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Review: Attachment and attachment-related outcomes in preschool children – a review of recent evidence

Jane Barlow1, Anita Schrader-McMillan1, Nick Axford2, Zoe Wrigley2, Shreya Sonthalia2, Tom Wilkinson2, Michaela Rawsthorn2, Alex Toft3 & Jane Coad3

1Health Services Research Unit, Warwick Medical School, University of Warwick, Medical School Building, Gibbet Hill Road, Coventry CV4 7AL, UK. E-mail: [email protected] 2Dartington Social Research Unit, Totnes, UK 3Centre for Children and Families Applied Research (CCFAR), Coventry University, Coventry, UK

Background: Secure attachment is associated with optimal outcomes across all domains in childhood, and both insecure and disorganised attachment are associated with a range of later psychopathologies. Insecure and dis- organised attachment are common, particularly in disadvantaged populations, pointing to the need to iden- tify effective methods of addressing such problems. Aims: This paper presents the findings of a review of secondary and primary studies evaluating the effectiveness of interventions aimed at improving attachment and attachment-related outcomes on a universal, targeted or indicated basis, which was undertaken as part of an update of the evidence base for a UK-based national programme targeting children aged 0–5 years (Healthy Child Programme). Method: A systematic search of key electronic databases was undertaken to iden- tify secondary and primary sources of data that addressed the research question and that had been published between 2008 and 2014; search sources included Cochrane Collaboration, NICE, EPPI Centre, Campbell Collabo- ration and PubMed, PsychInfo, CINAHL databases. Findings: Six systematic reviews and 11 randomised con- trolled trials were identified that had evaluated the effectiveness of universal, selective or indicated interventions aimed at improving attachment and attachment-related outcomes in children aged 0–5 years. Potentially effective methods of improving infant attachment include parent–infant psychotherapy, video feedback and mentalisation-based programmes. Methods that appear to be effective in improving attach- ment-related outcomes include home visiting and parenting programmes. Conclusions: A number of methods of working to promote attachment and attachment-related outcomes in preschool children are now being rec- ommended as part of the Healthy Child Programme. The implications in terms of the role and contribution of practitioners working in child and adolescent mental health service are discussed.

Key Practitioner Message

• Insecure and disorganised attachment are associated with later psychopathology. • Both types of attachment have a high prevalence, particularly in disadvantaged and maltreated children. • A number of methods of working show promise in terms of improving attachment security and reducing

insecure and disorganised attachment in a range of high-risk parent–child dyads, including parent–infant psychotherapy, programmes involving the use of video feedback and mentalisation-based programmes.

• These interventions should be provided by practitioners working in child and adolescent mental health ser- vices to parents and children under 5 years of age, where children are experiencing problems that may be underpinned by attachment difficulties.

Keywords: Healthy Child Programme; 0–5 years; intervention; attachment; parental sensitivity; early years

Background

Secure attachment has been shown to be significantly associated with a range of improved outcomes for chil- dren across all domains of functioning, including emo- tional, social and behavioural adjustment, scholastic

achievement and peer-rated social status (Sroufe, 2005), while both insecure and disorganised attachment are associated with a range of later problems (van der Voort, Juffer, & Bakermans-Kranenburg, 2014) including exter- nalising disorders (Fearon, Bakermans-Kranenburg, Van Ijzendoorn, Lapsley, & Roisin, 2010), dissociation (Lyons- Ruth, Yellin, Melnick, & Atwood, 2005), PTSD (MacDon- ald et al., 2008) and personality disorder (Steele & Siever, 2010). For example, one longitudinal study of children with disorganised attachment at 1-year of age found that

The copyright line for this article was changed on 7 January 2016 after original online publication.

Child and Adolescent Mental Health 21, No. 1, 2016, pp. 11–20 doi:10.1111/camh.12138

by 6 years of age the children were showing signs of con- trolling behaviours towards their parents, avoidance of their parents, dissociative symptoms, behavioural/oppo- sitional problems, emotional disconnection, aggression towards peers and low social competence in preschool (Lieberman & Amaya-Jackson, 2005).

Research conducted over the last few decades sug- gests that only two thirds of children are securely attached, and that disorganised attachment has a preva- lence of 15–19% in population samples (De Wolff & Van Ijzendoorn, 1997), up to 40% in disadvantaged popula- tions (Weinfield, Whaley, & Egeland, 2004) and 80% in maltreated populations (Cyr, Euser, Bakermans-Kra- nenburg, & Van Ijzendoorn, 2010).

An early systematic review of 12 studies found that parental sensitivity was a significant predictor of attach- ment security (De Wolff & Van Ijzendoorn, 1997). How- ever, such sensitivity only explained around one third of the total variance, and recent research has identified the importance of the specific nature or quality of the attunement or contingency between parent and infant (Beebe et al., 2010), the parent’s capacity for what has been termed ‘maternal mind-mindedness’ (Meins, Fernyhough, Fradley, & Tuckey, 2001) or ‘reflective function’ (Slade, Grienenberger, Bernbach, Levy, & Locker, 2005), and a range of anomalous forms of par- ent–infant interaction (Lyons-Ruth et al., 2005).

Early life experiences including, but not limited to, parenting behaviours and impact on the child’s rapidly developing neurological system (Boyce, Sokolowski, & Robinson, 2012). Social adversity disrupts developing brain architecture and other organ systems and regula- tory functions, with a range of long-term consequences in terms of children’s learning (i.e. linguistic, cognitive and socio-emotional skills), behaviour (adaptive vs. mal- adaptive responses) and physiology (i.e. hyper-respon- sive/chronically activated stress response; Shonkoff, Boyce, & McEwen, 2009).

