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NARRATIVE AND META-ANALYTIC REVIEW OF INTERVENTIONS AIMING TO IMPROVE MATERNAL–CHILD ATTACHMENT SECURITY NICOLE LETOURNEAU

Alberta Children’s Hospital Research Institute for Child and Maternal Health, University of Calgary PANAGIOTA TRYPHONOPOULOS

University of New Brunswick, Fredericton GERALD GIESBRECHT

Alberta Children’s Hospital CINDY-LEE DENNIS

University of Toronto SANJIT BHOGAL

University of Calgary BARRY WATSON

University of New Brunswick, Fredericton ABSTRACT: 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 quasirandomized 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.

Keywords: meta-analysis, systematic review, maternal–child attachment, maternal sensitivity, maternal reflective function, maternal representations, intervention Las tempranas relaciones afectivas seguras entre madre y ni˜no echan las bases de un saludable desarrollo social y mental de los ni˜nos. Las intervenciones que se enfocan en la sensibilidad materna y la funci´on reflexiva materna durante el primer a˜no de vida del infante pudieran ser la clave para promover una afectividad segura. Llevamos a cabo una revisi´on narrativa sistem´atica y un meta-an´alisis para examinar la eficacia de las intervenciones dirigidas a promover la sensibilidad materna y la funci´on reflexiva sobre la seguridad afectiva entre madre y ni˜no, tal como fue RESUMEN:

The research team acknowledges the support of the Norlien Foundation and the Alberta Children’s Hospital Foundation for their support. As well, the contributions of Research Assistants Jocelyn Edey and Carol Weller were appreciated. Direct correspondence to: Nicole Letourneau, Faculties of Nursing and Cumming School of Medicine, Alberta Children’s Hospital Research Institute for Child and Maternal Health, Office 2282, 2500 University Dr. NW, University of Calgary, Alberta, Canada, T2N 1N4; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 36(4), 366–387 (2015)  C 2015 Michigan Association for Infant Mental Health View this article online at wileyonlinelibrary.com. DOI: 10.1002/imhj.21525

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medida por esa norma de oro que es la Situaci´on Extra˜na y el Q-set. Los estudios fueron identificados a trav´es de investigaciones de bases de datos electr´onicas e incluyeron dise˜nos aleatorios y cuasi-aleatorios de grupos paralelos controlados. Los participantes fueron madres e infantes a quienes se les dio seguimiento hasta 36 mases despu´es del parto. Se incluyeron diez procesos de prueba con la participaci´on de 1628 pares de madre-infantes. El examen de los procesos de prueba que aportaron suficientes datos para una combinaci´on en meta-an´alisis, revel´o que las intervenciones de ambos tipos incrementan las posibilidades de una afectividad segura entre madre y ni˜no, en comparaci´on con la falta de intervenci´on o la intervenci´on est´andar (n=7 procesos de prueba; O: 2.77; 95% CI: 1.69, 4.53, n=965). De los 3 procesos de prueba no incluidos en el meta-an´alisis, dos mejoraron la probabilidad de una afectividad segura. Concluimos que las intervenciones dirigidas a mejorar la sensibilidad materna solamente o en combinaci´on con la reflexi´on materna, implementadas en el primer a˜no de vida de los infantes, son efectivas para promover una afectividad segura entre madre y ni˜no. La intervenci´on dirigida a familias bajo el m´as alto riego produjo los efectos m´as beneficiosos.

Palabras claves: Meta-an´alisis, Revisi´on Sistem´atica, Afectividad Materno-Infantil, Sensibilidad Materna, Funci´on Reflexiva Materna, Representaciones Maternas, Intervenci´on ´ ´ RESUM E:

