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Plots comparing treatment and control group estimated marginal means at Time 1 and Time 2 for outcomes with significant Time x Group interactions
Source publication
Recognition of the protective value of secure parent–child relationships has prompted a growing interest in parenting interventions informed by attachment theory. Circle of Security Parenting (COS-P) is one such program, specifically designed for scalability. Although widely disseminated internationally, evidence for the effectiveness of COS-P is v...
Citations
... It combines six subscales and one single item drawn from previously validated measures, retaining the original response formats and scoring procedures for each subscale. Focus Groups, Self-Confrontation Interviews (N = 6) Evaluate participants' subjective experiences sample of parents [29] and is being used in the current study to assess the impact of COS-P on these key parenting capacities. This questionnaire has also undergone validation with a sample of N = 1181 French foster carers as part of a larger research project on foster care conducted by our research team. ...
Background
Children in out-of-home care constitute a vulnerable population often experiencing mental health challenges related to early adversity and placement disruptions. The Circle of Security Parenting program® (COS-P) is an attachment-based intervention designed to enhance carer sensitivity and reflective competence, ultimately improving the quality of carer-child relationships.
Methods
This study protocol follows a mixed-methods randomized controlled trial evaluating the effectiveness of the COS-P program for foster carers in France. A total of 70 foster carers will be randomly assigned to either the intervention group (receiving COS-P in addition to Treatment as Usual) or the waitlist control group (receiving Treatment as Usual only). Quantitative measures, including the Caregiving Composite Questionnaire, Parenting Stress Index, and the Marschak Interaction Method, will be administered at baseline and at follow-up). Qualitative data will be collected through focus groups with foster carers and COS-P facilitators, and through self-confrontation interviews with a subset of foster carers.
Discussion
This study is the first to evaluate the COS-P program for foster carers in France. Findings will provide valuable insights into the program’s effectiveness in improving carer-child relationships and foster carer well-being, ultimately contributing to better outcomes for children in out-of-home care. The study will also explore potential moderators of treatment outcome, and shed light on the subjective experiences of participants.
Trial registration
This trial is registered on ClinicalTrials.gov : NCT06701877.
... Of the 166 coded videos (n = 88 at T1, n = 61 at T2, n = 17 at T3), 23% (n = 38) were double coded (ICC = 0.99, 95% CI, 0.98-0.96). Parent-reported mentalization was assessed using Diamond's reflective functioning scale (DRFS; [27]) administered as part of the Composite Caregiving Questionnaire (CCQ; [60]). The DRFS comprises 18 parent-report items, each answered on a 4-point scale. ...
... Parental self-efficacy regarding empathy and emotional understanding was assessed using the empathy and emotion subscales of the Tool to Measure Parenting Self-Efficacy (TOPSE; [48]), administered as part of the CCQ [60]. The TOPSE-empathy and the TOPSE-emotion scales each comprise 7 items answered on a fivepoint scale. ...
... Caregiving helplessness was assessed using the 'mother helpless' subscale of the Caregiving Helplessness Questionnaire (CHQ; [79]), administered as part of the CCQ [60]. The CHQ-mother helpless scale comprises 7 items, each answered on a five-point scale. ...
Background
Parent–Child Interaction Therapy—Toddler (PCIT-T) is an attachment-informed intervention model designed to meet the specific developmental needs of toddlers aged 12–24 months presenting with challenging behaviors.
Methods
This study used a randomized controlled design to evaluate outcomes of PCIT-T for children aged 14–24 months with disruptive behaviors. Ninety toddlers with parent-reported disruptive behavior were randomly allocated to PCIT-T (intervention), an active control condition (Circle of Security– Parenting™; COS-P), or a non-treatment control condition (wait-list; WL). Outcomes were assessed at baseline (Time 1), post treatment/post waitlist (Time 2) and 4-month follow-up (Time 3).