The provision of support for parenting with the aim of improving children’s social, emotional and beha- vioural wellbeing is a central part of the UK govern- ment-funded Healthy Child Programme (HCP; Shribman & Billingham, 2009, which is the key univer- sal public health service for improving the health and wellbeing of children through health and development reviews, health promotion, parenting support and screening and immunisation programmes. Its goals are to identify and treat problems early, help parents to care well for their children, to change health beha- viours and to protect against preventable diseases. The programme is evidence-based, and aims to prevent problems in child health and development, and con- tribute to a reduction in health inequalities. The evi- dence underpinning the current programme for 0- to 5- year-olds was recently updated (Axford et al., 2015) and this paper presents the findings of that review in terms of interventions that are aimed at improving attachment or attachment-related parenting behaviour.

Method

A review was undertaken of a range of electronic databases to identify systematic reviews of interventions that met the agreed inclusion criteria. The review also involved a search for ran- domised controlled trials (RCTs) published during the relevant

period that met the inclusion criteria and that had not been included in the existing reviews. The search was undertaken as part of an update of the HCP (Shribman & Billingham, 2009), and therefore focused explicitly on evidence published since the previous update (Barlow et al., 2008).

Inclusion and exclusion criteria Only studies published in English that met the following inclusion criteria were included:

• Study design – systematic reviews, reviews of reviews and RCTs.

• Intervention – any attachment-based intervention or inter- ventions provided on an individual or group basis that was, and aimed at improving attachment status or attachment- related outcomes (listed below).

• Population – parents of preschool children.

• Outcomes – attachment status or attachment-related out- comes including parent–infant/toddler interaction; parental sensitivity or reflective functioning; parental emotional availability or mental health; child emotional or social adjustment.

• Years – a search was undertaken for systematic review stud- ies during the period January 2008 to July 2014 and for RCTs that were not included in the systematic reviews dur- ing the period January 2009 to November 2014.

The following were excluded from the current report:

• Studies of sensitivity-based parenting interventions for pre- term infants (Benzies, Magill-Evans, Hayden, & Ballantyne, 2013; Evans, Whittingham, Sanders, Colditz, & Boyd, 2014) and all parenting programmes not explicitly targeting the above attachment related criteria.

Search terms and method In order to identify studies meeting the inclusion criteria, rele- vant databases were searched, including those of key organisa- tions (e.g. Cochrane Collaboration, NICE, EPPI Centre, Campbell Collaboration) and key electronic health, social science and education databases (e.g. PubMed, PsychInfo, CINAHL). A list of search terms that were used can be found in the full report (Axford et al., 2015). Experts in the respective fields were consulted and asked to identify any systematic reviews or primary studies that were not identified by the search of electronic databases.

Data synthesis Data from each of the included reviews and primary studies are presented using a narrative that both describes the intervention and summarises the results from the individual studies.

Results

A total of six systematic reviews and 11 RCTs meeting the criteria were identified. Table 1 provides a summary of the included studies. Results are presented first for impact on attachment and second for impact on attach- ment-related outcomes.

Attachment Six of the included papers provided an evaluation of the effectiveness of an intervention in changing infant attachment status (Table 1).

A systematic review of the effectiveness of parent–in- fant/toddler psychotherapy (PIP) included eight RCTs comparing the effectiveness of PIP with a no-treatment control group (four studies) or comparing PIP with other kinds of treatment (including an infant-led model of par-

12 Jane Barlow et al. Child Adolesc Ment Health 2016; 21(1): 11–20

T a b le

1 . S u m m a ry

o f in cl u d e d in te rv e n ti o n s in cl u d in g th e sy st e m a ti c re v ie w

o f se co

n d a ry

a n d p ri m a ry

st u d ie s e v a lu a ti n g th e e ff e ct iv e n e ss

o f in te rv e n ti o n s a im

e d a t im

p ro v in g a tt a ch

m e n t a n d

a tt a ch

m e n t- re la te d o u tc o m e s o n a u n iv e rs a l, ta rg e te d o r in d ic a te d b a si s

In te rv e n ti o n ty p e

S tu d y d e si g n

P o p u la ti o n

O u tc o m e s m e a su re d

C o n cl u si o n s

S tu d ie s a ss e ss in g a tt a ch

m e n t

P a re n t– in fa n t

p sy ch

o th e ra p y

O n e sy st e m a ti c re v ie w

o f

e ig h t R C T s (B a rl o w

e t a l. ,

2 0 1 5 )

D iv e rs e h ig h ri sk

p o p u la ti o n s in cl u d in g

m a lt re a ti n g a n d im

p ri so n e d w o m e n

A tt a ch

m e n t; p a re n ta l

in te ra ct io n ; p a re n ta l m e n ta l

h e a lt h

T w o st u d ie s th a t m e a su re d a tt a ch

m e n t sh o w e d a n

im p ro v e m e n t; li tt le

e v id e n ce

o f im

p a ct

a cr o ss o th e r

o u tc o m e s

In cl u d e s v id e o fe e d b a ck

O n e R C T (B e rn a rd

e t a l. , 2 0 1 2 )