Les relations d’attachement s´ecure maternel-enfant pr´ecoce posent la fondation du d´eveloppement social et mental sain. Les interventions mettant l’accent sur la sensibilit´e maternelle et le fonction r´eflexive maternelle durant la premi`ere ann´ee de la vie du b´eb´e pourraient eˆ tre la cl´e de la promotion de l’attachement s´ecure. Nous avons proc´ed´e a` une revue syst´ematique d’articles et a` une m´eta-analyse afin d’examiner l’efficacit´e d’interventions ayant pour but de promouvoir la sensibilit´e maternelle et la fonction de r´eflexion sur la s´ecurit´e de l’attachement maternel-enfant, telle qu’elle est mesur´ee par l’´etalon or Situation Etrange et le Q-test. Les e´ tudes ont e´ t´e identifi´ees a` partir de recherches de bases de donn´ees e´ lectroniques et ont compris des e´ tudes bas´ees sur des groupes de contrˆole parall`eles randomis´ees ou quasiment randomis´ees. Les participants e´ taient des m`eres et leurs nourrissons jusqu’`a 36 mois postpartum. Dix trials, auxquels ont particip´e 1628 paires m`ere-nourrisson ont e´ t´e inclues. L’examen des trials a offert suffisamment de donn´ees permettant d’ˆetre combin´ees dans la m´eta-analyse, r´ev´elant que les interventions des deux types augmentaient les chances d’un attachement maternel-enfant s´ecure, compar´e a` aucune intervention ou a` une intervention standard (n=7 trials; OR: 2,77; 95% CI: 1,69, 4,53, n=965). Des 3 trials n’ayant pas e´ t´e inclus dans les m´eta-analyses, deux ont am´elior´e les chances d’un attachement s´ecure. Nous concluons que les interventions ayant pour but d’am´eliorer la sensibilit´e maternelle seule ou combin´ee a` la r´eflexion maternelle, mises en place durant la premi`ere ann´ee des vies des nourrissons, sont efficaces pour la promotion des attachements s´ecures maternel-enfant. L’intervention destin´ee aux familles a` plus haut risque a produit les effets les plus b´en´efiques.

Mots cl´es: M´etaanalyse, Passage en revue syst´ematique, Attachement maternel-enfant, Fonction r´eflexive maternelle, Repr´esentations maternelles, Intervention ZUSAMMENFASSUNG: Eine fr¨uhe sichere Mutter-Kind-Bindung legt die Grundlage f¨ur eine gesunde soziale und geistige Entwicklung von Kindern. Interventionen, die auf m¨utterliche Sensitivit¨at und m¨utterliche Mentalisierungsf¨ahigkeit (reflective functioning) w¨ahrend des ersten Lebensjahres abzielen, k¨onnen der Schl¨ussel zur F¨orderung sicherer Bindung sein. Wir f¨uhrten ein systematisches narratives Review und eine Metaanalyse durch, um die Wirksamkeit von Interventionen zur F¨orderung der m¨utterlichen Sensitivit¨at und Mentalisierungsf¨ahigkeit und infolge dessen der Mutter-KindBindungssicherheit zu untersuchen. Dabei wurden Studien eingeschlossen, die diese Konstrukte mit dem Goldstandard: der fremden Situation und dem Q-Set messen. Die Studien wurden mithilfe der elektronischen Datenbankrecherche identifiziert und umfassten randomisierte oder quasi-randomisierte kontrollierte Parallelgruppen-Designs. Die Teilnehmer waren M¨utter und ihre Kinder, die bis zu 36 Monate nach der Geburt untersucht wurden. Zehn Studien mit 1628 Mutter-Kind-Dyaden wurden eingeschlossen. Die Untersuchung der Studien, die ausreichende Daten zur Kombination in der Meta-Analyse zur Verf¨ugung stellten, ergab, dass Interventionen der beiden Arten die Chancen auf eine sichere Mutter-Kind-Bindung im Vergleich zu keiner Intervention oder einer Standard-Intervention erh¨ohten (n = 7 Studien; OR: 2.77; 95% CI : 1.69, 4.53, n = 965). Von den 3 Studien, die nicht in die Meta-Analysen eingeschlossen wurden, verbesserte sich bei zwei Studien die Wahrscheinlichkeit einer sicheren Bindung. Wir schlussfolgern, dass im ersten Lebensjahr implementierte Interventionen zur Verbesserung der m¨utterlichen Sensitivit¨at allein oder in Kombination mit der m¨utterlichen Mentalisierungsf¨ahigkeit bei der F¨orderung einer sicheren Mutter-Kind-Bindung wirksam sind. Interventionen, die sich auf Hoch-Risiko-Familien ausrichteten, zeigten die vorteilhaftesten Effekte.

