,
typically during a feedback session where the clinicians
shared their impressions and recommendations. The
remaining 72 cases seen during this same block of time
were excluded either because they did not proceed beyond
the initial intake (n = 26) or they were assessed by one of
the two other teams at the center (n = 46). While these two
teams were starting to use RFP more frequently, some team
members were still being trained in the model. As such,
some families who may have been appropriate for RFP
were not recommended the treatment by the other two
teams simply due to initial unfamiliarity with the approach.
Note that if there were separate assessments for two siblings
within the same family, they were considered individual
cases only if more than one year lapsed between the
assessments. This was the case for only one of the families
included in the present study.
Analyses set 2
For our preliminary examination of RFP outcomes and the
identification of clinically relevant themes related to the
RFP treatment process, all families that participated in RFP
were included, regardless of which of the three teams at the
center saw them. Specifically, of the 42 families included in
analyses set 1, 17 participated in RFP. Five families that
completed a course of RFP but who were assessed and
treated by one of the other two teams were added to the
sample for our second set of analyses, increasing the total
number of RFP families to 22. Each of these cases were
treated by clinicians who were trained and/or supervised by
the developers of RFP.
Procedure
This case-series took place at SickKids Center for Com-
munity Mental Health (SickKids CCMH, formerly the
Hincks-Dellcrest Centre)—a non-profit children’s mental
health treatment center in an economically and culturally
diverse urban setting of Toronto, ON, Canada. We received
ethics approval from the organization’s Research Ethics
Committee to collect data by retrospective chart review.
Measures were completed for clinical purposes only, and all
treatment recommendations were made based on clinical
assessment and judgment.
Following case selection, clinical charts were reviewed.
Background information (e.g., demographics, family com-
position, presenting concerns, referral source) was obtained
from referral, intake, and assessment notes and entered into
our database. Information about the RFP treatment process
was collected from session notes written by clinicians and
3121
coded using a system developed by the authors (described
below). Clinicians were not given any guidance on how to
write their notes outside of standards of their professional
practice disciplines.
Measures
Referral patterns and family characteristics
Demographic data (e.g., age, gender) and information
regarding family composition (e.g., siblings, biological
relationship to primary caregiver(s), marital status of par-
ents), presenting concerns (including child, sibling, and
parent difficulties), referral source, children’s medical and
developmental history, and previous mental health services,
as well as family psychiatric history, including any history
of intrafamilial trauma reported by either parent, were col-
lected by reviewing intake and clinical assessment reports.
The LTP and Adult Attachment Interview (AAI; George
et al. 1984) are standard in our assessments. Clinician notes
about family interactions (from observations of dyadic
interactions and of the LTP) and qualitative information
about parental history of intrafamilial trauma (derived from
the AAI) were therefore available and accessed. Note, we
use the AAI to learn about the strengths and challenges in
the parents’ relationships with their primary caregivers and
do not code for attachment security. Raw data from the
Child Behavior Checklist (CBCL; Achenbach and Rescorla
2000, 2001) and/or the Parenting Stress Index (PSI-SF;
Abidin 2012) were available for a subset who completed
these measures as part of their clinical assessment. Treat-
ment recommendations following clinical assessment were
also noted.
Treatment process and outcomes
The second author developed an initial coding system in
consultation with the other two authors and based on the
RFP treatment manual (Philipp and Hayos 2015). In
developing the coding system, we followed published
guidelines on conducting retrospective chart reviews (e.g.,
Vassar and Holzmann 2013) and used similar methods to
those used by other researchers (e.g., Frank and Esbensen
2015). Variables considered related to the family alliance
and quality of parent-child interactions (e.g., parents’ ability
to follow their child’s lead, parental mentalization, smooth
transitions between various parts of the play) were selected
prior to coding any charts. Additional themes or variables
that emerged during coding were subsequently added to the
coding scheme. Every RFP session was coded, unless a
clinical note was missing. Because the detail written in
session notes varied greatly (e.g. depending on the clin-
ician), our coding system included “not indicated/unclear”
3122 Journal of Child and Family Studies (2018) 27:3117–3131

Table 1 Coded variables relating to treatment process and outcomes

Variable Description

Attendance The number of sessions where attendance was an issue (e.g., canceled appointments and no-shows, and details
about the reason(s) for missed sessions).
Concerns with modality Captured if parents expressed concerns about the treatment approach. Details about the specific concerns voiced
and when (e.g. at which session) the concerns were shared were collected.
