ArticleLiterature Review

Commentary on Guild et al. (2020): The Importance of Well-Designed Intervention Studies for Advancing Attachment Theory and its Clinical Applications

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Abstract

Guild and colleagues (this issue) report results of a long-term follow up after a randomized trial of the effectiveness of an attachment-theory-informed psychotherapeutic intervention for mothers with depression and their toddlers. Their paper shows the intervention can increase the likelihood of secure attachment in children of depressed mothers and that secure attachment explains more optimal social-emotional functioning in middle childhood in the treated group. This commentary discusses the contribution of the paper by Guild and colleagues and their broader body of work to our evolving understanding of developmental processes underpinning social-emotional competence in children of depressed parents, and to several ongoing controversies in the field: 1) the relevance of attachment-theory-informed interventions in the context of maternal depression; 2) the evidence gap regarding the efficacy and effectiveness of attachment-theory-informed interventions, particularly with respect to sustained benefits; 3) cost-benefits of early interventions; and 4) the need for theory driven research that explains how and under what circumstances attachment is related to later child outcomes.

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In response to the commentaries provided by Chu et al. (2020), Harmon et al. (2020), and McMahon & Maxwell (2020) on our longitudinal follow-up of Child-Parent Psychotherapy (CPP) with mothers with depression and their children, we focus on two domains: accessibility and scalability of CPP and identifying empirically supported mechanisms of change in attachment intervention research. In considering the accessibility and scalability of CPP, we discuss issues related to attrition, length of intervention, and implementation with caregivers with depression. Our discussion of mechanisms of change in attachment interventions explores active comparison conditions, theorized mediators, intervention modalities, assessment methods, and longitudinal research designs. This conversation is intended to highlight important areas for future research in the field of attachment interventions, with the goal of informing clinical and systems-level policies and practices.
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In her rather scathing review of ‘The predictive power of attachment’ (January 2017) Elizabeth Meins takes aim at misguided opinions about attachment that circulate in the policy arena. Certainly, policy makers, in an attempt to secure public money that children, families, and schools badly need, tend to exaggerate claims about the critical importance of early experience. The public discourse however should be sharply differentiated from the scientific discourse. Here we focus on Meins’s critique of attachment research. We list some of her comments about the evidence and show that they are largely mistaken.
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Numerous investigations have demonstrated that child–parent psychotherapy (CPP) promotes secure attachment between mothers and offspring. However, the role of postintervention attachment security as it relates to long-term child outcomes has never been evaluated. The present study therefore examined postintervention attachment status as a mediator of the association between CPP for depressed mothers and their offspring and subsequent peer relations among offspring. Depressed mothers and their toddlers were randomized to receive CPP ( n = 45) or to a control group ( n = 55). A prior investigation with this sample indicated that offspring who received CPP attained significantly higher rates of secure attachment postintervention, whereas insecure attachment continued to predominate for offspring in the control group. The present study examined follow-up data of teachers’ reports on participants’ competence with classroom peers when they were approximately 9 years old. Findings indicated that children who received CPP were more likely to evidence secure attachments at postintervention, which in turn was associated with more positive peer relationships at age 9.
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Disorganized attachment is associated with a host of negative developmental outcomes, leading to a growing interest in preventative interventions targeting the attachment relationship in infancy. The objective of this meta-analysis was to assess the effectiveness of interventions that aimed to prevent or reduce rates of disorganization among children at risk. We performed a literature search using PsycINFO, MEDLINE, and ProQuest databases for studies published between January 1989 and August 2016. All 16 studies (N = 1,360) included a control condition and reported postintervention rates of organized and disorganized attachments assessed by the Strange Situation Procedure. Results showed that, overall, interventions were effective in increasing rates of organized attachment compared to control conditions (d = 0.35, 95% CI [0.10-0.61]). Moderator analyses demonstrated that interventions were more effective (a) in more recently published studies than in older studies, (b) for maltreated samples than nonmaltreated samples, and (c) as children increased in age. These results have important implications for future development, tailoring, and implementation of attachment-based intervention programs.
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The deleterious effects of maternal depression on child emotional and behavioral development are well documented, yet many children exposed to maternal depression experience positive outcomes. The aim of this study was to identify psychosocial factors associated with the emotional–behavioral resilience of four-year-old children of first-time mothers experiencing depressive symptoms across the early childhood period. Data were from 1085 mother–child dyads in the Maternal Health Study collected prospectively at five time-points from pregnancy to child age four. Longitudinal trajectories of maternal depressive symptoms were identified, and children were regarded as resilient or competent if they scored in the normal range on the Total Difficulties subscale of the Strengths and Difficulties Questionnaire. We found that 22% of women had a pattern of moderate to high depressive symptoms, and within this group 78% of their children were identified as resilient. Maternal tertiary education and maternal involvement in home learning activities were unique predictors of children’s resilience. Higher maternal age at the time of pregnancy and financial security were factors associated with positive outcomes for all children. The findings highlight the importance of policy and intervention efforts to strengthen the quality of maternal–child interactions and the home learning environment to promote the emotional and behavioral functioning of children whose mothers are experiencing mental health difficulties in the early years of parenting.