Keywords: Meta-Analyse, systematisches Review, Mutter-Kind-Bindung, m¨utterliche Sensitivit¨at, m¨utterliche Mentalisierungsf¨ahigkeit, m¨utterliche Repr¨asentationen, Intervention dd: dddddddd−ddddddddddddddddddddddddddddddddddddddddddd1dddd ddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddd Strange Situation d Q-set dddddddddddddddddddddddddddddddddddddddddddd d−ddddddddddddddddddddddddddddddddddddddddddddddddddddddddd ddddddddddddddddddddddddddddddddddddddddddddddd36ddddddddddd ddddddddd1628ddd−ddddddd10dddddddddddddddddddddddddddddddddddd ddddddddddddddddddddddddddddddddddddddd−ddddddddddddddddddd d(n=7dd; OR: 2.77; 95% CI: 1.69, 4.53, n=965)ddddddddddddd3dddddddd2dddddddddddd likelihood

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* * * Attachment patterns impact children’s developmental trajectories, dramatically altering their psychosocial adaptation, emotional regulation, and ability to modulate arousal (Grossman, Grossman, & Waters, 2006; Sroufe, 2005). Attachment refers to the affective quality and organization of the relational transactions between a caregiver (most often the mother) and child (Sroufe & Waters, 1977). The quality of attachment is characterized by a child’s demonstration of comfort (or lack thereof) in interactions with the caregiver who does (or does not) provide the child with both a secure base for exploration and a safe haven in the face of distressing stimuli (Ainsworth & Bell, 1974; Bowlby, 1988; Cassidy & Shaver, 1999). In stressful situations such as a brief separation from a caregiver followed by reunion, securely attached children are able to freely express negative emotions, self-soothe using a balanced expression of emotions (positive and negative), and resolve their distress through proximity-seeking and receptiveness to the sensitive responsiveness of their caregiver (van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). These observable behaviors comprise the secure pattern of attachment (B type) (Ainsworth, Blehar, Waters, & Wall, 1978) and demonstrate the child’s expectation, based on past experience, that their

actions and emotions will be met with sensitive, responsive, and comforting actions from their primary caregiver. Indeed, it is wellestablished that the most powerful predictor of secure maternal– child attachment is sensitive, responsive caregiving (Ainsworth, Bell, & Staynton, 1974; Bowlby, 1988; Cassidy & Shaver, 1999; Zeanah & Smyke, 2008). In contrast, the insecure patterns of attachment are described as avoidant (A type) and ambivalent (C type). An avoidant pattern of attachment, which is characterized by minimal expressions of negative emotions in the presence of a mother who has previously been insensitive, rejecting, or ignoring of such emotions, may reflect the child’s history and defense mechanism against rejection. In contrast, children with an ambivalent attachment pattern maximize the expression of negative emotions and the display of attachment behaviors to draw the attention of their inconsistently responsive mother (Cassidy & Berlin, 1994; van IJzendoorn et al., 1999). In other words, the secure, avoidant, and ambivalent attachment patterns are considered “organized” because they represent children’s adaptations to their primary caregiver that maximize proximity and care. A fourth pattern of attachment, disorganized (D type), refers to a lack of a coherent, organized behavioral strategy to deal

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Narrative and Meta-Analytic Review of Infant Attachment Interventions