Maintaining the RFP structure A session-by-session variable noting if the family progressed through all five parts of RFP.
Transitions Difficulties with getting started or transitioning from one part of the session to the next were coded for, session-
by-session. Details about who initiated the transitions and any difficulties were noted qualitatively.
Following child’s lead Indicated if one or both parents had difficulties following their child’s lead during each session.
Simply present Indicated if either or both parents had difficulties sitting back and observing the play without intruding.
Sibling relationship A session-by-session variable that captured sibling conflict and sibling play during RFP.
Whole family play In relation to part three of each RFP session, coded if cooperative play involving all family members together
occurred (as opposed to exclusion of a family member or parallel play among dyads).
Maintaining boundaries Coded if one or both parents had difficulties setting and/or maintaining boundaries throughout the session.
Parental engagement Whether parents talked and/or reflected together about the play during part four of each RFP session was coded.
Parental reflection If parents’ discussion during parts 4 and 5 was about the session and their observations about the play. May
include reflections about how the play related to experiences outside of therapy.
Parental mentalization Captured if parents made (appropriate) mentalizing statements about their child or spouse’s experiences.
Shifts in family alliance Noted if any shifts in any session-by-session variables occurred across therapy. This was operationalized as a
shift that persisted for all or most of the remaining sessions. For example, if a family engaged in parallel play in
part 3 of RFP for the first 5 sessions, but at session 6 engaged in whole family play, and continued to do so for
the remaining 3 therapy sessions, this would be noted as a shift in Whole Family Play.
Treatment outcomes Included both parent and clinician reported outcomes. Derived from qualitative notes regarding improvements in
presenting concerns or the family alliance that were noted either during sessions or during the family’s final
feedback session.
Post-treatment plan Following treatment, what was the plan/outcome? What was the aftercare plan?
This is not an exhaustive list; only variables discussed in the paper are included here. In addition to codes, open text data was collected for most
variables. A “not indicated” code was used for all variables to account for the often-limited details in a session note. For more details about the
coding metrics used (e.g., levels of coding) and for examples, please consult the Operational Definitions of Coded Variables document, in
Supplementary Materials.

in lieu of “no” when there was too little detail to discern if a
specific theme was relevant for a session. Coding levels
(e.g., dichotomous yes/no and numerical rating scales) vary
somewhat between variables. We describe our coding sys-
tem (variables and coding levels) in Operational Definitions
of Coded Variables, available under Supplementary Mate-
rial. An overview summary of the session-by-session vari-
ables coded is also provided in Table 1.
Treatment response was evaluated retrospectively by: (a)
examining shifts in the themes coded session-by-session,
(b) reviewing clinician notes from feedback sessions
occurring in the middle of and at the end of therapy (these
included caregiver and clinician reports of changes in pre-
senting concerns or family dynamics), and (c) noting any
treatment recommendations made following RFP (e.g.,
additional services).
Inter-rater Reliability
The second author, and a trained research assistant inde-
pendently coded approximately 50% of the charts. To
minimize bias, neither the first nor the third authors was
involved in coding as they had either worked with or
supervised many of the treatments. All analyses were per-
formed by the second author. As per published guidelines
for retrospective chart reviews (Gearing et al. 2006; Vassar
and Holzmann 2013), another trained assistant randomly
selected and independently coded 15% of the charts to
assess reliability. Cohen’s Kappa coefficients were calcu-
lated across all variables, resulting in kappa values ranging
from 0.58 to 0.91, indicating moderate to almost perfect
agreement (Viera and Garrett 2005). Kappa coefficients for
the session-by-session variables ranged from 0.79 to 0.91,
indicating substantial to almost perfect agreement (Viera
and Garrett 2005).
Data Analysis
Data were descriptively analyzed to report on the char-
acteristics of families recommended RFP and to describe
key themes relevant for the course of RFP treatment.
Whenever there was insufficient information in a specific
chart or session note, and a “not indicated” code was given,
this was treated as missing data, and not included in relevant
Journal of Child and Family Studies (2018) 27:3117–3131
analyses. To examine differences between those families
who were indicated for and received RFP and those who did
not, continuous data were analyzed using two-tailed t-tests,
and categorical data were analyzed using chi-square tests.
When a cross tabulation table indicated expected counts of
<5 in at least 20% of cells, the Fisher’s Exact Test was used
and reported. Significance levels were set to p < .05.
