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RESEARCH ARTICLE
Enhancing parental reflective functioning through early
dyadic interventions: A systematic review and meta-analysis
Jane Barlow1Michelle Sleed2,3Nick Midgley2,3
Department of Social Policy and
Intervention, University of Oxford,
Oxford, UK
Research Department of Clinical,
Educational and Health Psychology,
University College London, London, UK
Anna Freud Centre, London, UK
Correspondence
Jane Barlow,Department of Social Policy
and Intervention, University of Oxford,
Oxford OX ER, UK.
Email: Jane.Barlow@spi.ox.ac.uk
Abstract
Parental reflective functioning (PRF) is an important predictor of infant attach-
ment, and interventions that target parent–infant/toddler dyads who are expe-
riencing significant problems have the potential to improve PRF. A range of
dyadic interventions have been developed over the past two decades, some of
which explicitly target PRF as part of their theory of change, and some that do
not explicitly target PRF, but that have measured it as an outcome. However, no
meta-analytic review of the impact of these interventions has been carried out to
date. The aim of this review was to evaluate the effectiveness of dyadic interven-
tions targeting parents of infant and toddlers, in improving PRF and a number
of secondary outcomes. A systematic review and meta-analysis was conducted in
which key electronic databases were searched up to October . Eligible stud-
ies were identified and data extracted. Data were synthesised using meta-analysis
and expressed as both effect sizes and risk ratios. Six studies were identified pro-
viding a total of participants. The results of six meta-analyses showed a non-
significant moderate improvement in PRF in the intervention group (standard-
ised mean difference [SMD]: –.; % confidence interval [CI] [–., .])
and a significant reduction in disorganised attachment (risk ratio: .; % CI
[., .]). There was no evidence for intervention effects on attachment secu-
rity (odds ratio: .; % CI [., .]), parent–infant interaction (SMD: –.;
% CI [–., .]), parental depression (SMD: –.; % CI [–., .]) or
parental global distress (SMD: –., % CI [–., .]). There were insuf-
ficient data to conduct subgroup analysis (i.e. to compare the effectiveness of
mentalisation-based treatment with non-mentalization-based treatment inter-
ventions). Relational early interventions may have important benefits in improv-
ing PRF and reducing the prevalence of attachment disorganisation. The impli-
cations for future research are discussed.
KEYWORDS
dyadic interventions, meta-analysis, parental reflective functioning, systematic review
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© The Authors. Infant Mental Health Journal published by Wiley Periodicals LLC on behalf of Michigan Association for Infant Mental Health
Infant Ment Health J. ;–. wileyonlinelibrary.com/journal/imhj 1
2BARLOW .
1BACKGROUND
1.1 Early childhood mental health
problems
Infant regulatory disturbances such as excessive crying,
feeding or sleeping difficulties and bonding/attachment
problems have a high prevalence in many countries. For
examples, the Copenhagen Child Cohort Study (n=,)
found a population prevalence of % in regulatory prob-
lems including emotional, behavioural, eating and sleep-
ing disorders, in children aged . years in the region of
% (Skovgaard, ;Skovgaardetal.,). In addi-
tion, a more recent survey on the mental health of chil-
dren and young people in England (Vizard et al., )
found that .% of children aged between and years
of age experience a mental health problem. Furthermore,
some regulatory disturbances are stable over time with
one study suggesting that as many as .% of infants and
toddlers (aged – months) show a continuity of emo-
tional and behavioural problems year after initial pre-
sentation (Briggs-Gowan, Carter, Bosson-Heenan, Guyer,
& Horwitz, ).
Problems of this nature are significant predictors of
longer term difficulties. For example, infant regulatory
problems have a strong association with behavioural prob-
lems, delays in motor, language and cognitive develop-
ment and continuing parent–child relational problems
(DeGangi, Breinbauer, Roosevelt, Porges, & Greenspan,
; Hemmi, Wolke, & Schneider, ). Similarly, inse-
cure and disorganised attachment patterns in infancy are
significant predictors of later psychopathology (Van Ijzen-
doorn, Schuengel, & Bakermans-Kranenburg, ); exter-
nalizing disorders (i.e. conduct and behaviour problems)
(Fearon, Bakermans-Kranenburg, & Van Ijzendoorn, )
and personality disorder (i.e. mental health problems
characterised by enduring maladaptive patterns of emo-
tional regulation, relating and behaviour) (Steele & Siever,
). Individual empirical studies have also found an
association between disorganised attachment and disso-
ciation (Dutra & Lyons-Ruth, ; Lyons-Ruth, );
post-traumatic stress disorder (PTSD) (Macdonald et al.,
) and an increased likelihood of children experienc-
ing symptoms that meet clinical criteria (Borelli et al.,
).