Results
At follow-up, the PCIT-T group displayed the highest levels of parenting sensitivity and positive parental verbalizations, and the lowest levels of negative child-directed verbalizations and non-attuned mind-minded statements. Of the three groups, the PCIT-T group showed the greatest degree of change on these variables, followed by the COS-P group and then the non-treated controls. The PCIT-T group were also the only group to show significant within-group improvements in sensitivity, self-reported parental reflectiveness, empathy and emotional understanding, parent-reported child social competence, child internalizing problems, and general behavior issues. Significant reductions in parental stress, child externalizing behaviors and parenting behaviors were seen for both the PCIT-T and COS-P groups.
Conclusions
Delivered in the early intervention period of toddlerhood, Parent–Child Interaction Therapy—Toddler has the potential to bring about significant changes for children presenting with early onset behavioral issues.
Trial registration
Australian New Zealand Clinical Trials Registry (ANZCTR), 12,618,001,554,257. Registered 24 September 2018 – retrospectively registered, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001554257.
... To evaluate these outcomes, observer-rated measures were predominantly used (n = 36, 90%) and 14 studies (35%) combined the observation with caregiver self-report measures (ABC: Berlin et al., 2018;COS: Røhder et al., 2022;Ramsauer et al., 2019;Cassidy et al., 2010Cassidy et al., , 2011GABI: Myers et al., 2022;Steele et al., 2010;Lighthouse MTB Parenting Programme: Byrne et al., 2019;MB;Alhusen et al., 2020;MTB: Slade et al., 2020;Sadler et al., 2013;New Beginnings: Bain, 2014;Sleed et al., 2013;Mellow Babies: Raouna et al., 2021). Three studies (7.5%) adopted caregiver self-report measures related to the caregiver-infant relationship only (COS: Maxwell et al., 2020; The Solihull Approach: Douglas & Bateson, 2017;Harris-Waller et al., 2019). ...
... A significant reduction in depression symptoms was most frequently reported following intervention (n = 8; COS: Maxwell et al., 2020;Cassidy et al., 2010;Røhder et al., 2022;Mellow Babies: Puckering et al., 2010;MB: McFarlane et al., 2017;MTB: Slade et al., 2020;WWW : Cohen et al., 1999). UCLA Family Development Project evaluated caregiver social support in two included studies and was reported to improve significantly following the intervention at 12 months (Heinicke et al., 1999) and 24 months (Heinicke et al., 2001). ...
... The review findings highlighted the predominant use of observational methods of the caregiver and infant, with few studies using only caregiver self-report measures (COS: Maxwell et al., 2020; The Solihull Approach: Douglas & Bateson, 2017;Harris-Waller et al., 2019). This finding was unexpected and offers contradictory evidence to Broberg's (2000) suggestion that attachment-based intervention outcomes are often reported through parental self-report measures. ...
As attachment-based interventions can improve caregiver-infant relationships and their subsequent psychological outcomes, the identification of relevant and effective interventions can facilitate their implementation into clinical practice. This systematic review aimed to a) provide an overview of manualised attachment-based interventions, without video-feedback as the main component, for caregivers and infants from conception to two years, and b) determine which of these interventions were effective in demonstrating improvements in caregiver-infant relational outcomes. To identify eligible interventions and their empirical evidence base, two search stages were conducted for 1) relevant interventions and 2) studies of interventions identified in the first stage that focussed on caregiver-infant relational outcomes. All studies included in Stage 2 were quality assessed and findings analysed. Twenty-six interventions were eligible for inclusion at Stage 1 but studies reporting on relational outcomes were identified for 16 interventions only. Forty studies reporting on those 16 interventions met inclusion criteria and were synthesised at Stage 2. Most studies were of good quality. Observer-rated measures were used in 90% of studies. There was evidence for these interventions in relation to improving caregiver-infant relational outcomes: 80% of studies reported a statistically significant positive change in a relational outcome for the intervention compared to pre-intervention or control group. The most promising evidence was identified for Attachment and Biobehavioral Catch-Up (ABC), Minding the Baby (MTB) and Circle of Security (COS). This systematic review offers guidance to healthcare professionals, commissioners and policymakers within perinatal sectors in relation to the training, delivery and implementation of evidenced manualised attachment-based interventions.