P a re n ts a t ri sk

o f m a lt re a tm

e n t a s

in d ic a te d b y re ce n t co

n ta ct

w it h

ch il d p ro te ct io n se rv ic e s

A tt a ch

m e n t

A lo w e r p ro p o rt io n o f ch

il d re n in

th e A B C g ro u p (3 2 % )

w e re

cl a ss ifi e d a s h a v in g a d is o rg a n is e d a tt a ch

m e n t

co m p a re d w it h ch

il d re n in

th e co

n tr o l g ro u p

(5 7 % ; e x cl u d in g ch

il d re n o v e r 2 4 m o n th s o ld

a t th e

ti m e o f a ss e ss m e n t) ; a h ig h e r p ro p o rt io n o f ch

il d re n

in th e A B C g ro u p w e re

cl a ss ifi e d a s se cu

re ly a tt a ch

e d

(5 2 % ) co

m p a re d w it h ch

il d re n in

th e co

n tr o l g ro u p

(3 3 % )

O n e R C T (M

o ss e t a l. , 2 0 1 1 )

M a lt re a ti n g p a re n ts

A tt a ch

m e n t; p a re n ta l

se n si ti v it y ; ch

il d b e h a v io u r

p ro b le m s

S ig n ifi ca n tl y m o re

ch il d re n se cu

re ly a tt a ch

e d (r e d u ct io n

in in se cu

re a n d d is o rg a n is e d a tt a ch

m e n t) ; si g n ifi ca n t

im p ro v e m e n ts in

p a re n ta l se n si ti v it y ; re d u ct io n in

in te rn a li si n g a n d e x te rn a li si n g p ro b le m s o f o ld e r

ch il d re n

O n e R C T – in d iv id u a ll y

a d m in is te re d C ir cl e o f

S e cu

ri ty

(C a ss id y e t a l. ,

2 0 1 1 )

P a re n ts o f ir ri ta b le

in fa n ts

A tt a ch

m e n t

Im p ro v e m e n ts in

h ig h ly b u t n o t m o d e ra te ly

ir ri ta b le

in fa n ts ; m a te rn a l a tt a ch

m e n t st a tu s w a s a n im

p o rt a n t

m o d if y in g fa ct o r

1 R C T – V IP P (K a li n a u sk ie n e

e t a l. , 2 0 0 9 )

M o th e rs lo w

in se n si ti v e

re sp o n si v e n e ss

A tt a ch

m e n t a n d se n si ti v it y

S ta ti st ic a ll y si g n ifi ca n t a n d la rg e e ff e ct

o n m o th e rs ’

se n si ti v e re sp o n si v e n e ss (d

= 0 .7 8 ), b u t n o e ff e ct

o n

a tt a ch

m e n t se cu

ri ty

M e n ta li sa ti o n -b a se d

p ro g ra m m e

O n e R C T – M in d in g th e B a b y

(S a d le r e t a l. , 2 0 1 3 )

F ir st -t im

e m o th e rs a g e d 1 4 – 2 5

e x p e ri e n ci n g a ra n g e o f

p ro b le m s – in cl u d in g ch

il d p ro te ct io n

is su e s, d e p re ss io n , h o m e le ss n e ss ,

p o v e rt y o r v io le n t re la ti o n sh ip s

A tt a ch

m e n t; m a te rn a l re fl e ct iv e

fu n ct io n in g ; m a te rn a l m e n ta l

h e a lt h ; su b se q u e n t

ch il d b e a ri n g ; m o th e r– in fa n t

a ff e ct iv e co

m m u n ic a ti o n

H ig h e r ra te s o f se cu

re a tt a ch

m e n t in

th e in te rv e n ti o n

g ro u p (6 4 %

cf 4 8 % ); a n d lo w e r ra te s o f d is o rg a n is e d

a tt a ch

m e n t (2 7 %

cf 4 3 % ). A ls o re d u ce d ra p id

su b se q u e n t ch

il d b e a ri n g ; tr e n d to w a rd s fe w e r o p e n

ca se s w it h ch

il d p ro te ct io n (0 %

cf 5 % ). N o d if fe re n ce s

fo r re fl e ct iv e fu n ct io n in g o r d e p re ss io n /p sy ch

o lo g ic a l

d is tr e ss , b u t tr e n d fo r im

p ro v e d co

m m u n ic a ti o n

S tu d ie s a ss e ss in g a tt a ch

m e n t- re la te d o u tc o m e s o n ly

In fa n t m a ss a g e

O n e sy st e m a ti c re v ie w

o f 3 4

R C T S (B e n n e tt e t a l. , 2 0 1 3 )

H e a lt h y p a re n t– in fa n t d y a d s – in fa n ts

le ss th a n 6 m o n th s o f a g e

P a re n t– in fa n t in te ra ct io n ;

m e n ta l h e a lt h ; in fa n t

te m p e ra m e n t; in fa n t

e m o ti o n a l a n d so ci a l

d e v e lo p m e n t; in fa n t p h y si ca l

a n d m e n ta l d e v e lo p m e n t

N o e v id e n ce

o f e ff e ct iv e n e ss w it h lo w -r is k p o p u la ti o n s

doi:10.1111/camh.12138 Attachment in preschool children 13

T a b le

1 . (c o n ti n u e d )

In te rv e n ti o n ty p e

S tu d y d e si g n

P o p u la ti o n

O u tc o m e s m e a su re d

C o n cl u si o n s

In cl u d e s v id e o fe e d b a ck

O n e sy st e m a ti c re v ie w

o f 2 9

st u d ie s (1 3 R C T s, 8 Q E D s,

8 p re – p o st d e si g n ; F u k k in k ,

2 0 0 8 )