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This study examined the effectiveness of the attachment-based Circle of Security 20-week intervention (COS) in improving parent emotional functioning in 83 families referred to a community clinical service with concerns about their young children’s behavior. Parenting stress and parent psychological symptoms were assessed pre and post intervention and mixed design repeated measures ANOVAs were used to assess change. Severity of presenting problems was considered as a moderator. Results showed clinically significant improvements in both aspects of parent emotional functioning, with changes accounted for by for those with more severe problems at the outset. Improvements for parents were associated with improved child behavior and more positive parent representations of the child and of parenting capacity. Findings suggest the intensive COS intervention is effective in reducing parenting stress and psychological symptoms in parents of children from aged 1–7 years. Questions remain about the mechanisms of change and the direction of effects.
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This study examined the efficacy of the attachment-based Circle of Security 20-week intervention in improving child behavioural and emotional functioning. Participants were 83 parents of children (1-7 years) referred to a clinical service with concerns about their young children's behaviour. Parents (and teachers, when available) completed questionnaires assessing child protective factors, behavioural concerns, internalizing and externalizing problems, prior to and immediately after the intervention. The following were considered as potential moderators: child gender and age, parent representations, reflective functioning, child attachment indices and severity of presenting problems, prior to treatment. Results showed significant improvement for parent ratings of child protective factors, behavioural concerns, internalizing and externalizing symptoms, all ps < .05, and children with more severe problems showed most improvement. Teachers also reported improvements, but change was significant only for externalizing problems (p = .030). Findings suggest Circle of Security is effective in improving child behavioural and emotional functioning in clinically referred children aged 1-7 years.
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Postnatal depression (PND) has negative effects on maternal well-being as well as implications for the mother–infant relationship, subsequent infant development, and family functioning. There is growing evidence demonstrating that PND impacts on a mother’s ability to interact with sensitivity and responsiveness as a caregiver, which may have implications for the infant’s development of self-regulatory skills, making the infant more vulnerable to later psychopathology. Given the possible intergenerational transmission of risk to the infant, the mother–infant relationship is a focus for treatment and research. However, few studies have assessed the effect of treatment on the mother–infant relationship and child developmental outcomes. The main aim of this paper was to conduct a systematic review and investigate effect sizes of interventions for PND, which assess the quality of the mother–infant dyad relationship and/or child outcomes in addition to maternal mood. Nineteen studies were selected for review, and their methodological quality was evaluated, where possible, effect sizes across maternal mood, quality of dyadic relationship, and child developmental outcomes were calculated. Finally, clinical implications in the treatment of PND are highlighted and recommendations made for further research.
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The hypothalamus–pituitary–adrenal axis is particularly sensitive to conditions of maltreatment. In particular, neglected children have shown a flatter slope with lower wake-up values relative to nonneglected children. An intervention, the Attachment and Biobehavioral Catch-Up (ABC), was developed to enhance biological and behavioral regulation in young children at risk for neglect. The effectiveness of the intervention was assessed in a randomized clinical trial for children with involvement with Child Protective Services. Following the intervention, children receiving the ABC intervention ( n = 49) showed more typical cortisol production, with higher wake-up cortisol values and a steeper diurnal slope, than children receiving the control intervention ( n = 51). These results suggest that the ABC intervention is effective in enhancing biological regulation.
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Infants in foster care need sensitive, responsive caregivers to promote their healthy outcomes. The current study examined the effectiveness of the Attachment and Biobehavioral Catch-up Intervention, a short-term, targeted, attachment-based intervention program designed to promote sensitive caregiving behavior among foster mothers. Ninety-six foster mother-infant dyads participated in this study; 44 dyads were assigned to the Attachment and Biobehavioral Catch-up Intervention, and 52 dyads were assigned to a control intervention. Results of hierarchical linear modeling indicated that foster mothers who were assigned to the Attachment and Biobehavioral Catch-up Intervention showed greater improvements in their sensitivity from pre- to postintervention assessment time points when compared with foster mothers who were assigned to the control intervention. We conclude that a short-term, targeted, attachment-based intervention is effective in changing foster mothers' responsiveness to their foster infants, which is critical for foster infants' healthy socioemotional adjustment.
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This chapter reviews what is currently known about the relations between attachment and psychopathology in childhood. This review focuses on the more common externalizing and internalizing disorders of childhood and does not cover developmental disabilities. The chapter begins with general comments on the role of attachment in the development of psychopathology. It then addresses 2 fundamental questions. First, how has the study of attachment contributed to the understanding of childhood disorders? The answer includes a review of how attachment has been linked to childhood difficulties, a discussion of modes of transmission and differential pathways of influence, and the presentation of a heuristic model for understanding the role of attachment relations. The second question is this: How can the field of childhood psychopathology enrich the further study of attachment? The chapter closes with suggestions for future research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This review aims to consider evidence for the impact of maternal psychopathology on the child’s attachment to the mother, and the role of this in mediating the known transmission of developmental and clinical risk to children. The studies reviewed focus on mothers with depression and psychotic disorder. A number of studies (mainly of mothers with depression) demonstrate an association between insecure/disorganised infant attachments and severe maternal psychopathology, whether chronic or current, in the presence of comorbid disorder, maternal insecure or unresolved attachment state of mind, trauma/loss, or low parenting sensitivity. Whether such effects last into middle childhood, however, is unclear. Our understanding of the role of attachment in determining developmental trajectories in this group is at an early stage. Some evidence suggests that attachment may have a role in mediating the intergenerational transmission of internalising and other problems in this group, although the presence of co-occurring contextual risk factors may account for the variability in findings. A multifactorial longitudinal approach is needed to elucidate such factors. However, the current literature highlights which subgroups are likely to be vulnerable and provides an evidence-based rationale for taking an attachment-based approach to intervention in this group.