with stressors and is characterized by child behaviors that are contradictory, misdirected, freezing, or fearful in the presence of the mother (Hesse & Main, 2006; Main & Solomon, 1990; Schuengel, Bakermans-Kranenburg, van IJzendoorn, & Blom, 1999). A variant of attachment theory is Crittenden’s (2010) dynamic maturational model (DMM) of attachment and adaptation. In this model, attachment is defined as self-protective strategies and behaviors that are learned via attachment relationships, reflect individual differences in how information regarding safety and danger are processed, and result from ongoing interaction of maturation with circumstance (Crittenden et al., 2010). The DMM retains the secure (B), insecure-avoidant (A), and insecureambivalent (C) patterns of attachment, but does not include disorganization (D). Rather than categorizing children who are distressed or troubled as “disorganized,” the DMM interprets their behavior in terms of self-protective strategies that serve to maximize protection under threatening or dangerous conditions (Farnfield, Hautam¨aki, Nørbech, & Sahhar, 2010). Indeed, many of the DMM subclassifications for A-type and C-type attachment overlap with Main and Solomon’s (1990) criteria for disorganization. The architecture of early attachment representations formed during infancy and childhood extend their influence into adulthood (van Rosmalen, van IJzendoorn, & Bakermans-Kranenburg, 2014). Longitudinal studies by Main and Hesse (1999), Waters, Hamilton, and Weinfield (2000), and Beckwith, Cohen, and Hamilton (1999) have shown that there is a strong association between the quality of attachment within a child’s first year and subsequent attachment representations during adolescence and early childhood (e.g., secure attachment with a caregiver at age 1 year predicted attachment relationships some 16 to 18 years later) (van Rosmalen et al., 2014). Waters et al. (2000) also noted that major life events such as divorce, serious illness, and parental death predicted changes in attachment representations. Thus, it may be reasonable to postulate that early intervention or therapy also may contribute to changes in attachment status (van Rosmalen et al., 2014). Conversely, Sroufe (2005) did not find any meaningful continuity in attachment patterns across infancy into early adulthood (i.e., up to 18 years of age). However, this study longitudinally followed a group of high-risk children (poor, deprived, and with abused or abusing parents), and variations in attachment representation may be more prevalent in children from families dealing with very difficult life circumstances (van Rosmalen et al., 2014). Nevertheless, there is considerable evidence that attachment security during infancy appears to be predictive of attachment security in adulthood, even though significant life events or changes in circumstances may shift attachment patterns (Waters et al., 2000; Weinfeld, Whaley, & Egeland, 2004). Secure attachment in infancy has been associated with positive behaviors such as resilience and curiosity in preschool children (Arend, Grove, & Sroufe, 1978), and self-reliance, selfregulation and social competence in adulthood (Fonagy et al., 2010; Fonagy, Lorenzini, Campbell, & Luyten, 2014; Sroufe, 2005). Children with secure attachments (vs. insecurely attached chil-



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dren) also are rated as having more optimal relationships with peers throughout childhood and adolescence (Schneider, Atkinson, & Tardif, 2001). Secure attachment also has been associated with children’s socioemotional development (Sagi-Schwartz & Aviezer, 2005). Significant associations have been observed between insecure and disorganized attachment and children’s externalizing behavior disorders (e.g., aggression, behavior problems, antisocial behavior) (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010; Lyons-Ruth, Alpern, & Repacholi, 1993). Internalizing behavioral disorders (e.g., anxiety, depression) also have been associated with insecure (avoidant A type) attachment (Colonnesi et al., 2011; Groh, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012; Madigan, Atkinson, Laurin, & Benoit, 2013). In young adults, suicidality and depression have been associated with unavailable emotional attachment with a primary caregiver in childhood (de Jong, 1992; Ledgerwood, 1999; Styron & Janoff-Bulman, 1997). Interventions to Promote Maternal–Child Attachment

Given the risk for multiple poor outcomes across the lifespan in social functioning, behavior, and mental health, efforts to promote secure maternal–child attachment hold promise for broad, profound, and enduring benefit. Interventions designed to promote secure maternal–child attachment may be broadly categorized into indirect and direct approaches. Indirect approaches tend to focus on interventions targeting psychosocial risk factors thought to interfere with maternal–child attachment, such as maternal depression and low social support (Berlin, 2005). Risk factors such as mental illness, substance abuse, intimate partner violence, and adolescent motherhood are well-known psychosocial problems associated with insecure or disorganized maternal–child attachment (Suchman, DeCoste, Rosenberger, & McMahon, 2012; van IJzendoorn, Goldberg, Kroonenberg, & Frenkel, 1992). Removal or mitigation of these psychosocial risk factors (e.g., more social support or fewer symptoms) is thought to enable mothers to become more sensitive and responsive to their infants, thus indirectly promoting secure maternal–infant attachment. Direct approaches to intervention to promote secure maternal–infant attachment focus specifically on the mothers’ (a) sensitive and appropriate responses to the child’s signals relevant to exploration, comfort, and soothing; or (b) maternal reflective function, or the mothers’ ability to reflect on her own and her child’s behavior, thoughts, and feelings in attachment/caregiving interactions and on her personal experience and history affecting current caregiving interactions (Berlin, 2005; Fonagy, Steele, & Steele, 1991; Slade, 2005). Maternal representations, drawn from mothers’ past experience with their own caregivers, affect mothers’ level of reflective function (Suchman, Pajulo, Kalland, DeCoste, & Mayes, 2012). Reflective function may be supported by focusing on maternal representations of attachment relationships with mothers’ own parents and/or how those affect maternal representations of their children (Fonagy et al., 1995; Slade, 2005); thus, addressing distorted maternal representations are frequently the