... Clarifying underlying physiological mechanisms may offer a feasible approach to interrupt the transmission of parental attachment insecurity and pathological narcissism to offspring (Cerniglia & Cimino, 2020). Fourth, our results support the implementation of family-based interventions aimed at reducing attachment insecurity (e.g., Circle of Security-Parenting [COS-P] and Attachment-based family therapy [ABFT]), which may be effective in ameliorating pathological narcissism (Diamond et al., 2007;Lordello, 2024;Maxwell et al., 2021). More importantly, our findings help identify which populations (e.g., anxiously attached narcissists) are more likely to benefit from attachmentbased interventions that can enhance the accuracy and efficiency of interventions targeting pathological narcissism. ...
The detrimental effects of pathological narcissism on individual development and intimate relationships have been widely studied. Although the exact origins of this phenomenon are still debated, the important role that family dynamics play in its emergence is increasingly being recognized. Previous researchers have pointed out that insecure attachment is associated with pathological narcissism; however, empirical findings are inconsistent. Hence, this study conducted a three-level random-effects meta-analysis based on 183 effect sizes from 29 articles (N = 8247 participants). Our findings have demonstrated the significant and positive link between insecure attachment and pathological narcissism (r = .18; 95% CI: 0.14, 0.22; p < .001). In addition, a moderator analysis was carried out to explore factors that may weaken or strengthen the primary association of interest. In total, there are five significant moderators, including insecure attachment style (F (3,176) = 13.72; p < .001), measurement tool of attachment insecurity (F (8,171) = 4.59; p < .001), measurement tool of pathological narcissism (F (6,173) = 5.21; p < .001), percentage of participants identifying as male (F (1,174) = 4.04; p = .046), and age (F (1,178) = 19.94; p < .001). This research highlights the positive correlation between attachment insecurity and pathological narcissism, providing family theorists with insights into how early family experiences influence personality formation and guiding family therapists in interventions for narcissistic pathology. K E Y W O R D S insecure attachment, meta-analysis, moderator analysis, pathological narcissism
... In an exploratory study by Kohlhoff et al. (2016), using a small pre-post design with 15 mothers with children under age 2, the authors found that COS-P participation resulted in increased levels of parental RF, decreased levels of caregiver helplessness, decreased feelings of fear, anger, and rejection towards the child and reductions in parenting stress. More recently, COS-P was found to improve parental mentalizing and self-efficacy and reduce caregiving helplessness and hostility in a multisite non-randomized waitlist control study (Maxwell et al., 2021). In contrast, three studies investigating whether COS-P can improve parental RF found no effect (Gray, 2015;Maupin et al., 2017;Zimmer-Glembeck et al., 2022). ...
Sensitive and responsive parenting is known to promote secure attachment. Caregiver reflective functioning (RF), one’s capacity to mentalize, is a critical mechanism for caregiver behaviors supportive of secure attachment. Interventions targeting RF can improve caregiving quality, and in turn, attachment security. One such promising intervention is Circle of Security-Parenting (COS-P), a brief eight-week parenting program designed to improve caregiver behaviors known to promote attachment security. Using a randomized wait-list control design, we examined the efficacy of the COS-P program in improving caregiver RF, and in turn, positive caregiver behaviors. The present sample of forty-six primary caregivers (3 fathers, 40 mothers, 1 grandfather, 2 grandmothers) were predominately low-income and people of color. Caregivers were randomly assigned to the COS-P intervention group or wait-list control group. Pre/post data collection included demographic information, interview to assess RF (PDI-R2-S), and a caregiver-child semi-structured play interaction (Crowell). As a result of the brief intervention, intervention caregivers, compared to control group caregivers, demonstrated significant growth in RF, behavioral responsiveness, and emotional responsiveness. Caregiver RF at posttest explained a significant amount of variance in both posttest behavioral and emotional responsiveness above and beyond pretest RF, pretest parenting behavior, and intervention condition. Using a randomized waitlist control trial, and a gold-standard measure of RF, these findings extend previous literature by not only demonstrating a significant intervention effect on key outcomes known to promote attachment security, but also by highlighting the important role that caregiver RF plays in this process.