P a re n ts a n d ch

il d re n , o n ly 2 3 fo cu

si n g

o n p a re n ts o f ch

il d re n u n d e r 5

P a re n ta l b e h a v io u rs – se n si ti v it y ,

re sp o n si v e n e ss , v e rb a l a n d

n o n -v e rb a l co

m m u n ic a ti o n ;

a n d ch

il d p ro b le m

b e h a v io u rs

S ta ti st ic a ll y si g n ifi ca n t im

p a ct

o n p a re n ti n g

b e h a v io u rs , p a rt ic u la rl y w it h p a re n ts in

h ig h -r is k

g ro u p s; sm

a ll to

m o d e ra te

e ff e ct

o n ch

il d b e h a v io u rs

O n e R C T – V IP P (N

e g r~ a o

e t a l. , 2 0 1 4 )

P a re n ts o f ch

il d re n a g e d 1 – 4 y e a rs

li v in g in

p o v e rt y

M a te rn a l e m o ti o n a l a v a il a b il it y ;

ch il d b e h a v io u r; fa m il y

e n v ir o n m e n t

S ig n ifi ca n t im

p ro v e m e n ts in

m a te rn a l e m o ti o n a l

a v a il a b il it y ; ch

il d b e h a v io u r a n d fa m il y e n v ir o n m e n t

O n e R C T (L in d e t a l. , 2 0 1 4 )

P a re n ts o f ch

il d re n u n d e r 2 y e a rs o f

a g e fo ll o w in g a ll e g a ti o n s o f

m a lt re a tm

e n t

C h il d n e g a ti v e a ff e ct

L o w e r le v e ls o f ch

il d n e g a ti v e a ff e ct

e x p re ss io n ,

in cl u d in g lo w e r o v e ra ll le v e ls o f a n g e r, lo w e r le v e ls

o f a n g e r to w a rd s p a re n t, a n d lo w e r le v e ls o f g lo b a l

a n g e r/ sa d n e ss

O n e R C T – V IP P (Y a g m u r

e t a l. , 2 0 1 4 )

T u rk is h m in o ri ty

m o th e r– in fa n t d y a d s

S e n si ti v it y ; d is ci p li n e

S ig n ifi ca n t im

p ro v e m e n ts in

se n si ti v e p a re n ti n g a n d

n o n -i n tr u si v e n e ss ; n o e ff e ct

o n m a te rn a l d is ci p li n e

H o m e v is it in g

O n e sy st e m a ti c re v ie w

o f 3 5

co n tr o ll e d st u d ie s N ie v a r

e t a l. , 2 0 1 0 )

A ra n g e o f ta rg e te d p o p u la ti o n s

P a re n ta l se n si ti v it y

M o d e ra te ly su cc e ss fu l (d

= .3 7 ) a t im

p ro v in g m a te rn a l

b e h a v io u rs , a s m e a su re d b y a co

m b in a ti o n o f su rv e y

a n d o b se rv a ti o n a l m e a su re s th a t a ss e ss e d th e h o m e

le a rn in g e n v ir o n m e n t a n d m a te rn a l se n si ti v it y

M e n ta li sa ti o n -b a se d

in te rv e n ti o n

O n e R C T – M o th e rs a n d

T o d d le rs P ro g ra m m e

(S u ch

m a n e t a l. , 2 0 1 1 )

S u b st a n ce -d e p e n d e n t m o th e rs

o f to d d le rs

M a te rn a l re fl e ct iv e fu n ct io n in g ;

p a re n t– ch

il d in te ra ct io n ;

ca re g iv in g b e h a v io u r; m a te rn a l

m e n ta l h e a lt h

M o d e ra te ly h ig h e r m e a n re fl e ct iv e fu n ct io n in g sc o re s

fo r th e M T P g ro u p , a n d sl ig h tl y h ig h e r sc o re s fo r

co h e re n ce , se n si ti v it y a n d q u a li ty

o f re p re se n ta ti o n

su b sc a le s fo r th e M T P g ro u p w h e n co

m p a re d w it h

th e co

m p a ri so n in te rv e n ti o n ; im

p ro v e d ca re g iv in g

b e h a v io u r, a n d im

p ro v e d m a te rn a l d e p re ss io n a n d

g lo b a l d is tr e ss

P a re n t– ch

il d

p sy ch

o th e ra p y

O n e R C T (G

h o sh

Ip p e n

e t a l. , 2 0 1 1 )

P a re n t– ch

il d d y a d s (3 – 5 y rs ) w h o h a d

e x p e ri e n ce d m u lt ip le

tr a u m a ti c li fe

e v e n ts

P a re n ta l m e n ta l h e a lt h ; ch

il d

P T S D ; d e p re ss io n a n d

b e h a v io u r p ro b le m s

S ig n ifi ca n t im

p ro v e m e n ts in

ch il d P T S D (5 %

cf 5 3 % ),

d e p re ss io n , co

o cc u rr in g d ia g n o se s a n d b e h a v io u r.