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focus of reflective function interventions aimed at promoting attachment security (Ordway, Sadler, Dixon, & Slade, 2014; Sadler et al., 2013; Suchman, DeCoste, Leigh, & Borelli, 2010; Suchman, DeCoste et al., 2012). Maternal sensitivity (De Wolff & van IJzendoorn, 1997) and maternal reflective function (Fonagy, Steele, & Steele, 1991) are regarded as critical parental antecedents to children’s attachment security. While maternal reflective functioning is the internal capacity to “mentalize” or envision mental states in oneself and one’s child (Fonagy, 2006; Fonagy, Gergely, Jurist, & Target, 2002), maternal sensitivity is characterized by observable parenting behavioral responses (e.g., soothing) to infant cues (e.g., fussing) (Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Brown, Mangelsdorf, & Neff, 2012; Crittenden & Bonvillian, 1984) that may or may not be underpinned by reflective function. Thus, these constructs are the most proximal targets for interventions aimed at improving maternal–infant attachment quality and thus comprise the variables of interest in seeking to answer the question “Do interventions focused on attachment actually improve attachment security?” While both of these direct approaches seek to change the infants’ experience of maternal care, sensitivity interventions do so by coaching or training the mother to read and respond appropriately to infant cues whereas reflective function interventions seek to enhance the mothers’ understanding of her own psychological representations of caregiving in terms of underlying mental states and intentions (Slade, 2005; Suchman et al., 2010). Past traumas (e.g., maternal histories of unresolved grief, emotional, physical, or sexual trauma) predispose mothers to poor reflective function, characterized by negative and distorted cognitions or representations of reality (Schuengel et al., 1999; Teti & Gelfand, 1997), and frightened, frightening, dissociated, or sexualized behaviors during interactions with their young children, which are associated with insecure or disorganized maternal–child attachments (LyonsRuth, Bronfman, & Atwood, 1999; Schuengel et al., 1999; Zeanah & Smyke, 2008). Alternatively, mothers with high reflective functioning have the ability to see their children as autonomous individuals with “minds of their own” (Fonagy, Steele, & Steele, 1991). For example, in the case of a fussing infant, a highly reflective caregiver would be able to recognize and address the source of the infant’s distress by considering what may be in the infant’s mind while a poorly reflective parent would possibly ignore or misinterpret the infant’s distress (Fonagy, Steele, & Steele, 1991; Fonagy, Steele, Steele, Moran, & Higgitt, 1991; Suchman, Decoste et al., 2012). Thus, higher parental reflective functioning has been empirically associated with improved attachment security (Fonagy et al., 1991) and theorized to do so via improvements in maternal sensitivity (Fonagy et al., 1991; Sadler et al., 2013; Suchmam, Pajulo et al., 2012). Previous systematic reviews of the effectiveness of attachment interventions have attempted to determine the beneficial effects of both direct and indirect types of interventions, with conflicting results (Bakermans-Kranenburg et al., 2003; Berlin, 2005; Egeland, Weinfield, Bosquet, & Cheng, 2000). Egeland et al.’s (2000) narrative systematic review (examining intervention suc-