Results
Analyses Set 1
Family Characteristics And Treatment Referrals
The following results are based on the 42 families assessed
by the one Infant and Preschool team regularly using RFP
between 1 January 2010 and 30 June 2014.
Demographics
Of the 42 families assessed, 38 identified one child of
concern, while the remaining four families sought services
for two children. Children identified as the primary client
were 57% male, and ranged in age from 1 month to 6 years,
10 months (M = 3.99, SD = 1.33). The majority (79%),
were 4 years or younger.
In terms of family constellations, the majority (71%) of
families assessed and referred for services comprised two-
parent households. Specifically, 55% comprised biological
parents living together, 10% adoptive parents living toge-
ther, and 7% a biological and stepparent living together. In
one case, the coparents were a mother and maternal
grandmother. More than a quarter of the families (29%)
referred for services were single parent households (all
single mothers). Finally, the majority (74%) of families had
more than one child—the highest proportion had two chil-
dren (52%); 26% had one child and 19% had three children.
One family had four children.
Overall Presenting Concerns
As per the intake and assessment notes available in client
charts, parents reported that child presenting concerns were
prevalent in the home setting for all 42 families, and ~68%
reported difficulties at daycare or school as well, with 35%
indicating significant problems at school. Nearly all families
assessed reported multiple presenting concerns (98%), with
an average of 8 concerns reported (SD = 3.13). The most
common presenting concerns (reported by parents) were
aggression (73%), tantrums (69%), sleep difficulties (67%),
anxiety (65%), and oppositionality (68%). Other presenting
concerns included sensory sensitivities or difficulties with
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sensory integration, mood dysregulation, challenges with
transitions, and bonding. Sibling conflict was reported in
45% of families comprised of more than one child. Diffi-
culties within the coparenting relationship were reported by
parents in 63% of the cases and were noted by clinicians (in
their formulation of the family) in 67%. Also, 64% of
parents indicated they were specifically seeking help with
parenting skills. In addition to child symptoms, parental
difficulties were also coded for during chart reviews,
revealing current parental mood difficulties (e.g., depressive
symptoms) in 31% of cases, and parental anxiety in 36%.
Finally, 50% of the parents reported feeling significantly
frustrated and/or overwhelmed by their child’s difficulties.
We had pre-treatment CBCL and PSI data for a subset of
the families. Forty-six percent of mothers (12 of 26) indi-
cated internalizing problems within the clinical range on the
CBCL, while 19% were in the sub-clinical range. In terms
of externalizing difficulties, 58% of mothers reported
clinically significant problems and 12% indicated sub-
clinical difficulties. Clinically significant internalizing and
externalizing difficulties were reported by 33% and 38% of
fathers (21 available reports), respectively. On the PSI, 48%
of mothers (12 of 25) indicated a clinically significant Total
Stress score, while only 29% of fathers (5 of 17 available
paternal reports) did.
Finally, nearly half (45%) of the children had received
specialized services (primarily psychoeducational or
developmental assessments and speech and language ser-
vices) outside of our center prior to their intake with us.
Additionally, most mothers (76%) and many fathers (67%)
reported having a psychiatric history—primarily a diagnosis
of depression and/or anxiety for mothers, and a diagnosis of
depression and/or attention deficit hyperactivity disorder for
fathers. In terms of intrafamilial trauma, 57% of mothers
(21 of 37) indicated they had experienced early childhood
trauma on the AAI, while 22% struggled to recall specific
memories during the interview. On the other hand, fathers
directly reported a trauma history in 29% of cases (8 of 28),
while 43% could not provide specific childhood memories
when probed during the AAI.
A Comparison Of Families Indicated For RFP vs. Other
Treatments
Among the 42 families assessed, 31 (74%) were recom-
mended relational therapy, of which 27 (87%) went on to
engage in a relational approach. The remaining 11 (26%)
families were recommended a non-relational approach;
however, one ultimately did receive WWW. Thus, a total of
28 families (~67% of the 42 assessed) received relational
therapy. The remaining 33% of families were either pro-
vided with non-relational support at our center or referred
out for specialized services. Of the families who engaged in
3124 Journal of Child and Family Studies (2018) 27:3117–3131

Table 2 Overview of treatments

Treatment recommended
recommended to and accessed
by families Single parent household Two-parent household
a
RFP WWW Mix Other RFP WWW Mix Other Total

Treatment received RFP – – – – 9 1 1 – 11

WWW – 5 – 1 – 4 1 – 11
Mix – – – – – 4 2 – 6
Other – 1 – 5 2 – 1 5 14
Total 0 6 0 6 11 9 5 5 42
One of the single parent households included a mother-grandmother coparenting team.