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This meta-analysis addresses the association between attachment security and each of three maternal mental health correlates. The meta-analysis is based on 35 studies, 39 samples, and 2,064 mother–child pairs. Social–marital support (r = .14; based on 16 studies involving 17 samples and 902 dyads), stress (r = .19; 13 studies, 14 samples, and 768 dyads), and depression (r = .18; 15 studies, 19 samples, and 953 dyads) each proved significantly related to attachment security. All constructs showed substantial variance in effect size. Ecological factors and approach to measuring support may explain the heterogeneity of effect sizes within the social–marital support literature. Effect sizes for stress varied according to the time between assessment of stress and assessment of attachment security. Among studies of depression, clinical samples yielded significantly larger effect sizes than community samples. We discuss these results in terms of measurement issues (specifically, overreliance on self-report inventories) and in terms of the need to study the correlates of change in attachment security, rather than just the correlates of attachment security per se.
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Although the association between maternal depression and adverse child outcomes is well established, the strength of the association, the breadth or specificity of the outcomes, and the role of moderators are not known. This information is essential to inform not only models of risk but also the design of preventive interventions by helping to identify subgroups at greater risk than others and to elucidate potential mechanisms as targets of interventions. A meta-analysis of 193 studies was conducted to examine the strength of the association between mothers' depression and children's behavioral problems or emotional functioning. Maternal depression was significantly related to higher levels of internalizing, externalizing, and general psychopathology and negative affect/behavior and to lower levels of positive affect/behavior, with all associations small in magnitude. These associations were significantly moderated by theoretically and methodologically relevant variables, with patterns of moderation found to vary somewhat with each child outcome. Results are interpreted in terms of implications for theoretical models that move beyond main effects models in order to more accurately identify which children of depressed mothers are more or less at risk for specific outcomes.
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A large body of literature documents the adverse effects of maternal depression on the functioning and development of offspring. Although investigators have identified factors associated with risk for abnormal development and psychopathology in the children, little attention has been paid to the mechanisms explaining the transmission of risk from the mothers to the children. Moreover, no existing model both guides understanding of the various processes' interrelatedness and considers the role of development in explicating the manifestation of risk in the children. This article proposes a developmentally sensitive, integrative model for understanding children's risk in relation to maternal depression. Four mechanisms through which risk might be transmitted are evaluated: (a) heritability of depression; (b) innate dysfunctional neuroregulatory mechanisms; (c) exposure to negative maternal cognitions, behaviors, and affect; and (d) the stressful context of the children's lives. Three factors that might moderate this risk are considered: (a) the father's health and involvement with the child, (b) the course and timing of the mother's depression, and (c) characteristics of the child. Relevant issues are discussed, and promising directions for future research are suggested.
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A narrative story-stem task was used to evaluate the efficacy of two competing, developmentally informed preventive interventions for maltreated preschoolers and their mothers designed to modify children's internal representations of self and of self in relation to other. One hundred and twenty-two mothers and their preschoolers (87 maltreated and 35 nonmaltreated) served as participants. Maltreating families were randomly assigned to either the preschooler-parent psychotherapy (PPP, n = 23), psychoeducational home visitation (PHV, n = 34), or community standard (CS, n = 30) intervention group at baseline. Thirty-five nonmaltreating (NC) families served as comparisons. Narratives were administered to children at baseline and at the postintervention evaluation. Children in the PPP intervention evidenced more of a decline in maladaptive maternal representations over time than PHV and CS children and displayed a greater decrease in negative self-representations than CS, PHV, and NC children. Also, the mother-child relationship expectations of PPP children became more positive over the course of the intervention, as compared to NC and PHV participants. These results suggest that an attachment-theory informed model of intervention (PPP) is more effective at improving representations of self and of caregivers than is a didactic model of intervention directed at parenting skills. Findings are discussed with respect to their implications for developmental theory, with a specific focus on attachment theory and internal working models of relationships.
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Is early preventive intervention effective in enhancing parental sensitivity and infant attachment security, and if so, what type of intervention is most successful? Seventy studies were traced, producing 88 intervention effects on sensitivity (n = 7,636) and/or attachment (n = 1,503). Randomized interventions appeared rather effective in changing insensitive parenting (d = 0.33) and infant attachment insecurity (d = 0.20). The most effective interventions used a moderate number of sessions and a clear-cut behavioral focus in families with, as well as without, multiple problems. Interventions that were more effective in enhancing parental sensitivity were also more effective in enhancing attachment security, which supports the notion of a causal role of sensitivity in shaping attachment.