1.2 Aetiology of regulatory problems
Infant regulatory and attachment problems can best be
understood in a relational context, with disturbances
to the parent–child relationship and parental psychoso-
cial adversity being significant risk factors for infant
Key Findings
. The findings of this review show a moderate
trend toward improvement in parental reflec-
tive functioning and a significant improvement
in disorganised attachment following the pro-
vision of a dyadic intervention to high-risk par-
ents in the postnatal period.
. There was no evidence of a significant improve-
ment in parent-infant interaction, parental
mental health, or security of attachment,
although the impact on maternal depression
was large.
. We found very few studies that had mea-
sured parental reflective functioning as part of
the evaluation of early dyadic interventions,
despite evidence regarding its importance in
the intergenerational transmission of attach-
ment.
Statement of relevance
This research suggests that relational early inter-
ventions may have important benefits in improv-
ing parental reflective functioning and reducing
the prevalence of attachment disorganisation, and
indicates the need for further research on this
topic.
emotional, behavioural, eating and sleeping disorders
(Skovgaard et al., ; Skovgaard., ). Infants are born
without the capacity to re-establish emotional regulation
when faced by distress, and thus rely on their primary
carers to help them regulate when they are frightened
or overwhelmed (Beebe et al., ; Tronick & Weinberg,
). The caregiver’s capacity to respond sensitively to the
infant’s needs has long been thought to be a key factor in
the development of secure attachments and infant emo-
tional regulation (Ainsworth, ; Spangler, Schieche,
Ilg, Maier, & Ackermann, ). However, one systematic
review found only modest correlations between maternal
sensitivity and infant attachment security (De Wolff & Van
Ijzendoorn, ), and a later meta-analysis found only a
very small effect size linking parental sensitivity and dis-
organised attachment (Van Ijzendoorn et al., ). These
findings suggested that other factors may play a role in the
development of attachment patterns, prompting a search
for other predictive factors that may underpin attachment
BARLOW . 3
security and resilience. Research since then has focused on
a number of other potential mechanisms including the par-
ent’s capacity for ‘reflective functioning’ (Slade, ; Fon-
agy, Steele, Moran, Steele, & Higgitt, ).
1.3 Reflective functioning
Infants and young children depend on the parent’s inter-
est in their subjective experience, and their capacity to
make the child’s behaviour meaningful by interpreting it
in terms of underlying mental states. This capacity has
been operationalised as ‘parental reflective functioning’
(PRF), and can be understood as a particular manifesta-
tion of mentalizing, that is the process by which we make
sense of each other and ourselves, implicitly and explic-
itly, in terms of subjective states and mental processes.
PRF is seen as underlying sensitive responding by help-
ing parents to mentally put themselves in the place of
the infant and imagine the infant’s experience (Fonagy
& Target, ). To date, few tools have been developed
to assess PRF, the most widely used being the Reflective
Functioning Scale (Fonagy, Target, Steele, & Steele, )
applied to the Parent Development Interview (PDI-RF:
Slade, Bernbach, Grienenberger, Levy, & Locker, )and
the Parental Reflective Functioning Questionnaire (PRFQ;
Luyten et al., ). The PDI-RF scale is a coding system
that is applied to semi-structured interviews with care-
givers, whereas the PRFQ is a parent self-report question-
naire.
Research to date suggests that PRF is strongly asso-
ciated with positive maternal parenting behaviours such
as flexibility and responsiveness, and use of the mother
as a secure base on the part of the infant, whereas low
PRF is associated with emotionally unresponsive mater-
nal behaviours such as withdrawal, hostility and intrusive-
ness (Ensink et al., ; Grienenberger, Kelly, & Slade,
). Consistent with this, the parents’ reflective func-
tioning about their attachment relationships, both past and
present, has been found to be associated with a child’s
secure attachment at months (Grienenberger, Kelly, &
Slade, ; Suchman, DeCoste, Leigh, & Borelli, ). In
an important study of intergenerational patterns of attach-
ment, Fonagy et al. () showed that mothers with a
history of deprivation who are able to acquire a capacity
for reflective functioning were more likely to have infants
with a secure attachment. The value of PRF in the devel-
opment of affect regulation and secure attachment in the
child has been demonstrated in a number of empirical
studies. For example, mothers’ reflective functioning about
their own early attachment relationships has been shown
to be associated with secure and organised infant attach-
ment (Ensink et al., ; Fonagy, Steele., & Steele., ),
and with less externalizing difficulties in children (Ensink,
Bégin, Normandin & Fonagy, ).