a
Mix refers to those families who were recommended a combination of WWW and RFP

Table 3 Descriptive data broken

RFP (n = Dyadic (n = Mixed (n = Non-relational (n = Overall (n =
down by treatment
11) 11) 6) 14) 42)
recommendation
Age
M (SD) 3.55 (1.29) 4.45 (1.32) 3.46 (1.88) 4.19 (1.04) 3.99 (1.33)
Gender N(%)
Male 5 (45) 7 (64) 3 (50) 9 (64) 24 (57)
Female 6 (55) 4 (36) 3 (50) 5 (36) 18 (43)
Family constellation N(%)
No siblings 0 (0) 6 (55) 2 (33) 3 (21) 11 (26)
One sibling 9 (82) 2 (18) 4 (67) 7 (50) 22 (52)
Two or more 2(18) 3 (27) 0 (0) 4 (29) 9 (22)
siblings
Two-parent 11 (100) 5 (45) 6 (100) 8 (57) 30 (71)
household
Single parent 0 (0) 6 (55) 0 (0) 6 (43) 12 (29)

a relational approach, 39% participated in RFP, 39% par-
ticipated in WWW, and another 22% received a combina-
tion of RFP and WWW. Table 2 provides an overview of
the treatments recommended to and accessed by our
families. The following comparisons include only the
families who participated in both RFP or a dyadic approach,
and excludes those who received a combination of the two
approaches. For ease of comparison, descriptive data are
summarized in Table 3 by treatment group.
No significant differences in age were found when
comparing children of families who were recommended
RFP (M = 3.55, SD = 1.29) relative to those who were
recommended dyadic therapy (M = 4.45, SD = 1.32), t(20)
= −1.62, p = 0.121, or another non-relational approach
(M = 4.19, SD = 1.04), t(23) = −1.37, p = .184. Similarly,
no associations between gender and treatment recommen-
dations were found; although a larger proportion of children
within the RFP cases were female (55%) relative to the
dyadic therapy (36%) and non-relational therapy (36%)
cases, this difference was not statistically significant, X2(2,
n = 36) = 1.08, p = .582.
Differences were observed in family constellations. All
the families indicated for RFP only (excluding those who
received both RFP and WWW) were two-parent house-
holds, compared to 45% of the families indicated for dyadic
therapy and 64% of those indicated for a non-relational
approach. This resulted in a significant association between
treatment recommendations and parental status (X2(2, n =
36) = 7.99, p = .018). Additionally, all of the families
indicated for RFP had more than one child, while less than
half (45%) of the families indicated for dyadic therapy had
multiple children, also a significant association (p = .012,
Fisher’s Exact Test). Families recommended for a non-
relational approach also mostly comprised of families with
multiple children (79%) and did not differ significantly from
the RFP families (p = .230, Fisher’s Exact Test).
Comparisons of child presenting concerns across treat-
ment groups revealed few significant associations. Diffi-
culties with peers were more common among RFP families
relative to those referred for dyadic therapy (45% and 0%
respectively; p = .010, Fisher’s Exact Test). Sibling conflict
was reported in 82% of the RFP families, but in only 20%
of the families referred for a dyadic approach (p = 0.035,
Fisher’s Exact Test) and 14% (p = 0.008 Fisher’s Exact
Test) of those referred for a non-relational approach
reported difficulties with siblings (controlling for those
Journal of Child and Family Studies (2018) 27:3117–3131
families with no siblings). Finally, our RFP families had a
higher proportion of children experiencing mood dysregu-
lation compared to the non-relational families (64% and
21% respectively, p-value = .035, Fischer’s Exact Test). No
other significant differences were found in child presenting
concerns.
In terms of parent characteristics, with respect to parental
mental health issues, there were no significant differences
between the families referred to RFP vs. a dyadic approach
or a non-relational model. While AAIs were not coded for
attachment status, clinician summaries about the interviews
were coded for a history of trauma. Specifically, we coded if
the parent reported a history of sexual abuse, physical
abuse, exposure to domestic violence, severe corporal
punishment, emotional abuse, or if the parent described
relational disruptions more generally (e.g., parent was often
absent). There were no significant differences in the report
of childhood trauma among those parents referred for RFP
vs. one of the other treatment options. Overall, combining
all forms of trauma, 65% of mothers (24 of 37) reported a
trauma history, while 24% of fathers reported a trauma
history (7 of 29). Notably, more than half of fathers (55%)
were reported to have difficulties recalling specific mem-
ories on the AAI (for mothers this number was 32%).