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Attachment theory and research have offered fundamental insights into early sociopersonality development for the past quarter-century. As its scope expands throughout the life course with applications to developmental psychopathology, however, attachment work faces important conceptual and methodological challenges. These include (a) expanding Bowlby's theoretical formulations to address developmental changes in the nature of attachment organization beyond infancy, the converging influence of multiple attachment relationships, and the nature and development of internal working models: (b) systematically validating assessments of attachment security for older ages in the context of enhanced theoretical understanding of how attachment itself changes with age; (c) new methodological approaches to understanding the relations between attachment and later behavior in light of empirical evidence of stability and change in attachment security and the need for explicit theoretical predictions of the sequelae of attachment security; and (d) more complex conceptualizations of the associations among attachment, contextual risk, and later behavior. These are similar to the challenges facing the original pioneers of attachment theory and research, suggesting that familiar problems must now be reconsidered against the landscape of new applications of attachment work and the insights of contemporary developmental science.
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The Circle of Security intervention uses a group treatment modality to provide parent education and psychotherapy that is based on attachment theory. The purpose of this study was to track changes in children's attachment classifications pre- and immediately postintervention. Participants were 65 toddler- or preschooler- caregiver dyads recruited from Head Start and Early Head Start programs. As predicted, there were significant within-subject changes from disorganized to organized attachment classifications, with a majority changing to the secure classification. In addition, only 1 of the 13 preintervention securely attached children shifted to an insecure classification. Results suggest that the Circle of Security protocol is a promising intervention for the reduction of disorganized and insecure attachment in high-risk toddlers and preschoolers.
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The development of insecure attachment relationships in the offspring of mothers with major depressive disorder (MDD) may initiate a negative trajectory leading to future psychopathology. Therefore, the provision of theoretically guided interventions designed to promote secure attachment is of paramount importance. Mothers who had experienced MDD since their child's birth were recruited (n = 130) and randomized to toddler-parent psychotherapy (DI) or to a control group (DC). Nondepressed mothers with no current or history of major mental disorder and their toddlers also were recruited for a nondepressed comparison group (NC; n = 68). Children averaged 20.34 months of age at the initial assessment. Higher rates of insecure attachment were present in both the DI and the DC groups at baseline, relative to the NC group. At postintervention, at age 36 months, insecure attachment continued to predominate in the DC group. In contrast, the rate of secure attachment had increased substantially in the DI group and was higher than that for the DC and the NC groups. These results demonstrate the efficacy of toddler-parent psychotherapy in fostering secure attachment relationships in young children of depressed mothers.
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Maternal depression is prevalent, and puts children at risk. Little evidence addresses whether treatment for maternal depression is sufficient to improve child outcomes. An experiment was conducted testing whether psychotherapeutic treatment for mothers, suffering from major depression in the postpartum period, would result in improved parenting and child outcomes. Participants included depressed women randomly assigned to interpersonal psychotherapy (n = 60) or to a waitlist (n = 60), and a nondepressed comparison group (n = 56). At 6 months, depressed mothers were less responsive to their infants, experienced more parenting stress, and viewed their infants more negatively than did nondepressed mothers. Treatment affected only parenting stress, which improved significantly but was still higher than that for nondepressed mothers. Eighteen months later, treated depressed mothers still rated their children lower in attachment security, higher in behavior problems, and more negative in temperament than nondepressed mothers. Initial response to treatment did not predict reduced risk for poor child outcomes. Early maternal negative perceptions of the child predicted negative temperament and behavior problems 18 months after treatment. Treatment for depression in the postpartum period should target the mother-infant relationship in addition to the mothers' depressive symptoms.
Article
Although evidence shows that attachment insecurity and disorganization increase risk for the development of psychopathology (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010; Groh, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012), implementation challenges have precluded dissemination of attachment interventions on the broad scale at which they are needed. The Circle of Security–Parenting Intervention (COS-P; Cooper, Hoffman, & Powell, 2009), designed with broad implementation in mind, addresses this gap by training community service providers to use a manualized, video-based program to help caregivers provide a secure base and a safe haven for their children. The present study is a randomized controlled trial of COS-P in a low-income sample of Head Start enrolled children and their mothers. Mothers (N = 141; 75 intervention, 66 waitlist control) completed a baseline assessment and returned with their children after the 10-week intervention for the outcome assessment, which included the Strange Situation. Intent to treat analyses revealed a main effect for maternal response to child distress, with mothers assigned to COS-P reporting fewer unsupportive (but not more supportive) responses to distress than control group mothers, and a main effect for one dimension of child executive functioning (inhibitory control but not cognitive flexibility when maternal age and marital status were controlled), with intervention group children showing greater control. There were, however, no main effects of intervention for child attachment or behavior problems. Exploratory follow-up analyses suggested intervention effects were moderated by maternal attachment style or depressive symptoms, with moderated intervention effects emerging for child attachment security and disorganization, but not avoidance; for inhibitory control but not cognitive flexibility; and for child internalizing but not externalizing behavior problems. This initial randomized controlled trial of the efficacy of COS-P sets the stage for further exploration of “what works for whom” in attachment intervention.