cess rates) included 15 programs focused on indirect approaches, including maternal mental health and social support, and direct approaches, including maternal sensitivity and/or reflective function. They concluded that interventions, either direct or indirect, were only marginally successful in promoting maternal–child attachment, measured various ways (Egeland et al., 2000). In contrast, Bakermans-Kranenburg et al. (2003) conducted a systematic review and meta-analysis of 29 programs focusing on the same direct and indirect intervention types and found diverging results. When all interventions were combined in the analysis, they observed a small to medium effect size (d = .19) related to attachment measured various ways. However, when they completed sensitivity analyses, restricting their analysis to only studies that used the gold standard Strange Situation Procedure (Ainsworth et al., 1978) to measure attachment, no beneficial effect was found. Potentially, the inclusion of such a wide range of interventions (direct and indirect) prevented them from observing effects on the Strange Situation. Berlin (2005) conducted a narrative systematic review that included 14 studies. While still examining interventions that focused on indirect and direct approaches, they restricted their criteria to include only randomized controlled trials with no-treatment control groups, where the primary aim of the trial was to improve maternal–infant attachment. An additional strength of Berlin’s review was the requirement that all interventions had to be implemented before the child was 1 year old, the age by which children should have developed an organized attachment system (Ainsworth et al., 1978; Bowlby, 1988). Their more rigorous analysis revealed that interventions were beneficial for promoting maternal–child attachment (measured various ways), but that, again, no specific type of intervention (i.e., direct or indirect) was more beneficial than another. However, when they performed sensitivity analysis including only trials that used the Strange Situation Procedure to assess attachment, only 4 of 11 (36%) were found to be successful in promoting secure attachment. In summary, none of the existing reviews of the effectiveness of attachment interventions has revealed strong endorsement for beneficial effects of intervention on attachment security, measured by the gold standard. Further, each of the three reviews drew different conclusions based on the trends that they observed in the data. BakermansKranenburg et al. (2003) concluded that interventions were more likely to have a larger effect on attachment if they focused on maternal sensitivity, started when infants were older than 6 months of age, and included 16 sessions or fewer. In contrast, Egeland et al. (2000) concluded that interventions should be intensive and combine both maternal sensitivity and reflective function components. Berlin (2005) took the middle ground, suggesting that the timing and intensity should match the needs of the mother and infant. However, all agreed that direct interventions focused on maternal sensitivity and/or reflective function will likely produce more beneficial effects on maternal–child attachment, providing the impetus for this updated review. Although there is no strict critical period for becoming attached, there are certainly sensitive periods in which attachment representations are formed (van Rosmalen et al., 2014). Bowlby

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Narrative and Meta-Analytic Review of Infant Attachment Interventions

(1988) himself noted that attachment is open to environmental influences—both good and bad—up to the age of 5 years; however, corrective attachment experiences that may help to steer children toward security can occur even after this period of sensitivity. In other words, rather than definitive mental representations of attachment by age 5, children have a dynamic “internal working model” of attachment that continually processes environmental information and adapts to the changing circumstances (van Rosmalen et al., 2014). The impressionable nature of children’s internal working model of attachment underscores how these early years are a prime window of opportunity for promoting attachment relationships. While there is considerable evidence supporting the efficacy and beneficence of attachment-based interventions for children aged 0 to 5 years (Bakermans-Kranenburg et al., 2003; Moss et al., 2011; van Zeijl et al., 2006), for this review, we were primarily interested in the effectiveness of interventions delivered in the first postpartum year. This focus was motivated by the proliferation of large, population-based, home-visiting programs designed to support early parent–child relationships and promote attachment, which are commonly conducted within the child’s first year (Bakermans-Kranenburg et al., 2003; Barlow, Bennett, Midgley, Larkin, & Wei, 2015; Ordway, Sadler, Dixon, Close, Mayes & Slade, 2014). Given that the intent of this review is to inform current practice and when we consider that families with young infants will have numerous encounters with healthcare professionals within the first year, it becomes pragmatic and necessary to conduct a specific exploration of attachment-based interventions that have been effective in that age range. In summary, past reviews have revealed marginal effectiveness at best and have produced conflicting conclusions. These findings may be due to the wide range of interventions (direct and indirect), wide variety of study methods, time frames for intervention, and study qualities; and differing review methods (e.g., percentage success vs. effect sizes) included in past reviews. With the passage of time, more studies are now available for inclusion in an updated, rigorous review with renewed focus. Moreover, more studies are now available for analysis that have utilized the gold standards (Strange Situation Procedure: Ainsworth et al., 1978; Q-set Attachment Questionnaire: Waters & Deane, 1985). Thus, the primary goal of this systematic review and meta-analysis was to determine the effectiveness of direct interventions focused on either maternal sensitivity or reflective function, conducted prior to the infant’s second year of life, on maternal–child attachment security. Secondary goals focused on determining (a) the effectiveness of direct interventions on a range of outcomes, including maternal– child interaction, infant behavior and development, and maternal mental health; (b) characteristics of successful interventions; and (c) updating information from the previous reviews. METHOD