In the context of taking care of infants, reflective func-
tioning is thought to promote sensitive parenting by help-
ing the parent look beyond behaviours to consider what
the child is feeling and to inhibit negative interactions
by helping the parent regulate their own negative reac-
tions and remain focused on the infant’s needs. Even when
their baby is distressed, parents with higher PRF are more
likely to be able to remain relatively calm, and not take it
personally when their infant is dysregulated (Schultheis,
Mayes, & Rutherford, ). This in turn helps the infant
to become regulated. Over time, these patterns of feeling
secure in the belief that others will be there when in dis-
tress underlie the feeling that it is safe and rewarding to
express and share feelings with others when distressed,
and in turn be available and supportive of others when they
are in distress (Ensink et al., ).
1.4 Dyadic psychological interventions
and reflective functioning
A focus on mental states is a central part of most psy-
chological therapies, and it has as such been argued that
a range of therapeutic approaches, including psychody-
namic therapy, Cognitive Behavioural Therapy and Dialec-
tical Behaviour Therapy, can improve the capacity for
mentalisation (Fonagy & Adshead, ). This focus on
promoting mentalizing as a shared feature of a range
of psychological therapies has empirical support in rela-
tion to both adult (Goodman, ) and child therapies
(Goodman, Midgley, & Schneider, ). Mentalisation-
based treatment (MBT) was developed as a particular
approach to working with adults with borderline person-
ality disorder (BPD), based on a hypothesis that BPD
could best be understood as a ‘disorder of mentalizing’,
and that a particular therapeutic focus on promoting this
capacity could ameliorate some of the well-known fea-
tures of BPD, such as poor affect regulation and inter-
personal relations. MBT’s success in improving the men-
talizing abilities of patients with BPD (Bateman & Fon-
agy, ,) led to the development of mentalisa-
tion or reflective functioning–based interventions for a
range of clinical populations, including children and fam-
ilies (Midgley & Vrouva, ; Midgley et al., ), as
well as parent–infant/toddler dyads who are experienc-
ing significant social problems (e.g. Minding the Baby
[MTB]: Sadler et al., ) and substance dependency
(the Mother and Toddler Program: Suchman, DeCoste,
McMahon, Rounsaville, & Mayes, ). These interven-
tions focus on enhancing mothers’ capacity to make sense
of the baby’s thoughts, emotions and intentions, thereby
4BARLOW .
laying the foundation for sensitive responsiveness and
secure attachment.
As with therapies that target adults, it seems likely that
there may be many routes to developing PRF in parent–
child dyadic therapies regardless of whether that is the pri-
mary aim of the intervention. For example behaviourally
focused sensitivity interventions such as video feedback,
which provide the mother with the opportunity to watch
herself and her infant/toddler during moments of positive
interaction, are used by the therapist to help the mother
to develop a reflective stance by encouraging her to think
about her infant’s internal world (e.g. the therapist might
say to the mother ‘what do you think your baby was feeling
at that moment’?). This is also true of other attachment and
psychotherapeutic approaches; for example Watch, Wait
and Wonder (Cohen et al., ) is an infant-led therapy
that also encourages the mother to develop a reflective
stance by allowing the baby to take the initiative, by watch-
ing and wondering about this activity, and also through
discussion with the therapist about the feelings that this
arouses in her as a person.
1.5 Rationale for review
A range of dyadic interventions have been developed over
the past two decades, some of which explicitly target PRF
as part of their theory of change, and some that do not
explicitly target PRF, but that have measured it as an out-
come. There has to date been one review of PRF and the
use of clinical interventions to improve it (Camoirano,
), but this included all studies irrespective of the study
design and provided only a narrative summary (i.e. no
meta-analysis of data).
The current review updates the existing review (i.e. in
which searches were completed in July ), and includes
only rigorously conducted studies that have made use of an
RCT design and used a recognised measure of parental RF;
it also provides a meta-analysis of the data, where appro-
priate.
2REVIEW STRATEGY
Published and unpublished studies were identified using
searches of the following online databases: MEDLINE,
PsychINFO, EMBASE CINAHL, ERIC and SSCI. The
stems of the following identifiers or keywords were used
to search the title or abstract either separately or in
conjunction: ‘mentalization’, or ‘mentalisation’, or ‘reflec-
tive functioning*’ or ‘mind-mindedness’ or ‘insightful-
ness’ combined with terms to identify interventions and
RCTs. In order to increase the sensitivity of the search, no
methodological or outcome terms were used. Search terms
were adapted as appropriate for the different databases.