Article
After decades of research on early attachment relationships, questions remain concerning whether the evidence supports claims made by attachment theory, in particular, that variation in early attachment predicts children's developmental adaptation or maladaptation, and that characteristics of children's temperament does not determine attachment. To evaluate these claims, we conducted meta-analyses on early attachment and children's social competence with peers, externalizing problems, internalizing symptoms, and temperament. In this article, we summarize our findings, which support attachment theory—though we note caveats. We also call for new measurement models, a focus on mediating and moderating mechanisms, and multisite replications.
Article
Parent-infant psychotherapy (PIP) is a dyadic intervention that works with parent and infant together, with the aim of improving the parent-infant relationship and promoting infant attachment and optimal infant development. PIP aims to achieve this by targeting the mother’s view of her infant, which may be affected by her own experiences, and linking them to her current relationship to her child, in order to improve the parent-infant relationship directly. OBJECTIVES 1. To assess the effectiveness of PIP in improving parental and infant mental health and the parent-infant relationship. 2. To identify the programme components that appear to be associated with more effective outcomes and factors that modify intervention effectiveness (e.g. programme duration, programme focus). SEARCH METHODS We searched the following electronic databases on 13 January 2014: Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS Citation Index, Science Citation Index, ERIC, and Sociological Abstracts. We also searched the metaRegister of Controlled Trials, checked reference lists, and contacted study authors and other experts. SELECTION CRITERIA Two review authors assessed study eligibility independently. We included randomised controlled trials (RCT) and quasi-randomised controlled trials (quasi-RCT) that compared a PIP programme directed at parents with infants aged 24 months or less at study entry, with a control condition (i.e. waiting-list, no treatment or treatment-as-usual), and used at least one standardised measure of parental or infant functioning. We also included studies that only used a second treatment group. DATA COLLECTION AND ANALYSIS We adhered to the standard methodological procedures of The Cochrane Collaboration. We standardised the treatment effect for each outcome in each study by dividing the mean difference (MD) in post-intervention scores between the intervention and control groups by the pooled standard deviation. We presented standardised mean differences (SMDs) and 95% confidence intervals (CI) for continuous data, and risk ratios (RR) for dichotomous data. We undertook meta-analysis using a random-effects model. MAIN RESULTS We included eight studies comprising 846 randomised participants, of which four studies involved comparisons of PIP with control groups only. Four studies involved comparisons with another treatment group (i.e. another PIP, video-interaction guidance, psychoeducation, counselling or cognitive behavioural therapy (CBT)), two of these studies included a control group in addition to an alternative treatment group. Samples included women with postpartum depression, anxious or insecure attachment, maltreated, and prison populations. We assessed potential bias (random sequence generation, allocation concealment, incomplete outcome data, selective reporting, blinding of participants and personnel, blinding of outcome assessment, and other bias). Four studies were at low risk of bias in four or more domains. Four studies were at high risk of bias for allocation concealment, and no study blinded participants or personnel to the intervention. Five studies did not provide adequate information for assessment of risk of bias in at least one domain (rated as unclear). Six studies contributed data to the PIP versus control comparisons producing 19 meta-analyses of outcomes measured at post-intervention or follow-up, or both, for the primary outcomes of parental depression (both dichotomous and continuous data); measures of parent-child interaction (i.e. maternal sensitivity, child involvement and parent engagement; infant attachment category (secure, avoidant, disorganised, resistant); attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and secondary outcomes (e.g. infant cognitive development). The results favoured neither PIP nor control for incidence of parental depression (RR 0.74, 95% CI 0.52 to 1.04, 3 studies, 278 participants, low quality evidence) or parent-reported levels of depression (SMD -0.22, 95% CI -0.46 to 0.02, 4 studies, 356 participants, low quality evidence). There were improvements favouring PIP in the proportion of infants securely attached at post-intervention (RR 8.93, 95% CI 1.25 to 63.70, 2 studies, 168 participants, very low quality evidence); a reduction in the number of infants with an avoidant attachment style at post-intervention (RR 0.48, 95% CI 0.24 to 0.95, 2 studies, 168 participants, low quality evidence); fewer infants with disorganised attachment at post-intervention (RR 0.32, 95% CI 0.17 to 0.58, 2 studies, 168 participants, low quality evidence); and an increase in the proportion of infants moving from insecure to secure attachment at post-intervention (RR 11.45, 95% CI 3.11 to 42.08, 2 studies, 168 participants, low quality evidence). There were no differences between PIP and control in any of the meta-analyses for the remaining primary outcomes (i.e. adverse effects), or secondary outcomes. Four studies contributed data at post-intervention or follow-up to the PIP versus alternative treatment analyses producing 15 meta-analyses measuring parent mental health (depression); parent-infant interaction (maternal sensitivity); infant attachment category (secure, avoidant, resistant, disorganised) and attachment change (insecure to secure, stable secure, secure to insecure, stable insecure); infant behaviour and infant cognitive development. None of the remaining meta-analyses of PIP versus alternative treatment for primary outcomes (i.e. adverse effects), or secondary outcomes showed differences in outcome or any adverse changes. We used the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach to rate the overall quality of the evidence. For all comparisons, we rated the evidence as low or very low quality for parental depression and secure or disorganised infant attachment. Where we downgraded the evidence, it was because there was risk of bias in the study design or execution of the trial. The included studies also involved relatively few participants and wide CI values (imprecision), and, in some cases, we detected clinical and statistical heterogeneity (inconsistency). Lower quality evidence resulted in lower confidence in the estimate of effect for those outcomes. AUTHORS' CONCLUSIONS Although the findings of the current review suggest that PIP is a promising model in terms of improving infant attachment security in high-risk families, there were no significant differences compared with no treatment or treatment-as-usual for other parent-based or relationship-based outcomes, and no evidence that PIP is more effective than other methods of working with parents and infants. Further rigorous research is needed to establish the impact of PIP on potentially important mediating factors such as parental mental health, reflective functioning, and parent-infant interaction.