... Below, attachment theory as presented by COS-P will be discussed and used as a framework to understand the attachment-based elements of PCIT. The COS-P program helps parents understand attachment theory with the use of a graphic that highlights important theoretical concepts and the role of the parent (Marvin et al., 2002;Maxwell et al., 2021) (The graphic is available at https://www.circleofsecurityinternational. com/circle-of-security-model/what-is-the-circle-of-security/). ...
Disruptive behavior difficulties, such as aggression, non-compliance, and emotional outbursts, are common among children exposed to maltreatment. Parent–Child Interaction Therapy (PCIT) is an effective parenting intervention for addressing child behavior difficulties, however, treatment retention and engagement among parents remain a concern in the clinical setting. This paper describes how the delivery of an intervention that teaches attachment theory concepts (Circle of Security-Parenting, COS-P) prior to PCIT can increase engagement and retention among parents of maltreated children and inform new coaching practices. A detailed description of how to extend and integrate COS-P concepts with PCIT for maltreated families using specific strategies is provided. Recommendations, limitations, and next steps for research are presented.
... It contains both educational and therapeutic aspects (Marvin, Cooper, Hoffman & Powell, 2002), and there is considerable use of pre-produced video vignettes of parent-child interactions to illustrate patterns of parental struggles in identifying and responding to young children's attachment needs. Research demonstrates the efficacy of the COSP TM intervention, in terms of facilitating change in parents' ability to cope with their children's emotional needs (Maxwell, McMahon, Huber, Reay, Hawkins & Barnett, 2021). Nonetheless, the sample sizes in some of the studies were small and results were based on non-experimental designs (Maupin, Samuel, Nappi, Heath & Smith, 2017). ...
... It is contended that the PEM measure would be able to capture shifts in the caregiver's quality of interactive behavior with the infant., Moreover, as parental mentalizing seems to be an important capacity involved in the intervention (Maupin et al., 2017;Maxwell et al., 2021), an outcome measure of parental mentalizing would be important to better understand the role parental mentalizing indeed plays in promoting the intervention aims, especially in infancy. Finally, it appears that the practice applied in COSP TM , namely, watching and discussing parent-infant interactions, fosters and promotes the parent's embodied mentalizing capacities. ...
... Building on previous studies using self-reports to measure effects of the COSP TM , we also include self-reports of the mothers' parental stress, parental competence, and self-compassion as secondary outcomes. These three parenting variables are central to parental care and to the parent-infant relationship (e.g., Dubois-Comtois, Moss, Cyr & Pascuzzo, 2013;George & Solomon, 2011), and have been shown in previous work to change in a positive direction following positively COSP TM interventions (e.g., Huber et al., 2018;Maxwell et al., 2021). We hypothesize that mothers participating in the intervention group will demonstrate a significant increase in their global PEM rating, as well as decrease in ECC frequency, in comparison to the control group. ...
Supported by a large body of work demonstrating the impact of infant attachment representations on subsequent development, numerous therapeutic programs have been developed to promote secure attachment, with increasing focus on parental mentalizing. Nonetheless, empirical evidence supporting their effectiveness has yet to be fully established. The current pilot study (N = 24) was designed to evaluate whether and to what extent parents' shifts in parental mentalizing following a brief attachment‐based group intervention, namely circle of security parenting (COSP; Cooper, Hoffman & Powell, 2009) can be captured using the parental embodied mentalizing instrument (PEM; Shai & Belsky, 2017). Compared to a waiting list–control group, this small‐scale study examined whether community‐based low‐risk mothers of infants aged 5–48 months show an increase in their observed PEM capacities following the intervention. Secondary self‐reported outcome variables parental stress, feeling of competence, and self‐compassion. Findings show that PEM ratings improved significantly over time in the COSP group, but not in the control group. Intervention group mother–infant dyads also presented significantly longer embodied interactions communication post intervention compared to the control group. No effects of the COSP on parental stress, competence, or self‐compassion were found. Despite the small sample size, these results tentatively suggest that COSP can improve embodied mentalizing abilities.
... Yalom and Leszcz (2020) describe group therapy as having generally similar core mechanisms of change, including processes that: provide relief from recognizing universality of their experience, instill hope through the observation and narratives of other participants, and provide corrective relational and emotive experiences from the facilitators. Group parenting programs have grown in popularity in community service provision; in particular, attachment informed programs that provide psychoeducational support to enrich parents' understanding of their children's emotional needs, encouraging sensitive, responsive care-giving to promote attachment security (Maxwell et al., 2021;Powell et al., 2013). ...