Searches were conducted for papers published in English,
for the entire time periods for which the databases are
available up until October .
2.1 Inclusion/exclusion criteria
Only studies that met the following criteria were included:
Randomised controlled trials (RCTs) evaluating the effec-
tiveness of early interventions targeting parents of infants
or toddlers up to months of age, with the aim
of improving parental functioning and/or parent–infant
interaction. Studies had to have measured PRF as an
outcome using a standardised (i.e. interview-based or
parent-report) instrument. We also extracted data for sec-
ondary outcomes – attachment security or parent–infant
interaction, and parental mental health. Studies were
excluded if they involved the delivery of an interven-
tion without a standard treatment or non-intervention
control group. We did not include unpublished doctoral
dissertations.
Titles and abstracts were reviewed by the lead author,
and final decisions about the papers to be included were
made by two study authors. Two review authors conducted
the ‘Risk of bias’ assessments using The Cochrane Collab-
oration ‘Risk of bias’ assessment tool (Higgins & Green,
), with each domain being assessed as at low, high or
unclear (uncertain) risk of bias.
2.2 Computation of effect sizes
Data were extracted using a standardised data extraction
process. In all cases, we extracted the post-intervention
data, except where the data were reported by age of the
infant, in which case we selected the most immediate post-
intervention point (usually -months of age). Effect sizes
were calculated using Revman (The Nordic Cochrane
Centre, The Cochrane Collaboration, ). Distributions
of scores from primary papers have been presented as odds
ratios (ORs) or standardised mean differences (SMDs),
depending on the nature of the primary data, with % con-
fidence intervals (CIs). Data were combined using a ran-
dom effects model due to the high level of heterogeneity in
outcomes measured. Statistical heterogeneity was assessed
using the Istatistic. The importance of the observed value
of Iis dependent on the magnitude and direction of effects
and strength of evidence for heterogeneity (e.g.p-value
from the χtest, or a CI for I). An Igreater than %
was interpreted as evidence of substantial heterogeneity. A
χtest of heterogeneity was performed and a significance
BARLOW . 5
FIGURE 1 PRISMA flow chart of included studies
level <. was interpreted as evidence of heterogeneity.
Effect sizes were weighted according to the inverse of their
variance to ensure that studies in with the more precise
estimates had a greater influence on the overall effect size
(Hedges & Olkin, ).
3RESULTS
The PRISMA flow chart (Figure ) shows that a total of
records were identified following removal of dupli-
cates, and that these were all screened with full-text
articles being assessed for suitability. A total of six stud-
ies were included (see Table ), the remaining studies
being excluded because they were not RCTs; or they
provided follow-up rather than immediate post interven-
tion data; the children were over months old; they
were an ongoing study; or they provided no quantitative
data.
The included studies targeted a range of parents, includ-
ing high-risk primiparous women with demographic risk
factors (Sadler et al., ; Sleed, Slade, & Fonagy, );
mothers experiencing mental health problems and high
levels of social adversity (Fonagy, Sleed, & Baradon, );
mother–infant dyads in prison (Fonagy et al., )orthose
taking part in substance treatment programs (Suchman
et al., ). Only one of the six studies included toddlers
(Suchman et al., ), the remainder targeted babies <
months.
A number of interventions were delivered, all of which
were dyadic, relational and manualised attachment-based
interventions. Four interventions were explicitly informed
by concepts relating to mentalisation in terms of the under-
lying theory of change (Sadler et al., ; Sleed et al.,
; Suchman et al., ,), the remaining two being
informed by psychoanalytic theory with a primary focus
on changing maternal representations of the infant (Fon-
agy et al., ; Sleed, Baradon, & Fonagy, ).
6BARLOW .
TABLE 1 Included studies
Author Results – Post-intervention
Primary included
studies Population
Intervention and control
conditions Outcome measure used and timing Intervention Control
Fonagy et al., Parents with mental health
problems who were also
experiencing high levels
of social adversity and
their young infants (<
months)
Psychoanalytic
parent–infant
psychotherapy (mean
number of sessions )
(PIP) (n=);
Standard secondary and
specialist primary care
treatment (n=)
Parental representations – The Parent Development
Interview (PDI)
Parent–infant interaction – Emotional Availability Scale
(EAS); Coding Interactive Behaviour System (CIB)
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
Depression – Centre for Epidemiological Studies
Depression Scale (CES-D)
Global distress – Brief Symptom Inventory (BSI)
Master – Mastery Scale (MS)
Mother–Object Relations Scale (MORS)
- Warmth
- Intrusion
Parenting Stress Index (PSI) – total score
Ages and Stages Questionnaire (ASQ: SE)
month follow-up reported (not month)
. (.)