Article
Circle of Security is an attachment theory based intervention that aims to promote secure parent-child attachment relationships. Despite extensive uptake of the approach, there is limited empirical evidence regarding efficacy. The current study examined whether participation in the 20-week Circle of Security intervention resulted in positive caregiver-child relationship change in four domains: caregiver reflective functioning; caregiver representations of the child and the relationship with the child; child attachment security, and attachment disorganization. Archived pre- and postintervention data were analyzed from 83 clinically referred caregiver-child dyads (child age: 13-88 months) who completed the Circle of Security intervention in sequential cohorts and gave permission for their data to be included in the study. Caregivers completed the Circle of Security Interview, and dyads were filmed in the Strange Situation Procedure before and after the intervention. Results supported all four hypotheses: Caregiver reflective functioning, caregiving representations, and level of child attachment security increased after the intervention, and level of attachment disorganization decreased for those with high baseline levels. Those whose scores were least optimal prior to intervention showed the greatest change in all domains. This study adds to the evidence suggesting that the 20-week Circle of Security intervention results in significant relationship improvements for caregivers and their children.
Article
Early secure maternal-child attachment relationships lay the foundation for children's healthy social and mental development. Interventions targeting maternal sensitivity and maternal reflective function during the first year of infant life may be the key to promoting secure attachment. We conducted a narrative systematic review and meta-analysis to examine the effectiveness of interventions aimed at promoting maternal sensitivity and reflective function on maternal-child attachment security, as measured by the gold standard Strange Situation (M. Ainsworth, M. Blehar, B. Waters, & S. Wall, 1978) and Q-set (E. Waters & K. Deane, 1985). Studies were identified from electronic database searches and included randomized or quasi-randomized controlled parallel-group designs. Participants were mothers and their infants who were followed up to 36 months' postpartum. Ten trials, involving 1,628 mother-infant pairs, were included. Examination of the trials that provided sufficient data for combination in meta-analysis revealed that interventions of both types increased the odds of secure maternal-child attachment, as compared with no intervention or standard intervention (n = 7 trials; odds ratio: 2.77; 95% confidence interval: 1.69, 4.53, n = 965). Of the three trials not included in the meta-analyses, two improved the likelihood of secure attachment. We conclude that interventions aimed at improving maternal sensitivity alone or in combination with maternal reflection, implemented in the first year of infants' lives, are effective in promoting secure maternal-child attachments. Intervention aimed at the highest risk families produced the most beneficial effects. © 2015 Michigan Association for Infant Mental Health.
Article
Importance A number of interventions for at-risk children have shown benefits for children’s hypothalamic-pituitary-adrenal axis activity immediately after treatment. It is critical to examine whether such changes are maintained over time, given that physiological regulation is implicated in later mental and physical health outcomes.Objective To examine whether differences in diurnal cortisol production between children receiving the active parenting intervention and children in the control group persisted at a preschool follow-up (approximately 3 years following intervention).Design, Setting, and Participants Between-subject comparison of cortisol patterns among 2 groups of children (experimental and control groups) involved with Child Protective Services following allegations of neglect. The participants included 115 children (43.5% female) between 46.5 and 69.6 months of age (mean [SD], 50.73 [4.98] months) who had been previously randomly assigned to either the Attachment and Biobehavioral Catch-up (ABC) intervention (n = 54) or the control intervention (n = 61).Interventions The experimental ABC intervention focused on 3 aims: increasing parental nurturance to child distress, increasing synchronous interactions, and decreasing frightening parental behavior. The control intervention provided educational information about child development to parents. Both interventions were manualized and involved 10 sessions implemented by a trained parent coach in the families’ homes or other places of residence.Main Outcomes and Measures Salivary cortisol samples collected at waking and bedtime for children on 3 separate days.Results Analyses revealed significant differences in cortisol production at the preschool follow-up, such that children in the ABC intervention group showed more typical patterns of cortisol production than children in the control intervention group. Specifically, children in the ABC group exhibited higher mean (SD) log-transformed morning levels than children in the control group (−0.87 [0.45] vs −1.05 [0.43] μg/dL, respectively [to convert to nanomoles per liter, multiply by 27.588]; β = 0.18; P = .03). Bedtime cortisol levels did not differ significantly between the ABC and DEF groups (mean [SD], −1.19 [0.49] vs −1.17 [0.48] μg/dL, respectively; β01 = −0.01; P = .87). Those in the ABC group showed a steeper decline in cortisol across the day (mean, −0.31 μg/dL) than those in the control group, who showed a blunted cortisol rhythm (mean, −0.12 μg/dL) (β = −0.19; P = .02).Conclusions and Relevance Differences in cortisol production between the experimental and control groups persisted at the preschool follow-up and resembled differences initially observed 3 months following intervention. This is encouraging evidence that the ABC intervention for Child Protective Services–referred children may have long-lasting effects on a physiological stress system critical for health and adjustment.Trial Registration clinicaltrials.gov Identifier: NCT02093052
Article
Research has informed practice since the origins of developmental psychology, but only recently has basic science and practice begun to be consistently integrated with one another. In addition, considerable research documents the utility of empirically-supported interventions, yet it has been difficult to implement such interventions outside of the research context. This paper describes two Randomized Clinical Trials (RCTs) for maltreated infants and preschoolers as an example of successful community, funder, and researcher partnerships. Key strengths and challenges involved in designing and conducting the studies are discussed, and the necessity of considering the developmental and cultural appropriateness of empirically-supported interventions is highlighted. Programs designed to provide data on the effectiveness of interventions initially evaluated in RCTs are presented. These initiatives indicate that it is possible to create successful evidence-based interventions, even within the complex world of the child welfare system. These studies provide information on developmental and outcome intervention differences that contribute to the scientific literature and have real-world implications for policy makers, funders, and ultimately, for children.