S ig n ifi ca n t im

p ro v e m e n ts in

m a te rn a l P T S D a n d

d e p re ss io n

G ro u p -b a se d p a re n ti n g

p ro g ra m m e

O n e R C T – M e ll o w

B a b ie s

(P u ck e ri n g e t a l. , 2 0 1 0 )

D e p re ss e d m o th e rs o f in fa n ts

P a re n t– in fa n t in te ra ct io n ;

p a re n ta l m e n ta l h e a lt h

S ig n ifi ca n t im

p ro v e m e n ts in

m a te rn a l d e p re ss io n a n d

in so m e b u t n o t a ll a sp e ct s o f p a re n t– in fa n t

in te ra ct io n , in cl u d in g p o si ti v e a n ti ci p a ti o n , p o si ti v e

re sp o n si v e n e ss , n e g a ti v e a u to n o m y a n d n e g a ti v e

co n tr o l

P re v e n ti v e in te rv e n ti o n s

(e .g . in cl u d in g

in te rp e rs o n a l

p sy ch

o th e ra p y , n o n -

d ir e ct iv e co

u n se ll in g ,

C B T , in fa n t

m a ss a g e , h o m e -b a se d

in te ra ct io n co

a ch

in g ,

p a re n t tr a in in g ,

su p p o rt g ro u p a n d

m o th e r– in fa n t

th e ra p y )

O n e sy st e m a ti c re v ie w

in cl u d in g 1 3 co

n tr o ll e d

st u d ie s (K e rs te n -A

lv a re z

e t a l. , 2 0 1 1 )

D e p re ss e d m o th e rs

M a te rn a l se n si ti v it y

S m a ll -t o -m

e d iu m

e ff e ct

o v e ra ll o n se n si ti v it y (g

= .3 2 )

14 Jane Barlow et al. Child Adolesc Ment Health 2016; 21(1): 11–20

ent–infant psychotherapy, counselling/CBT and inter- action guidance) (Barlow, Bennett, Midgley, Larkin, & Wei, 2015). Parent–infant/child psychotherapy involves a therapist working with the parent and infant/toddler together, establishing a therapeutic alliance with the parent in order to identify unconscious patterns of relat- ing in terms of the parent’s own experiences of being par- ented and their internal working models. The aim of the therapy is to help the parent to recognise the way in which their current interactions are shaped by past experiences in order to enable them to respond more freely and sensitively to their infant (Barlow et al., 2015). The included studies targeted parents experiencing a range of problems, such as those who have maltreated their children and parents in prison. Meta-analyses based on data from two of the included studies indicated that parents who received PIP were more likely to have an infant who was rated as being securely attached to the parent; however, there were no significant differ- ences in studies comparing outcomes of PIP with one of the other models of treatment (e.g. video feedback, coun- selling, CBT). The authors concluded that PIP is a promising model in terms of improving infant attach- ment in high-risk families but that further research is needed into its impact on potentially important mediat- ing factors, such as mental health, reflective functioning and parent–infant interaction, and its effectiveness rela- tive to other methods of working.

Bernard et al. (2012) evaluated the effectiveness of the Attachment and Biobehavioural Catch-Up (ABC) pro- gramme in an RCT involving 113 parents and 120 young children (aged 1.7–21.4 months) at risk of maltreat- ment, as indicated by recent contact with Child Protec- tion Services. ABC is a manualised intervention that typically involves around ten 1-hr sessions that focus primarily on providing parents with ‘in the moment’ feedback about their interactions with their child using video feedback to highlight parents’ strengths, challenge weaknesses, and celebrate changes in behaviours (Lind, Bernard, Ross, & Dozier, 2014). The study found that a lower proportion of children in the ABC group (32%) were classified as having a disorganised attachment com- pared with children in the control group (57%), an effect that was sustained after excluding children over 24 months old at the time of assessment. Further, a higher proportion of children in the ABC group were classified as securely attached (52%) compared with children in the control group (33%), although this effect was not sustained after children over 24 months old at the time of assessment were excluded.

Moss et al. (2011) evaluated the effectiveness of a home-delivered programme using video feedback with maltreating parents. The programme consisted of eight weekly home visits of approximately 90 min structured in four sequences, including discussion on a parent- chosen theme, videotaped interactive session, video feedback session and wrap-up session. The RCT involv- ing 67 maltreating caregiver-child dyads found signifi- cant improvements for the intervention group in parental sensitivity; more intervention children became secure and fewer remained insecure; and more interven- tion children moved from being disorganised to organ- ised. Older children in the intervention group showed lower levels of internalising and externalising problems (Moss et al., 2011).Ta

b le

1 . (c o n ti n u e d )

In te rv e n ti o n ty p e

S tu d y d e si g n

P o p u la ti o n

O u tc o m e s m e a su re d

C o n cl u si o n s

R e la ti o n sh ip -b a se d

p ro g ra m m e s

(e .g . h o m e v is it in g ,

V IP P , P a re n t–

In fa n t P ro g ra m m e ,

F a m il y C h e ck -U

p a n d

p re g n a n cy

p ro g ra m m e s

fo cu

si n g o n

a lc o h o l u se )

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o f 1 8

in te rv e n ti o n s – 1 5 R C T s

(M o rt e n se n &

M a st e rg e o rg e , 2 0 1 4 )