. (.)
. (.)
% (n=)
% (n=)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
–. (.)
. (.)
. (.)
. (.)
% (n=)
% (n=)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Sadler et al ()Primiparous pregnant
women attending
nurse-midwifery group
prenatal care sessions.
Mentalisation-based home
visiting programme
(Minding the Baby -
MTB) (n=)Usual care
control group (n=)
Maternal reflective functioning – The Parent
Development Interview (PDI)
Maternal Depression Centre for Epidemiological
Studies Depression Scale (CES-D)
Global distress – Brief Symptom Inventory (BSI)
Maternal–child relationship – Atypical Maternal
Behaviour Instrument for Assessment and
Classification (AMBIANCE)
- Disrupted
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
AMBIANCE assessed at months; all other measures at
months.
. (.)
. (.)
. (.)
(.%
(n=%)
.% (n=)
.% (n=)
. (.)
. (.)
. (.)
.%
(n=%)
.%
(n=)
.%
(n=)
Slade et al () Young first time mothers
living in underserved,
poor, urban communities
Mentalisation-based home
visiting programme
(Minding the Baby
[MTB]) (n=)
Usual treatment control
group (n=)
Maternal reflective functioning postnatal – Parent
Development Interview – Revised (PDI)
Maternal child relationship – Atypical Maternal
Behaviour Instrument for Assessment and
Classification (AMBIANCE) Scale ( months)
- Disrupted
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Disorganised
. (.)
. (.)
.% (n=)
.% (n=)
. (.)
. (.)
. (.)
. (.)
. (n=)
.% (n=)
. (.)
. (.)
(Continues)
BARLOW . 7
TABLE 1 (Continued)
Author Results – Post-intervention
Primary included
studies Population
Intervention and control
conditions Outcome measure used and timing Intervention Control
Maternal Depression Centre for Epidemiological
Studies Depression Scale (CES-D)
Post-traumatic stress disorder (PTSD) – Mississippi
Scale for the Assessment of PTSD – Civilian Form
Assessed at months infant age
Sleed et al Mothers and babies in
prison
Attachment-based group
intervention (New
Beginnings) (mean
number of session .)
(n=);
Prisoners with no
intervention (n=)
Parental Reflective Functioning – Parent Development
Interview (PDI)
Mother-Infant Interaction – Coding Interactive
Behaviour Scales (CIB) – Dyadic Attunement
Mother Object Relations Scale (MORS) – Warmth
Invasion
Centre for Epidemiological Studies Depression Scale
(CES-D)
All assessed immediately post-intervention
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Suchman et al () Mothers of babies/toddlers
taking part in
substance-treatment
program
-week attachment-based
individual parenting
therapy (The Mothers
and Toddlers Program –
MTP) (n=
Parenting education (PE)
(n=)
Parental reflective functioning – Parent Development
Interview (PDI)
Caregiving behaviour – Nursing Child Assessment
Satellite Training (NCAST) Total Contingency for
Caregiving Behaviour
Depression – Beck Depression Inventory (BDI)
Global Distress – Brief Symptom Inventory (BSI)
Substance Use
Assessed immediately post-intervention
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
. (.)
Suchman et al () Mothers caring for a child
between and
months with a history of
alcohol and drug
addiction
-week mentalisation
based individual therapy
(Mothering from the
Inside Out – MIO)
(n=)
Parent education (PE)
(n=)
Parental reflective functioning – Parent Development
Interview (PDI)
Representations of the child – Working Model of the
Child Interview (WMCI)
Mother-Infant Interaction – Coding Interactive
Behaviour Scales (CIB)
– Maternal sensitivity
Global distress - Brief Symptom Index (BSI)
Attachment – The Strange Situation Procedure (SSP)
- Secure
- Insecure/Disorganised
Assessed at months infant age
. (.)
. (.)
. (.)
. (.)
.%
.%
. (.)
. (.)
. (.)
. (.)
.%
.%
8BARLOW .
MTB (Sadler et al., ) comprises a mentalisation-
based home visiting program, which is delivered by a team
that includes a nurse practitioner and a clinical social
worker. The intervention begins in pregnancy and contin-
ues to the child’s second birthday with an average of
sessions of hr being delivered. The focus of the sessions
depends on the family’s needs at the time of the visit but the
intervention is anchored in the development of a therapeu-
tic relationship (e.g. support, empathy, reassurance and
praise) and a reflective stance (i.e. being curious with the
mother about the child’s and parent’s thoughts and feel-
ings).