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Infant disorganized attachment is a major risk factor for problematic stress management and later problem behavior. Can the emergence of attachment disorganization be prevented? The current narrative review and quantitative meta-analysis involves 15 preventive interventions (N = 842) that included infant disorganized attachment as an outcome measure. The effectiveness of the interventions ranged from negative to positive, with an overall effect size of d = 0.05 (ns). Effective interventions started after 6 months of the infant's age (d = 0.23). Interventions that focused on sensitivity only were significantly more effective in reducing attachment disorganization (d = 0.24) than interventions that (also) focused on support and parent's mental representations (d = −0.04). Most sample characteristics were not associated with differences in effect sizes, but studies with children at risk were more successful (d = 0.29) than studies with at-risk parents (d = −0.10), and studies on samples with higher percentages of disorganized attachment in the control groups were more effective (d = 0.31) than studies with lower percentages of disorganized children in the control group (d = −0.18). The meta-analysis shows that disorganized attachments may change as a side effect of sensitivity-focused interventions, but it also illustrates the need for interventions specifically focusing on the prevention of disorganization.
Article
Research has informed practice since the origins of developmental psychology, but only recently has basic science and practice begun to be consistently integrated with one another. In addition, considerable research documents the utility of empirically-supported interventions, yet it has been difficult to implement such interventions outside of the research context. This paper describes two randomized clinical trials (RCTs) for maltreated infants and preschoolers as an example of successful community, funder, and researcher partnerships. Key strengths and challenges involved in designing and conducting the studies are discussed, and the necessity of considering the developmental and cultural appropriateness of empirically-supported interventions is highlighted. Programs designed to provide data on the effectiveness of interventions initially evaluated in RCTs are presented. These initiatives indicate that it is possible to create successful evidence-based interventions, even within the complex world of the child welfare system. These studies provide information on developmental and outcome intervention differences that contribute to the scientific literature and have real-world implications for policy makers, funders, and ultimately, for children.
Article
Young children who have experienced early adversity are at risk for developing disorganized attachments. The efficacy of Attachment and Biobehavioral Catch-up (ABC), an intervention targeting nurturing care among parents identified as being at risk for neglecting their young children, was evaluated through a randomized clinical trial. Attachment quality was assessed in the Strange Situation for 120 children between 11.7 and 31.9 months of age (M = 19.1, SD = 5.5). Children in the ABC intervention showed significantly lower rates of disorganized attachment (32%) and higher rates of secure attachment (52%) relative to the control intervention (57% and 33%, respectively). These results support the efficacy of the ABC intervention in enhancing attachment quality among parents at high risk for maltreatment.
Conference Paper
Also published as: Juffer, F, Bakermans-Kranenburg, MJ, Klein Velderman, M, Stolk, MN, Van Zeijl, J, Alink, LRA, Mesman, J, Van IJzendoorn, MH (2006). Attachment-based inteventions in infancy: Promoting positive parenting with video feedback. Infant Mental Health Journal, 27 (3), No. 55.
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This study addresses the extent to which insecure and disorganized attachments increase risk for externalizing problems using meta-analysis. From 69 samples (N = 5,947), the association between insecurity and externalizing problems was significant, d = 0.31 (95% CI: 0.23, 0.40). Larger effects were found for boys (d = 0.35), clinical samples (d = 0.49), and from observation-based outcome assessments (d = 0.58). Larger effects were found for attachment assessments other than the Strange Situation. Overall, disorganized children appeared at elevated risk (d = 0.34, 95% CI: 0.18, 0.50), with weaker effects for avoidance (d = 0.12, 95% CI: 0.03, 0.21) and resistance (d = 0.11, 95% CI: -0.04, 0.26). The results are discussed in terms of the potential significance of attachment for mental health.