L o w -i n co

m e m o th e r– ch

il d d y a d s

P a re n ti n g b e h a v io u rs –

p a re n t– in fa n t in te ra ct io n

L im

it e d e v id e n ce

o f e ff e ct iv e n e ss a cr o ss a ll

in te rv e n ti o n s; th e m o st e ff e ct iv e p ro g ra m m e s

w e re

sh o rt e r in

d u ra ti o n a n d p ro v id e d d ir e ct

se rv ic e s to

th e p a re n t– ch

il d d y a d u se d in te rv e n o rs

w it h p ro fe ss io n a l q u a li fi ca ti o n s a n d a ss e ss e d

p a re n t– ch

il d in te ra ct io n s w it h fr e e -p la y ta sk s

doi:10.1111/camh.12138 Attachment in preschool children 15

One RCT (Cassidy, Woodhouse, Sherman, Stupica, & Lejuez, 2011) examined the effectiveness of an individu- ally delivered version of the group-based Circle of Secu- rity programme, which involves the use of videotaped feedback to help the mother enhance her observation skills and to recognise infant signals related to these needs. The programme also seeks to help parents to understand and manage psychological factors that may interfere with their responses. This programme involves three 1-hr home visits every 3 weeks between 6.5 and 9 months. Approximately 2 weeks later, a final visit is delivered during which the home visitor gives the mother a copy of videotapes used in the intervention and dis- cusses any ongoing parenting concerns (Cassidy et al., 2011). An RCT involving 220 parents of irritable infants found evidence of improved attachment security for the highly (89% cf. 62%) but not moderately irritable infants (63% cf. 58%). Maternal security was also an important moderating factor, with highly irritable infants of securely attached mothers being more likely to become securely attached compared with no effect for moder- ately irritable infants. For fearful mothers, highly irrita- ble infants were equally likely to be secure in the intervention group (69% probability) and in the control group (69% probability); similarly, for moderately irrita- ble infants, no effect of intervention emerged. For more dismissing mothers, the intervention was efficacious for highly irritable infants but not for moderately irritable infants of more dismissing mothers. By contrast, when mothers were classified as preoccupied, there was evi- dence of an intervention effect for moderately irritable infants but not highly irritable infants.

Kalinauskiene et al. (2009) conducted an RCT of the Video-feedback Intervention to Promote Positive Parent- ing (VIPP) developed at Leiden University (Juffer, Baker- mans-Kranenburg, & Van IJzendoorn, 2008) with 54 Lithuanian mothers rated low in sensitive responsive- ness. The intervention comprised five 90-min sessions at home (the last one with fathers) and was delivered by two clinical psychologists. Infants were aged 6 months and 12 days on average at the first visit. The intervention had a statistically significant and large effect (d = .78) on mothers’ sensitive responsiveness, but there was no effect on attachment security. The authors concluded that a relatively brief and low-cost programme can effec- tively support mothers who lack sensitivity in interac- tions with their infants.

Sadler et al. (2013) examined the effectiveness of Minding the Baby (MTB), a mentalisation-based home visiting intervention focused on improving the reflective functioning of first-time mothers aged 14–25 experienc- ing a range of problems during the perinatal period, including child protection issues, depression, homeless- ness, poverty or violent relationships. ‘Mentalisation’ refers to the ability to understand behaviour in terms of mental states (Fonagy, Gergely, Jurist, & Target, 2002). MTB is home-visiting programme delivered by two spe- cially trained practitioners (a qualified nurse and social worker alternate) for an hour a week, from the third tri- mester of pregnancy until the infant is 2 years of age. Clinicians provide developmental guidance, crisis inter- vention, and parenting and practical support in order to increase reflective parenting, promote the mother–infant attachment relationship, and model and foster a range of parenting skills (Sadler et al., 2013). The RCT involved

139 mothers of mostly Latina, African-American or Car- ibbean descent with low education and income, some of whom (11%) had child protection concerns, and found a significantly higher percentage of secure infants in the MTB group (n = 41, 64%) compared with the control group (n = 30, 48%). In addition, a significantly lower percentage of intervention group dyads (27%) were clas- sified as having disorganised attachment, compared with the control group dyads (43%). The intervention group mothers had fewer instances of rapid subsequent childbearing and a trend towards fewer open cases with child protection services than mothers in the control group (0% compared to 5%). There were no significant differences between groups in maternal reflective func- tioning, depression or psychological distress but a trend towards improved communication for teenage mothers – 67% of the intervention group teenage mothers versus 94% of the control group had scores in the disrupted range.

Attachment-related outcomes Five systematic reviews and five RCTs evaluated the effectiveness of interventions in improving an attach- ment-related outcome (Table 1).

One systematic review of infant massage was identi- fied (Bennett, Underdown, & Barlow, 2013), comprising 34 RCTs involving healthy parent–infant dyads in which the infant was under the age of 6 months. Infant mas- sage involves the teaching of infant massage strokes within a group setting of around 6–8 mothers for 1–2 hrs on a weekly basis. No significant differences were found for a range of aspects of infant temperament, parent–in- fant interaction and mental development. The authors concluded that the findings do not currently support the use of infant massage with low-risk groups of parents and infants, that there may be more potential for change with demographically and socially deprived parent–in- fant dyads, and that future research should focus on this.

One review of 29 studies (13 RCTs, eight quasi-experi- mental designs, eight pre-post designs) examined the effectiveness of video feedback on parental behaviours, sensitivity, responsiveness, verbal and non-verbal com- munication and child problem behaviours (Fukkink, 2008). Of these, 23 included children aged under 5 years. A meta-analysis showed a statistically signifi- cant positive effect for video feedback intervention on parenting behaviours. Brief video-feedback interven- tions with parents in high-risk groups were the most effective. The aggregate effect on child behaviour was described as being between ‘small’ and ‘average’. The authors concluded that family programmes that include video feedback achieve the intended dual level effect in terms of parents improving their interaction skills, which in turn help in the development of their children.