The Mothers and Toddlers Program (Suchman et al.,
) and Mothering from the Inside Out (Suchman et al.,
) consist of weeks of individual parenting therapy
designed as an adjunct to outpatient substance abuse treat-
ment. The focus is on the therapeutic alliance, and the use
of a mentalizing stance on the part of the therapist to help
parents begin to understand the way in which their actions
are influenced by thoughts, emotions and intentions.
New Beginnings (Sleed et al., ) and Parent Infant
Psychotherapy (PIP) (Fonagy et al., ) are both rela-
tional interventions that focus on parents’ representations
(internal working models) of the parenting role and the
baby, while at the same time focusing on the baby’s com-
munications, the meaning of these and parents’ responses
in the here and now of the sessions. Past and current rela-
tional experiences may be addressed, but in both interven-
tions the baby is an active participant and central focus
of the sessions. New Beginnings is a group-based eight-
session intervention, whereas PIP is an open-ended inter-
vention that involves a therapist, one or both parents and
the baby.
Figure shows the results of the critical appraisal. Over-
all, the included studies were of moderate quality with
most meeting only three of the quality appraisal criteria.
3.1 Reflective functioning
All six studies included an assessment of RF using the PDI
(Slade et al., ). The meta-analysis included a total of
participants, and the results were not significant but
show a trend favouring the intervention group: Standard-
ised Mean Difference (SMD) –. (% CI [–., .],
p=.) but with significant heterogeneity (χ=.,
df =, p<.; I=%) (see Figure ).
3.2 Mother–infant interaction
All studies included a measure of parental sensitiv-
ity/contingency that could be combined in a meta-analysis
FIGURE 2 Summary of risk of bias of included studies. +Con-
dition was met low risk; −Condition was not met (in this case
because it was not possible to do so) high risk; Remainder not known
unknown risk
providing an overall sample size of . Three studies
used the Coding Interactive Behaviour (CIB) coding (Feld-
man, ) (Fonagy et al., ; Sleed et al., ; Such-
man et al., ); one study used the Nursing Child Assess-
ment Teaching Scale (NCAST; Bernard & Eyers, ;
(Suchman et al., ); and two studies used the Atypi-
cal Maternal Behaviour Instrument for Assessment and
Classification (AMBIANCE, version ; Bronfman, Par-
sons, & Lyons-Ruth, ; Sadler et al., ; Slade et al.,
).
We combined data from the ‘Total Contingency’ domain
of the NCAST, and the overall disruption score on the
AMBIANCE. The results show no evidence of effectiveness
– SMD: –. (% CI [–., .], p=.) and high levels
of heterogeneity (χ=., df =, p=., I=%) (see
Figure ).
3.3 Attachment
Four studies measured attachment, all of which used using
the Strange Situation Procedure (SSP) (Ainsworth, Blehar,
Waters, & Wall, ) (Fonagy et al., ; Sadler et al.,
BARLOW . 9
FIGURE 3 Forest plot of meta-analysis for reflective functioning
FIGURE 4 Forest plot of meta-analysis for mother–infant interaction
; Slade et al., ; Suchman et al., ). A total of
participants were included in the meta-analysis of
secure attachment (see Figure ) and in the meta-
analysis of disorganised attachment (see Figure ). The
results indicate that although rates of secure attachment
were not higher than those of controls (OR: .; % CI
[., .], p=.) with a high level of heterogeneity
(χ=., df =, p=., I=%), the rates of disor-
ganised attachment – the most pathognomonic of attach-
ment classifications – were significantly lower in the inter-
vention groups (OR: .; % CI [., .], p=.)
with low levels of heterogeneity (χ=., df =, p=.,
I=%).
3.4 Parental depression
Five of the included studies measured parental depression.
Four used the Centre for Epidemiological Studies Depres-
sion Scale (CES-D) (Radloff, ) (Fonagy et al., ;
Sadler et al., ; Slade et al., ; Sleed et al., );
and one used the Beck Depression Inventory (BDI) (Beck,
Steer, & Brown, ) (Suchman et al., ). A total of
participants were included, and the results show a
large but non-significant difference favouring the control
group (SMD: –., % CI [–., .], p=.) with an
acceptable level of heterogeneity (χ=., df =, p=.,
I=%) (see Figure ).
3.5 Parental global psychiatric distress
Four of the included studies measured global distress using
the Brief Symptom Inventory (Derogatis, ;(Fonagy
et al., ; Sadler et al., ; Suchman et al., ,).
A total of participants were included, and the results
show a small but non-significant improvement favouring
the intervention group (SMD: –., % CI [–., .]).