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This article reviews the various literatures on the adjustment of children of depressed parents, difficulties in parenting and parent-child interaction in these families, and contextual factors that may play a role in child adjustment and parent depression. First, issues arising from the recurrent, episodic, heterogeneous nature of depression are discussed. Second, studies on the adjustment of children with a depressed parent are summarized. Early studies that used depressed parents as controls for schizophrenic parents found equivalent risk for child disturbance. Subsequent studies using better-defined samples of depressed parents found that these children were at risk for a full range of adjustment problems and at specific risk for clinical depression. Third, the parenting difficulties of depressed parents are described and explanatory models of child adjustment problems are outlined. Contextual factors, particularly marital distress, remain viable alternative explanations for both child and parenting problems. Fourth, important gaps in the literature are identified, and a consistent, if unintentional, "mother-bashing" quality in the existing literature is noted. Given the limitations in knowledge, large-scale, long-term, longitudinal studies would be premature at this time.
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In this paper the effectiveness of preventive or therapeutic interventions aiming at enhancing parental sensitivity and children's attachment security is addressed. Sixteen pertinent studies have been reviewed, and 12 studies have been included in a quantitative meta-analysis (N = 869). Results show that interventions are more effective in changing parental insensitivity (d = .58) than in changing children's attachment insecurity (d = .17). Longer, more intensive, and therapeutic interventions appear to be less effective than short-term preventive interventions. Interventions which are effective at the behavioral level may not necessarily lead to changes in insecure mental representations of the parents involved. The implications of changes at the behavioral level (sensitivity; attachment) without accompanying changes at the representational level will be discussed.
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We analysed results from seven American and British studies that compared groups of mothers with and without clinically diagnosed depression, and assessed the attachment category of their infants (under 3 years) using the Strange Situation. The samples were predominantly middle-income and free of risk factors other than maternal depression. Meta-analysis using loglinear modelling and standardised residuals showed that the effect of depression on the distribution of infants' attachment was statistically heterogeneous. However, after removing one outlier study, the effect of depression was homogeneous across the remaining six studies. Infants of depressed mothers showed significantly reduced likelihood of secure (B) attachment and marginally raised likelihood of avoidant (A) and disorganised (D) attachment. The first two effects varied considerably in magnitude between studies, whereas the increase in disorganised attachment, from 17% to 28% on average, was consistent.
Article
The efficacy of toddler-parent psychotherapy (TPP) as a preventive intervention for promoting secure attachment in the offspring of depressed mothers was evaluated, 63 mothers with major depressive disorder being randomly assigned to TPP (n = 27) or to a no treatment group (n = 36) and compared with a control group (n = 45) of women with no current or past mental disorder. At baseline, comparable and higher rates of attachment insecurity were found in the two depressed offspring groups as compared with the non-depressed control group. At the post-treatment follow-up, offspring in the intervention group attained rates of secure attachment that were comparable with those of youngsters in the non-depressed control group. In contrast, the children in the depressed control group continued to demonstrate a greater rate of attachment insecurity than children in the non-depressed control group. The findings support the efficacy of an attachment-theory based model of intervention for fostering developmental competence in the offspring of depressed mothers.
Article
Empirical studies have revealed a significant, but modest association between maternal depression and insecure mother-child attachment. Across studies, however, a substantial number of mothers with depression are able to provide a sensitive caretaking environment for their children. This paper aimed to explore whether a mother's own state of mind regarding attachment moderated the association between postpartum depression and insecure mother-child attachment. Mothers (n = 111), mainly middle-class mothers, and their infants participated in a longitudinal study of postnatal depression, maternal attachment state of mind and child attachment. Depression was assessed using a diagnostic interview (at 4 and 12 months) and symptom checklists (at 4, 12 and 15 months). The Adult Attachment Interview was conducted at 12 months and the Strange Situation procedure at 15 months. Mothers diagnosed as depressed were more likely to have an insecure state of mind regarding attachment. Infants of chronically depressed mothers were more likely to be insecurely attached; however, the relationship between maternal depression and child attachment was moderated by maternal attachment state of mind. Results are discussed with reference to resiliency factors for women with postnatal depression and implications for intervention.
Article
This prospective study aimed to determine predictors of persistent postnatal depression between child age one and four years, in a sample of mothers already identified as having a high incidence of postnatal depression at four months after birth and a relatively high prevalence of symptoms of depression at child age one year. Data (self-report questionnaires and interview) were initially collected from 127 mothers of first-born infants recruited from a parent-craft hospital at four months postpartum. Women again completed questionnaires and interviews one year after the birth. Persistence of depression between one and four years was assessed by symptom checklists and diagnostic interview. Ninety-two mothers (72%) of the original sample participated at four years. Eleven women who had first onset of depression after one year were excluded from analyses. Thirty-eight percent of the remaining sample (56% of those diagnosed with depression at 4 months) reported ongoing depression between one and four years. Severity of depressive symptoms at four months and maternal state of mind regarding attachment (assessed at 1 year) were significant predictors of persistent depression. Women with an insecure state of mind regarding attachment at one year were seven times more likely to report ongoing depression. Findings confirm that postnatal depression is ongoing for many women and that vulnerability to persistent depression needs to be viewed in the context of inter-generational family problems. Severity of symptoms at four months postpartum can be used to identify those mothers most at risk of persistent depression.
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