Finally, based on our clinical experience, we felt that a
dyadic approach was more likely to be recommended if one
parent appeared to be more distressed about their relation-
ship with the child than their coparenting partner. In cases
where both parents completed the PSI, we calculated a
difference score by subtracting one parent’s Total Stress
score from the other. The average difference score for the
dyadic therapy group (M = 241.2, SD = 37.99) was larger
than that of the RFP (M = 174.8, SD = 56.26) group;
however, this difference did not reach statistical sig-
nificance, t(8) = −2.187, p = .060.
Analyses Set 2
A Session-By-Session Analysis Of Themes Regarding
Treatment Process And Outcomes
The remaining results are based on the 22 families that took
part in RFP. Nineteen of these families initially sought
services for one child (four of these families had only one
child), while three were concerned about two children (each
of these families had only two children). In each of these 22
cases, one child of primary concern was identified. The age
range of these children was 1 month to 5 years, 5 months
(M = 3.64, SD = 1.37). Because session notes from one of
the clinical charts were not available at the time of our
review, the following session-by-session findings included
21 cases. The number of RFP sessions families had varied
depending on their needs and if the family discontinued
3125
treatment early (range of 1–22 sessions), with families most
commonly receiving 8 sessions (mode). We coded every
RFP session note available for each family so that we could
examine shifts and improvements in the family system
across time (i.e., all sessions).
Maintaining the RFP Structure
For the most part, families were able to follow the RFP
session structure; only four (19%) deviated from the struc-
ture. All deviations from the RFP paradigm involved par-
ents skipping part four, (parents’ discussion while the
children play on their own) and typically occurred in early
sessions (usually the first 1–3). Only one family had
ongoing difficulties with part four. One family directly
indicated, following an early session, that they were con-
fused about the structure.
Transitions
About 57% of families showed improvements in transitions
between each of the four parts of the play task, while 21%
of the families had good transitions from the outset.
Smoother transitions were observed somewhere between
sessions 3 and 15 (mode: 6). Difficulties with transitioning
often involved children having tantrums or refusing to start
playing at the beginning of the session. Additionally, par-
ents often struggled to negotiate with each other when to
switch to the next part (e.g., a parent would step in intru-
sively, or signals from the simply present parent would be
ignored).
Following Child’s Lead
Improvements in parents’ ability to follow their children’s
lead in play were observed in 89% of the families. Shifts
were observed to occur as early as session three and as late
as session 13. During their reflections, many of these par-
ents explained that following their children’s lead was quite
different from how they were used to playing at home. One
father indicated he simply felt “more comfortable” in the
teaching role. Another father explained that it was espe-
cially hard for him to follow his children’s lead when their
play became aggressive (albeit at a normative level). One
mother stated that it felt strange to “just sit there” and be
present with her child who was often “happy to play,” even
when his mother was not actively involved.
Simply Present
Parents’ ability to remain simply present during sessions
were indicated in only 9 of the 21 charts reviewed. Of these,
(56%) showed improvements in their ability to remain
3126
simply present while (22%) never had issues with it. Dif-
ficulties typically involved intrusions into the play (e.g. the
simply present parent making suggestions from the side-
lines), a failure, by the simply present parent, to redirect
children to the active parent when the simply present parent
was approached by a child, or a lack of engagement (e.g.,
simply present parents would appear disinterested in the
play, not attending to what was going on). For the one
family who continued to struggle, there were significant
difficulties noted within the coparenting relationship.
Sibling Relationship
In terms of the quality of sibling interactions during therapy
sessions, very few instances of sibling conflict were
described by clinicians. Similarly, we coded for sibling play
during part 4 of RFP, as well as sibling play throughout the
session, however, clinician notes mostly did not mention the
quality of play during sessions. Therefore, the variable
“sibling relationship” was dropped from further analyses.
Whole Family Play
With regards to the ability to come together and play in part
3, 75% of the families improved somewhere between ses-
sion 2–10 (mode = 3), shifting from primarily parallel play
(e.g., with each parent playing with one child), or where one
parent was excluded, to whole family play. The remaining
25% of families demonstrated whole family play right from
the start of treatment. Qualitative shifts in the play were also
noted by therapists, including the degree of warmth and
laughter observed during the play.