There was again a high level of heterogeneity (χ=.,
df =p=., I=%) (see Figure ).
4DISCUSSION
Although other reviews have examined the effectiveness of
early dyadic interventions in improving parental sensitiv-
ity (e.g. Bakermans-Kranenburg, Van Ijzendoorn, & Juffer,
) and attachment security (e.g. Barlow, Bennett, Midg-
ley, Larkin, &Wei, ), this is the first quantitative review
to explicitly focus on PRF as an outcome of early dyadic
interventions.
Despite the evidence regarding the importance of PRF
in promoting sensitive parenting behaviours and infant
attachment security, this review found only six studies
that measured the effectiveness of a dyadic intervention
in improving reflective functioning in parents of infants
and toddlers. A meta-analysis of findings from these six
studies, including parent–infant/toddler dyads, found
10 BARLOW .
FIGURE 5 Forest plot of meta-analysis for secure attachment
FIGURE 6 Forest plot of meta-analysis for disorganised attachment
that there was a non-significant but trend-level improve-
ment in PRF in the intervention group, as assessed by
the Reflective Functioning Scale on the Parent Develop-
ment Interview. PRF is important because of its association
with positive maternal parenting behaviours and infant
attachment security. Furthermore, infants in the interven-
tion group were less likely to be classified as having a dis-
organised attachment. These findings suggest that dyadic
attachment-based interventions can have important long-
term benefits for infants and toddlers.
The fact that intervention effects were found on the PDI-
RF measure is encouraging because the variability on the
FIGURE 7 Forest plot of meta-analysis for maternal depression
FIGURE 8 Forest plot of meta-analysis for maternal global distress
BARLOW . 11
RF scale is limited, with the majority of parents in clinical
populations showing RF levels only at the moderate to low
end of the scale, thereby reducing the potential range and
sensitivity to treatment change (Sleed et al., ). How-
ever, the fact that this systematic review found treatment
effects on PRF in the large pooled sample suggests that this
instrument may be sensitive to treatment change in suffi-
ciently powered studies. Improvements in parental RF that
are numerically small may be clinically very important.
The positive intervention effect on infant attachment
disorganisation is also clinically important because this
group of infants are most at risk of later psychopathol-
ogy (Carlson, ;Holmes,). Although the meta-
analysis did not show any intervention effects on attach-
ment security or parent–infant interactions, these find-
ings may suggest that the interventions were successful
in interrupting pathways to disorganisation through medi-
ating factors other than maternal sensitivity, which only
accounts for a small amount of variance in predicting
attachment disorganisation (Van Ijzendoorn et al., ).
It is now widely accepted that the pathway to disorgani-
sation is marked by a wider range of disrupted parental
behaviours, such as frightening, frightened/disoriented,
role reversed and withdrawal behaviours (Madigan et al.,
). That we were not able to detect impacts on the inter-
action is possibly due to the fact that this meta-analysis
was conducted using combined data from three quite dif-
ferent measures of parent–infant interaction, only one of
which (the AMBIANCE) specifically measures disrupted
maternal behaviours associated with disorganisation. This
may have made it difficult to detect any overall effects
of the interventions on such disrupted behaviours (e.g.
Sadler et al., ). The mechanism of change in such
interventions may not therefore simply be about improv-
ing parents’ sensitive responsiveness to their infants, but
rather helping them to mentalise their own and their
child’s psychological experiences, thereby reducing dis-
rupted behaviours that can lead to attachment disorgani-
sation.
The results of this review did not indicate an overall
intervention effect on parental mental health – depression
or general psychiatric distress. This finding is likely due to
the heterogeneous nature of the various samples included.
The one study that explicitly targeted parents with men-
tal health difficulties (Fonagy et al., ) did in fact show
strong treatment effects on a range of mental health diffi-
culties; this suggests that positive outcomes in this domain
are secondary and probably only likely for parents identi-
fied as experiencing mental health difficulties in the first
place.
The studies varied in the degree to which they focused
on mentalisation with four being explicitly mentalisation-
based interventions (Sadler et al., ; Slade et al., ;
Suchman et al., ,), and the remaining two being
based on a different theory of change regarding parental
internal working models (Fonagy et al., ; Sleed et al.,
). Although the two studies with a different theory of
change (Fonagy et al., ; Sleed et al., ) showed evi-
dence of improved PRF albeit with only borderline signif-
icance, it is highly likely that a focus on internal working
models is also effectively changing PRF.