Three RCTs were identified that evaluated the effec- tiveness of video feedback with a range of high-risk par- ent–child dyads involving children under the age of 5 years, including Portuguese parents living in poverty (Negr~ao, Pereira, Soares, & Mesman, 2014), parents of children under 2 years of age following allegations of maltreatment (Lind et al., 2014) and Turkish minority parents living in the Netherlands (Yagmur, Mesman, Malda, Bakermans-Kranenburg, & Ekmekci, 2014). Negr~ao et al. (2014) examined the use of VIPP and Sensi-

16 Jane Barlow et al. Child Adolesc Ment Health 2016; 21(1): 11–20

tive Discipline (VIPP-SD) with 55 Portuguese mothers of children aged 1–4 years who were living in poverty and about whom there were concerns in terms of their care- giving. The six sessions were spread over 3–4 months, and mother and child interaction was videotaped fol- lowed by feedback of videos recorded in the previous ses- sion. The RCT found significant improvements favouring the intervention group in overall measures of maternal emotional availability, child behaviour and family envi- ronment, with post hoc results showing significant improvements in a number of domains: maternal non- intrusiveness, child responsiveness and involvement. The domains of maternal sensitivity, structuring and non-hostility also improved but failed to achieve signifi- cance. The results also showed a significant improve- ment in family cohesion but not expressiveness or conflict. Lind et al. (2014) examined the effectiveness of the ABC intervention with 260 US vulnerable parents of children under 2 years of age following allegations of maltreatment. The results of the RCT showed significant differences favouring the ABC group in terms of lower levels of negative affect expression. Children in the ABC group displayed lower overall levels of anger, lower levels of anger towards parent and lower levels of global anger/ sadness. Yagmur et al. (2014) evaluated the effective- ness of a culturally sensitive adaptation of VIPP-SD for 86 Turkish minority parents in the Netherlands (VIPP- TM). The intervention involved six home visits lasting 2.5–3 hr over 4 months. Visits were recorded and used to illustrate themes. The RCT found significant improve- ments favouring the intervention groups for sensitive parenting and non-intrusiveness. There was no effect on maternal discipline overall or on the subscales for lax- ness, physical discipline or supportive presence.

One systematic review was identified that evaluated the effectiveness of home visiting on attachment-related outcomes (Nievar, Van Egeren, & Pollard, 2010). Home visiting programmes are manualised interventions that involve an intensive series of home visits beginning pre- natally (in some models) and continuing during the child’s first 2 years of life. They are delivered by specially trained personnel who provide information, support and training regarding child health, development and care. Common themes include early infant care, infant health and development and parenting skills, but programmes may also cover maternal health and well-being, diet, smoking, drug/alcohol use, exercise, transition to par- enthood and the parent’s relationship with their partner. This review included 35 controlled studies evaluating the effectiveness of home visiting programmes and found that interventions were moderately successful (d = .37) at improving maternal behaviours, as measured by a combination of survey and observational measures that assessed the home learning environment and maternal sensitivity.

One RCT evaluated the effectiveness of a mentalisa- tion-based programme known as the Mothers and Tod- dlers Programme (MTP), which comprises 12 weeks of individual therapy as an adjunct to standard outpatient substance abuse treatment programmes (Suchman, Decoste, Mcmahon, Rounsaville, & Mayes, 2011). The aim of MTP is to improve maternal capacity for reflective functioning and for sensitivity and responsiveness to toddler emotional cues. The results of this small RCT involving 47 women and their children found moderately

higher mean reflective functioning scores for the MTP group, and slightly higher scores for coherence, sensitiv- ity and quality of representation subscales for the MTP group, when compared with the comparison interven- tion (Suchman et al., 2010). There was improved caregiving behaviour for MTP mothers, and improve- ments in depression and global distress. At 6-week fol- low-up, the combined data for women receiving the 12- and 24-week programmes showed that the higher mean reflective functioning score was maintained but reduced. At follow-up, there was also a slightly higher quality of maternal representation for the MTP group and moder- ately higher mean Nursing Child Assessment Satellite Training scores for child communication with the mother for the MTP group. However, effects for depres- sion were not sustained at 6-week follow-up (Suchman et al., 2011).

One further relevant RCT evaluating the effectiveness of parent–child psychotherapy was identifed. Ghosh Ippen, Harris, Van Horn, and Lieberman (2011) exam- ined the effectiveness of a standard parent–child psy- chotherapy intervention that was delivered by a psychotherapist and involved a mean number of 32 weekly sessions of 60 min duration with both the parent and child aimed at enhancing the parent’s capacity to provide safe and developmentally appropriate caregiving to the child. The results of an RCT with 75 parent–child dyads involving preschool age children (3–5 years) who had experienced multiple traumatic and stressful life events found significant improvements favouring the intervention group for child PTSD (5% cf. 53%), depres- sion, co-occurring diagnoses and behaviour, maternal PTSD and depression.

One RCT examined the effectiveness of a group-based programme spanning the perinatal period in improving parent–infant interaction (Puckering, McIntosh, Hickey, & Longford, 2010). Mellow Babies is a 14-week group- based day programme targeting women experiencing depression and is underpinned by cognitive behavioural theory. Morning sessions provide the mothers with an opportunity to reflect on their own lives, draw links between past and present feelings and relationships and consider ways of managing depression using broadly cognitive behavioural approaches. In the afternoon, par- ticipants engage in play-time involving interaction coaching, baby massage, looking at picture books, lap games and nursery rhymes to promote sensitive interac- tion and attunement, after which videos of mothers interacting with their babies are used to demonstrate sensitive interaction. The results of the small RCT involv- ing 20 mothers found significant improvements in maternal depression and parent–infant interaction in terms of positive anticipation, positive responsiveness, negative autonomy and negative control. There were also trends favouring the intervention group for negative dis- tress, positive control, positive cooperation and positive autonomy. There were no significant differences between groups for positive distress, negative anticipation, nega- tive responsiveness or negative cooperation.