Parental Engagement
As noted in Table 1, this variable refers to parents’ ability to
engage with each other during part four. Fifty-percent of
parents were already doing this well from the outset, and the
remaining 50% improved in this domain, typically some-
where between sessions 5 and 15 (Mode 6). It took the most
time (i.e., number of sessions) to see improvements in this
aspect of the family alliance.
Maintaining Boundaries
Closely related to parental engagement was parents’ ability
to set clear but flexible boundaries, especially during part
four. We noted improvements in this domain for 60% of our
families, which occurred between sessions three and eight
(mode = 5), while 20% did well with maintaining bound-
aries from the start. Improvements in parents’ nonverbal
cues were often noted, and often occurred at the same time
as the children managing better on their own.
Journal of Child and Family Studies (2018) 27:3117–3131
Parental Mentalization
Improvements in parents’ mentalization were identified in
75% of families, while 13% were already showing a strong
mentalization capacity from the start of treatment. Shifts in
mentalization included the increased frequency of mentali-
zation observations, and improvements in the quality of
mentalizations (i.e., going from misattuned attributions to
more flexible mentalization of child’s behavior and emo-
tional expressions).
Acceptability
Somewhere between sessions one through four (mode = 3),
77% of the families participating in RFP expressed some
uncertainty about the approach (i.e., our “concerns with
modality” variable). Most commonly, there were requests
for a more direct approach (e.g., behavior management
strategies), questions around the utility of a play-based
approach, and doubts about the benefit of having the chil-
dren in the room during the discussion with the therapist.
However, of those families who had a chart note about their
final feedback session or phone call (n = 17), all indicated
that they understood and valued the process. Finally, only 3
of the 21 cases (14%) discontinued RFP prematurely. One
family was lost to follow up due to a move out of the
catchment area; one family stopped showing up for their
appointments; the third family pursued a specialized
assessment for autism at the recommendations of the clin-
ician and the team.
Final Feedback from Parents and Clinicians
Amongst those families who completed a final feedback
session or phone call (n = 17), all but one reported
improvement in the presenting symptoms of their child.
Most of these improvements were related to decreased
tantrums and aggression, better sibling relations, and better
peer relations as well. The one family who did not experi-
ence improvements in their child’s presenting concerns had
a child with very severe feeding difficulties. Improvements
in the family with respect to cooperation and affection were,
as reported by both families and clinicians, noted in 85.71%
of these families. Several parents also noted improvements
in their ability to reflect on and mentalize their child’s
experiences. For example, one family stated that they are
much better able to figure out what the child is feeling and
thinking.
Disposition of Families Post-Treatment
In addition to looking at attrition and completion rates, we
also looked at referrals for further services post treatment
Journal of Child and Family Studies (2018) 27:3117–3131
and what parents reported both during the intervention as
well as in their post treatment interviews. Only 17% of
families were referred on to another service such as indi-
vidual therapy for the child or dyadic work for the child and
one of the parents. In over 83% of the cases, no further
relational treatment was deemed necessary; 30% of this
subset did require other services such as psychological/
cognitive assessment, speech and language therapy or
occupational therapy.
Discussion
Early pioneers of family therapy recognized the importance
of including the very young into family interventions
(Minuchin 1985) and the utility of play to engage children
(Satir 1972). Yet, the focus of infant and preschool clin-
icians was on dyadic treatments. The push to consider a
whole-family approach for both assessment and treatment in
this younger population is relatively more recent (Cornett
and Bratton 2014; McHale et al. 2000; Willis et al. 2017).
Many sites now use the LTP in their evaluation of infants
and preschoolers and to work with the coparents (see Fivaz-
Depeursinge and Philipp 2014; and other articles in this
issue). As well, evidence based treatments, such as Emotion
Focused Family Therapy (Johnson and Lee 2000) and Filial
Therapy (Guerney 1964), have been adapted for younger
children and their parents (Cornett and Bratton 2014; Willis
et al. 2016), however these treatments are still not targeting
children under three years of age.
In this case series, we evaluated the feasibility and
acceptability of RFP which, like earlier dyadic approaches,
aims to improve pRF and attunement, while also addressing
coparenting and sibling issues. The intervention was
derived from existing, evidence-based models, and our
preliminary findings suggest that RFP is feasible, accep-
table, and valued by families who are struggling with their
child’s symptoms.