In terms of the mentalisation-based interventions, fur-
ther thought should be given to whether the way in which
these have been translated into practice in terms of the
program content, frequency and duration and fidelity to
the program model provides the necessary mechanisms
to bring about change in key outcomes such as PRF, sen-
sitivity and child attachment status. One paper (Such-
man, Decoste, Rosenberger, & McMahon, ) that has
explicitly examined the mechanisms involved in the effec-
tive delivery of a mentalisation-based intervention for
mothers and toddlers (Suchman et al., ,) iden-
tified the core model components as being the fostering
of reflective functioning, fostering of representation qual-
ity, and development of attachment-based developmental
guidance. This study found that therapist fidelity to the
unique and essential mentalisation-based practices asso-
ciated with improved maternal reflective functioning and
representation quality (RQ) led to improvement in each of
these domains as well as maternal caregiving behaviour. It
also found that improvement in overall RQ uniquely corre-
sponded to improvement in caregiving behaviour, account-
ing for around % of the variance. Improvement in parental
depression was also found to have unique predictive valid-
ity, accounting for around % of the variance. Overall,
% of the predicated variance in caregiving behaviour was
accounted for by the proposed mechanisms of change.
This review has a number of limitations. We identified
only a small number of studies, most of which had low
numbers of participants; thus, the resulting meta-analyses
were in all likelihood underpowered as reflected by the
moderate to large but nonsignificant results for some of
the secondary outcomes. Furthermore, although there was
significant unexplained statistical heterogeneity, it was not
possible to undertake subgroup analysis to explore this
further. The unexplained heterogeneity may reflect the
diverse and sometimes high risk (e.g. prison population
and substance-dependent women) involved in some of the
included studies. It may also reflect the diverse nature of
the interventions included in the meta-analysis; for exam-
ple the interventions ranged from dyadic home-based pro-
grammes to dyadic clinic-based programmes, and parent
only group and individual interventions. In addition, we
used the immediate post-intervention follow-up data col-
lection point, and few studies had longer term follow-
up data available. This is a major limitation of studies
12 BARLOW .
of very early interventions because it may take time for
reductions in risk factors to translate into improved dyadic
functioning as measured by standardised instruments. For
example, the alleviation of maternal psychiatric sympto-
mology is likely to increase the infant’s capacity to form
a secure attachment to his/her mother (Atkinson et al.,
), but the effects of such improvements may not be
seen behaviourally within the relatively short follow-up
periods of most studies.
It is important that future studies include larger sam-
ples and a consistent set of measures, particularly in the
assessment of variables that might explain how such inter-
ventions effectively disrupt pathways to attachment dis-
organisation. These could include measures of parental
behaviour (such as the AMBIANCE; Bronfman et al.,
) or multidimensional measures of parental represen-
tations (such as the Assessment of Representational Risk)
that explicitly measure factors associated with attachment
disorganisation. In addition, future studies should have
longer follow-up periods to enable a truly developmental
understanding of the impact of early interventions.
The sample of studies included in this review were
also limited by the small number of studies that had
included an evaluation of PRF, leaving open the possi-
bility that other, more effective interventions, may also
be impacting on PRF but without this impact being cap-
tured by research evaluation. For example, many inter-
ventions that are showing high levels of effectiveness in
terms of maternal sensitivity and infant attachment secu-
rity, such as video feedback, have not measured their
impact on PRF (Sleed et al., ). Given the hypoth-
esis that improving PRF may be a shared mechanism
across a range of different intervention programmes (not
only mentalisation-based interventions), it will be impor-
tant for future studies of a wide range of dyadic parent–
infant interventions to find ways to capture their impact
on PRF.
5CONCLUSION
Despite the importance of PRF in terms of the aetiology of
infant regulation and attachment, this review suggests that
such functioning is not yet being routinely assessed when
examining the effectiveness of dyadic interventions for par-
ents and infants or toddlers. The findings also suggest
that dyadic attachment-based interventions are a poten-
tially effective method of improving PRF and reducing the
chances of disorganised attachment in the infant. A range
of factors were discussed with regard to the failure to show
any benefit in terms of the remaining outcomes including
the studies being underpowered and having diverse high-
risk populations, the translation into practice of the pro-
gramme mechanisms and the sensitivity of measures of
change in high-risk groups.
CONFLICT OF INTEREST
One of the authors (MS) was involved in the conduct of one
of the included studies.
ORCID
Jane Barlow https://orcid.org/---
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How to cite this article: Barlow J, Sleed M,
Midgley N. Enhancing parental reflective
functioning through early dyadic interventions: A
systematic review and meta-analysis. Infant Ment
Health J.;–.
https://doi.org/./imhj.