State-of-the-science Cochrane systematic review methods were employed for the systematic review. Cochrane methods utilize a highly standardized and structured approach to data collection,



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critical appraisal, and analysis of primary research facilitated by the use of Review Manager (RevMan; 2012) software to ensure transparency and reproducibility (Higgins & Green, 2009). Studies focused on mother–child attachment were identified through the bibliographic databases of the Cochrane CINAHL, Dissertation Abstracts, ERIC, EMBASE, MEDLINE, PsychINFO, and Web of Science, and hand searching of journals, meeting abstracts, technical or research reports, monographs, doctoral dissertations, bibliographies of retrieved papers, and relevant Web sites. The following terms were used in the search strategy: (women OR female OR mother∗ OR maternal) AND (newborn OR child∗ OR infant OR toddler OR baby) AND (parent∗ OR child rearing) AND (attachment OR mother-child relation∗ OR maternal behavior OR maternal sensitivity OR parental sensitivity OR security) AND (randomized controlled trial OR quasi-randomized controlled trial OR quasi-experimental OR controlled study OR clinical controlled trial OR random allocation OR evaluation study). No publication language or date of publication limits was set during database searches. The literature search is current to October 2013. Two trained research assistants reviewed the title, abstract, or description of all trials identified by the literature search. All databases were searched on the same day, with the same search strategy and search terms. Those that appeared to address the subject of maternal–child attachment were selected for full text review to determine if they met inclusion criteria. The lead author addressed any discrepancies and had final decision of inclusion. Befitting Cochrane guidelines, only randomized or quasirandomized controlled trials were included. Mothers and infants up to 36 months’ postpartum were included, irrespective of whether they were deemed high-risk (e.g., postnatal depression, domestic violence, and concerns about child abuse). To minimize potential confounders, children experiencing a neurodevelopmental or specifically defined disability (e.g., physical or cognitive impairment and sensory deficits, variously defined in the studies) were excluded. To be included, the primary aim of the trial was to improve maternal–infant attachment in the first year of infant life via increasing maternal sensitivity and appropriate responsiveness to the child’s signals relevant to exploration, comfort, and soothing; and/or increasing maternal ability to reflect on (a) her own and her child’s behavior, thoughts, and feelings in attachment/caregiving interactions; and/or (b) her personal experience, history, and maternal representations affecting current caregiving interactions. The control group must have been assigned to receive no intervention, standard care, or be assigned to a wait-list group. Outcome Measures

The primary outcome was the number of infants demonstrating secure attachment with their mother based on the Strange Situation Procedure (Ainsworth et al., 1978) or the Q-set Attachment Questionnaire (Waters & Deane, 1985), the most widely acceptable, reliable, and valid measures of infant–mother attachment. Data for the Strange Situation was dichotomized into two categories, with infants assessed as securely attached (B) compared to infants whose

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attachment was assessed as being insecure. Insecure attachment included the following types: avoidant (A), resistant/ambivalent (C), or disorganized (D). Q-set data were continuous, with scores ranging from −1.0 to +1.0. Secondary outcome measures of interest included measures of (a) maternal–child interaction; (b) child behavior; and (c) maternal depression, stress, and parenting efficacy. Quality Assessment

Two research assistants independently assessed the quality of all included studies using the Physiotherapy Evidence Database (PEDro) (Moseley, Herbert, Sherrington, & Maher, 2002). The PEDro includes 10 methodological criteria, each of which was scored 1 if present or 0 if absent. Example items include: (a) participants were randomly allocated to groups; (b) allocation was concealed; (c) groups were similar at baseline regarding the most important prognostic indicators; (d) blinding of all subjects; and (e) intention-totreat analysis was performed. Blinding of assessors was considered adequate if the reader could be satisfied that the apparent effect (or lack of effect) of the treatment was not due to the assessor’s bias impinging on their measured outcomes. Studies were deemed to use intention-to-treat analysis if the trial: (a) explicitly stated that an intention-to-treat analysis was performed or (b) experienced no dropouts or losses to follow-up and stated that patients were analyzed according to the original group assignment. The methodological quality of the studies was categorized as excellent (score 9–10), good (score 6–8), fair (score 4–5), or poor (score ࣘ3 or less) according the levels of evidence. Any discrepancies between raters were resolved by the lead author. Data Extraction