Referral Patterns for RFP
As expected, only a subset of two-parent families was
referred to RFP, and sibling challenges were more prevalent
in these families, with a higher proportion of families
referred to RFP reporting sibling conflict compared to
families indicated for dyadic therapy (after controlling for
families without siblings). RFP provided a space for sib-
lings to interact in a therapeutic setting. Interestingly,
challenges with peers was also more common in the
families referred to RFP. Contrary to our hypotheses, the
proportion of families identified as having coparenting
difficulties was similar across all treatments. Of note, some
of the families who struggled with coparenting that were
3127
referred to a dyadic therapy or who were recommended an
alternative service had an intervening problem. In one case,
the mother needed immediate support for her substance
abuse. In another case, there were clear disruptions in the
mother−child relationship as opposed to the whole family
system. More commonly (five cases), the identified child
was presenting with symptoms requiring specialized
assessment (e.g. to rule out Autism Spectrum Disorder).
Given our small sample size, this question warrants further
exploration.
Outcomes
Improvements in presenting concerns were reported in
nearly all the families who completed a final feedback
session. Parents also noted improvements in other qualities
of the family, including increased affection and decreased
sibling conflict. Together with the recent reports on adap-
tations of Emotion Focused Family Therapy (Willis et al.
2016), and Filial Therapy (Child Parent Relationship
Therapy; Cornett and Bratton 2014) to include younger
children and coparents, these preliminary findings suggest
that family-based work, particularly if it incorporates play,
can be helpful for families with very young children.
Moreover, in our study, many children were four years and
younger (including younger siblings), suggesting that even
young preschoolers, toddlers, and babies can participate in
this work, should it be indicated. Future research should
include long-term follow-up of families to determine if
gains are maintained and to assess any “sleeper effects”
(Bakermans-Kranenburg et al. 2003), with further symptom
reduction, functional improvement, and gains consolidating
post treatment.
While video is not used in a didactic manner in RFP, but
to support parents’ reflections and observations with the
therapist, we must not underestimate its role in our inter-
vention. Others have used this medium in dyadic inter-
ventions such as Interaction Guidance (McDonough 2000;
Rusconi-Serpa et al. 2009) and Video-Feedback Interven-
tion to promote Positive Parenting (VIPP; Juffer et al.
2017). Juffer et al. (2017) describe the value of using video
as serving “as a mirror to see and reflect on one’s own
parenting behavior…” (p. 205).
Shifts in Family Functioning
The LTP paradigm has identified family characteristics
conducive to a strong family alliance. Through the course of
RFP, clinicians observed improvements in several of these
indicators of family functioning. First, clinicians noted an
increase in whole-family interactions. At the beginning of
treatment, many chart notes described families struggling to
join in a shared activity in part three. By the end of
3128
treatment, the notes included comments about joyful inter-
actions, with everyone included. In addition to the therapist
observations, documented in our charts, the parents also
commented on improvements in family interactions outside
of therapy. Second, chart notes indicated improvements in
parents maintaining the “simply present” role, neither
intruding on the play, nor fully excluding themselves from
enjoying it at a distance. This shift suggests greater appre-
ciation of, and trust in, the coparent. The next step is to
include post treatment LTPs to assess more rigorously
change from our intervention.
The session-by-session notes also provided us with data
about how the family, particularly the couple, handled all
transitions in the play. How coparents navigate their family
through the various parts of the play task can tell us about
their coparenting and communication style. Chart notes
indicated that transitions were increasingly smooth as
treatment progressed. Parents became better at using verbal
as well as non-verbal cues. Transitions are a common
challenge for all families, particularly for those with mental
health issues. In RFP, families can practice them in a con-
tained, playful setting. Based on the feedback we received
from parents, these skills seemed to generalize outside of
the play space as well.
One of the last things to change for families was part
four, when parents discuss their observations of the play.
Early in treatment, many families “forgot” to do this part or
were unable to set clear limits, continuing to interact with
their children instead of with each other. Others repeatedly
asked their children to play on their own and never engaged
in a coparental discussion. While this domain was the
slowest to improve (usually session 6), all families even-
tually did do part four. Parents sent clearer signals to their
children that they were having their own discussion, mov-
ing away and using adult speech, creating what Minuchin
(1974) called a “clear but flexible boundary”. As one couple
put it, “it needs to be a wall, but with a window, so we can
see what they’re doing.”