We report on two preliminary evaluations of a group intervention, targeting vulnerable
infants and their mothers within the first 6-months postpartum. The
Mother–Baby Nurture R program aims to strengthen the developing infant–mother attachment relationship by increasing maternal mentalizing. These studies were undertaken with pre-post evaluations with the mothers of infants under 10-months of age. The mother–infant dyads participated in ten 2-h group sessions. Study one (N = 69 dyads) included self-reported maternal depression, anxiety, and parenting confidence. In study two (N = 27 dyads), parenting stress and reflective functioning were measured by self-report, and reflective functioning coded on the 5 min speech sample (completed by N = 22). Results from study one confirmed a decrease in depression (p < .001, d = .79) and anxiety (p < .001, d = .72) symptoms, and an increase in mothers’ scores for parenting confidence (p < .001, d=−.98). Results from Study Two demonstrated a significant decrease in parenting stress (p < .001, d = .94) and significant improvement in measures of self-report reflective functioning (p = .007, .024; d = .56, .61). These findings are preliminary yet promising indications that this program could be effective in alleviating parenting stress, depression, and anxiety, and improving mother’s reflective functioning and parenting confidence. Further research is needed, with a control group and long-term follow-up assessments.
... The program provides videos and handouts to demonstrate and teach the fundamentals of attachment. Guided reflection and group discussion encourages parents to apply these principles to their own child and their relationship with them (Huber et al., 2015a(Huber et al., , 2015bKohlhoff et al., 2016;Maupin et al., 2017;Maxwell et al., 2021;Sadowski et al., 2022). ...
... Mom Power (MP) Muzik et al. (2015), USA "+" n/a "+" n/a n/a n/a n/a n/a n/a K. Rosenblum et al. (2018), USA "+" n/a n/a n/a n/a n/a n/a n/a n/a Franz et al. (2011), Germany n/a n/a n/a n/a n/a "+" n/a n/a n/a Weihrauch et al. (2014), Germany n/a n/a n/r n/a n/a n/r n/a n/a n/a Huber et al., (2015aHuber et al., ( , 2015b, Australia "+" n/a n/a "+" n/a n/a n/a baseline presenting problems n/a Kohlhoff et al. (2016), Australia "0" n/a n/a n/a "+" n/a n/a n/a n/a Maupin et al. (2017), USA "0" n/a "+" n/a n/a n/a n/a n/a n/a Maxwell et al. (2021), Australia "+" n/a "+" n/a n/a n/a n/a n/a n/a Sadowski et al. (2022), Australia "+" n/a n/a n/a "+" n/a n/a n/a n/a ...
... Use of positive parenting strategies is associated with improved parent-child relationships, improved self-regulatory skills, and reduced disruptive behaviors in young children [46,47]. Positive parenting skills programs have been identified as deliverable by different interventionists, including clinicians and paraprofessionals [48,49]. Attachment-focused interventions are a second promising practice in this domain and have been developed for high-risk families who have experienced significant trauma or adversity [50][51][52]. ...
The rise in child and adolescent mental health concerns has led to the need for an expanded workforce to meet the needs of our nation's families. Peer paraprofessionals (PPs) have proven to be impactful in the areas of adult mental health (MH) and substance use disorders, and for persons with chronic medical conditions. PPs can contribute to addressing child, adolescent, and family MH needs by being deployed in community settings and providing both emotional and tangible support to families and children. Additional use of PPs can address equity gaps in MH services by improving access to support and enhancing the cultural acceptability of MH interventions. A concentrated effort to expand and develop this workforce may help to alleviate the strain on the current MH system. The Georgetown University Infant and Early Childhood Certificate program is a paraprofessional training program that prepares community members to meet the MH needs of families with young children. The authors will describe the results of a qualitative study examining the landscape of peer paraprofessional services in DC that was conducted to support the expansion of the peer workforce to include individuals with expertise in infant and early childhood mental health.