Two reviews examined a range of sensitivity- and rela- tionship-focused interventions in specific populations, including depressed mothers (Kersten-Alvarez, Hosman, Riksen-Walraven, Van Doesum, & Hoefnagels, 2011) and low-income mother–infant dyads (Mortensen & Mastergeorge, 2014). Kersten-Alvarez et al. (2011)

doi:10.1111/camh.12138 Attachment in preschool children 17

included 10 controlled studies evaluating 13 preventive interventions (including interpersonal psychotherapy, non-directive counselling, CBT, infant massage, home- based interaction coaching, parent training, support group and mother–infant therapy) aimed at improving sensitivity in depressed mothers, and found a small-to- medium effect overall (g = .32). Interventions providing infant massage were found to be highly effective in improving maternal sensitivity. Mortensen and Master- george (2014) included 18 studies (15 of which were RCTs) of 19 relationship-based interventions (including home visiting, VIPP, Parent–Infant Programme, Family Check-Up, and pregnancy programmes focusing on alcohol use), all targeting disadvantaged mother–child dyads. Most of the interventions took place exclusively in the home. A meta-analysis focusing on observed parent– child interaction found a small mean effect size (d = .23).

Discussion

The results of this review of systematic reviews, and RCTs not included in the reviews, show that parent–in- fant psychotherapy, video feedback and mentalisation- based programmes appear to be promising approaches to improving attachment in a range of high-risk infants, including those with maltreating parents. These and other interventions, such as home visiting and parent- ing programmes, also appear to be effective in improving a range of attachment-related outcomes, such as aspects of parent–infant/toddler interaction related to maternal sensitivity and reflective functioning. Although only evidence published since 2008 has been included, these results confirm the findings of earlier systematic reviews (e.g. Bakermans-Kranenburg, Van Ijzendoorn, & Juffer, 2003; Barnes & Freude-Lagevardi, 2003).

The theories of change underpinning the different pro- grammes are diverse and range from psychoanalytic models (e.g. parent–infant psychotherapy) that focus primarily on changing the parents’ internal working models, through programmes that focus explicitly on improving parents’ capacity for reflective functioning (e.g. MTB, Mother and Toddler Programme) to those that focus more explicitly on the interaction between the par- ent and infant/toddler, and on sensitive parenting based on attachment theory (video feedback and VIPP). There is, however, an increasing eclecticism, with programmes focusing explicitly on parent–child interactions drawing on different theoretical traditions, and almost all (apart from the home visiting programmes) building in the use of video feedback.

There is also considerable divergence in terms of the frequency and duration of interventions, with home vis- iting programmes such as MTB involving intensive visits over a prolonged period of time, and most other types of programme involving intensive work over brief periods of time, typically a few months (e.g. Video-feedback and parent–infant psychotherapy). The limited evidence available regarding the comparative effectiveness of these interventions shows that there is little difference between them (Barlow et al., 2015), and increasing evi- dence supporting the use of brief, sensitivity-focused interventions (cf. Bakermans-Kranenburg et al., 2003).

A number of implementation issues were identified. The Mortensen and Mastergeorge (2014) review of inter- ventions that targeted low-income mother–child dyads

found that the most effective programmes were shorter in duration, provided direct services to the parent–child dyad, used intervenors with professional qualifications and assessed parent–child interactions with free-play tasks.

Although some of these interventions need to be deliv- ered by specialist practitioners (e.g. psychologists and parent–child psychotherapists), many of the remaining interventions are manualised (e.g. ABC, VIPP), and some can arguably be delivered effectively by health visitors as part of the HCP (Shribman & Billingham, 2009) following appropriate training (e.g. video-feedback). There is a high prevalence of disorganised attachment, particularly in disadvantaged populations, and the strong associa- tion between such attachment patterns and later prob- lems suggests the need for specialist CAMHS practitioners to have the necessary skills to deliver some of these methods of working.

The current review is limited in terms of the fact that we did not search for studies prior to 2008, and only included primary studies that met the inclusion criteria but were not included in existing reviews. We were, as such, reliant on the findings of systematic reviews, some of which had methodological limitations in terms of the inclusion of less rigorous studies, and the comprehen- siveness of their searches. We also adopted wide inclu- sion criteria (e.g. parent–infant interaction and parental mental health problems), which may have resulted in the inclusion of studies that have less focus on attachment.

Conclusion

This review has identified some interventions that appear to be effective in improving attachment but the evidence is limited, and most studies have focused pre- dominantly on attachment-related outcomes. Although both insecure and disorganised attachment have a high prevalence in disadvantaged populations in particular, and both are strongly associated with a range of later problems including externalising and personality disor- ders, many of the methods of working identified by this review are not yet routinely available to preschool chil- dren in the UK. Practitioners working within a range of CAMHS settings should have the skills to deliver some of the identified methods of working with parent–child dyads, including video feedback and mentalisation- based techniques.

Acknowledgements

The research was funded by Public Health England. The views expressed in this article are those of the authors only. J.B. was Vice-chair of the NICE Children’s Attachment Guideline Com- mittee, and Deputy Chair of the related National Collaborating Centre for Mental Health (NCCMH) review team (NICE, 2015). The authors have declared that they have no competing or potential conflicts of interest.

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Accepted for publication: 30 September 2015 Published online: 25 November 2015

20 Jane Barlow et al. Child Adolesc Ment Health 2016; 21(1): 11–20