We also coded for the parents’ ability to follow their
children’s lead and to reflect on their children’s experiences
as distinct from their own. We see these two elements as
telling us something about parental reflective capacity. In
asking parents to follow their child’s lead, we are inviting
them to focus on their child’s intentions. Chart notes indi-
cated that while there was variability as to the timing
(session 3–13), parents’ ability to follow the child’s lead
improved for 89% of the families. In terms of mentalizing
statements noted in the charts, a small proportion of the
parents (13%), already made reflective observations of their
children from the outset. Seventy five percent of the parents
were noted to increase the quality and quantity of menta-
lizing comments through the course of treatment. These
observations are promising, but require more rigorous
Journal of Child and Family Studies (2018) 27:3117–3131
investigation, with the caveat that our ability to measure
change in pRF is limited. Treatment programs using pRF as
an outcome measure have seen limited results, with change
only seen in those with the lowest pRF scores before the
intervention (Slade et al. 2005a, b) or with the greatest
levels of pre-treatment psychological distress (Paris et al.
2015). Others have found no improvement in pRF (Fonagy
et al. 2016). Clearly, there is work to be done to better
understand the role of pRF in change across treatments.
Acceptability and Feasibility of the Approach
All families who completed a course of RFP, for whom a
feedback session note was available, expressed under-
standing, and valuing the process. Furthermore, our attrition
rate, 14%, was quite low for this brief intervention. Many
parents questioned the model mid-way through their work.
Clients often question psychotherapy treatments, particu-
larly in the early stages. In fact, drop out from treatment is
greatest in the early weeks, with an estimated 47% across a
variety of settings (Barrett et al. 2008; Garfield 1994; Lor-
ion and Felner 1986; Sparks et al. 2003; Wierzbicki and
Pekarik 1993). Although many of our families questioned
the process, most continued with treatment until the end. In
response to parents’ expressed concerns about the model,
we now socialization families to the model before starting
RFP. Socialization to the model is a pre-treatment inter-
vention found to improve compliance and the therapeutic
alliance (Roos and Wearde 2009). In this session, we talk
with parents about struggles common for families in this
type of treatment. We also use the family’s pretreatment
LTP to provide feedback and to socialize parents to
observing and reflecting on their own interactions.
Limitations
Our sample size was quite small and we relied on the
impressions and comments of the clinicians and the infor-
mation reported to them by parents. Furthermore, because
this study relied on chart notes and some files had little
detail, we cannot assume that if something was not men-
tioned in a note, it was not relevant in that session. For
example, little was written by clinicians about sibling con-
flict and play, and because of this, we were unable to
comment on session-by-session improvements in sibling
relations in our study. To manage this absence of detail, we
used a “not indicated” code and treated these as missing
data, excluding that cell in the analysis. One further issue
was that all households in this sample had two cohabitating
parents. At the time, we did not have a model for single
parents or separated couples who were struggling with
sibling issues. Inspired by the work of others using the LTP
in high conflict divorce and separated families (Lubrano
Journal of Child and Family Studies (2018) 27:3117–3131
et al. 2011; McHale and Irace 2010) as well as with “fragile
families” (McHale et al. 2012), we now include
all coparents into adapted versions of RFP (see New
Developments).
Currently, we have a prospective study underway to
corroborate our preliminary findings from this retrospective
study. We are using pre- and post-treatment measures as
well as observations of the family during the LTP. Our hope
is to eventually mount a multi-center randomized, con-
trolled study of RFP.
In terms of the diversity of our sample, our Center is in a
multicultural, diverse urban setting (Gray and Davey 2016).
While we have not done a formal comparative evaluation of
this treatment with families from divergent cultures, the
stance of following the parents’ lead has allowed us to be
open to and explore various aspects of culture and family
with the clients we treat. We have on occasion eliminated
the use of video for families who have personal or religious
beliefs that would make its use uncomfortable. Same-sex
couples have engaged in RFP, and we have also completed
treatments in French, Spanish, and Mandarin.
Author Contributions D.P. collaborated with the study design and
wrote the paper. K.C. collaborated to develop the study’s coding
system, completed data analyses, wrote the methods and results sec-
tions, and collaborated in editing the final manuscript. C.H. collabo-
rated with the study design, writing, and editing the manuscript.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval Ethics approval was obtained from a committee of
the Ethics and Review board of SickKids Centre for Community
Mental Health (CCMH), formerly the Hincks-Dellcrest Centre.
Informed Consent Informed was not required for this retrospective
chart review.
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