Two research assistants independently extracted data from included studies onto a pilot-tested, data-abstraction form. Extracted data included sample characteristics, intervention characteristics, outcomes (including baseline and postintervention scores), and statistical findings. Primary authors were contacted if additional information was required to include the trial in the meta-analyses. Statistical Analysis and Data Synthesis

All data were entered and analyzed using Review Manager software (Higgins & Green, 2009; Review Manager [RevMan], 2012). For dichotomous variables (Strange Situation Procedure), individual and pooled statistics were calculated as odds ratio (OR) with 95% confidence intervals (CIs). For continuous variables (Attachment Q-set), individual and pooled statistics were calculated as standardized mean difference with 95% CIs. When two controlintervention comparisons used the same group twice as comparator (e.g., a three-arm study that had two intervention arms, but only one control arm), the number of participants in the group used twice was halved to avoid overrepresentation. We assessed statistical heterogeneity using the τ 2 , ι2 , and χ 2 statistics. We regarded heterogeneity as substantial if ι2 was greater than 30% or if there

was a low p value ( 6). Study participants included mothers who were: (a) financially stressed (Cassidy et al., 2011; P. Cooper et al., 2009; Svanberg et al., 2010); (b) caring for an adoptive (Juffer et al., 2005; Juffer et al., 1997) or irritable (Cassidy et al., 2011; van den Boom, 1995) infant; (c) depressed (van Doesum et al., 2008); (d) from intact families (Kalinauskiene et al., 2009; Santelices et al., 2010), yet observed to be insensitive to their infants (Kalinauskiene et al., 2009); or (e) from complex situations (maltreating, large family size, unstable marriages, and/or financially stressed) (Cicchetti et al., 2006).

All trial interventions focused on increasing maternal sensitivity alone (P. Cooper et al., 2009; Juffer et al., 2005; Juffer et al., 1997; Kalinauskiene et al., 2009; Svanberg et al., 2010; van den Boom, 1995; van Doesum et al., 2008) or in combination with reflective function (Cassidy et al., 2011; Cicchetti et al., 2006; Santelices et al., 2010). Studies that focused only on increasing maternal sensitivity employed a variety of methods, such as a personalized book focused on sensitive and playful parenting (Juffer et al., 2005; Juffer et al., 1997); video feedback of mother–child interactions (Juffer et al., 2005; Juffer et al., 1997; Kalinauskiene et al., 2009; Svanberg et al., 2010; van Doesum et al., 2008); modeling, cognitive restructuring, and infant massage (van Doesum et al., 2008); and teaching about infant cues and contingent maternal responsiveness (P. Cooper et al., 2009). Studies aimed at increasing maternal sensitivity in combination with reflective function (and underlying maternal representations) did so by home visiting to help mothers reflect on parenting and attend to infant attachment and exploratory behaviors while observing videorecorded mother–child interactions (Cassidy et al., 2011), group workshops with mothers followed by individualized video

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Participants RECRUITMENT CENTER: Hospital setting STUDY POPULATION: Mothers in financial stress and their biological child SIZE OF STUDY POPULTION: 174 mother–child pairs: 86 intervention group, 88 control group INCLUSION CRITERIA: Infants scoring in the top-20% on irritability composite scores on the Neonatal Behavioral Assessment Scale EXCLUSION CRITERIA: None listed CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): 24.1 (5.23) years Education: 77% less than college degrees Income: 72% with income become $14,000–45,000 CHILDREN: Ethnicity: 20.5 Caucasian, 43.2% Black, 19.5% Other, 14.1% Latino, 2.7% Asian RECRUITMENT CENTER: Department of Human Services–Child Protective Service, assistance program STUDY POPULATION: 12-month-old infants in maltreating families and their mothers, mothers in financial stress, with large family size or unstable marriages, and their biological child SIZE OF STUDY POPULTION: 189 mother–child pairs: 24 PPI intervention, 32 IPP intervention, 81 community standard, 52 nonmaltreated controls INCLUSION CRITERIA: Maltreatment determinations classified by trained coders via the Maltreatment Classification System; no additional details provided EXCLUSION CRITERIA: Child in foster care Receiving Temporary Assistance to Needy Families CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): 26.98 (5.98) years Ethnicity: 74.6% minority race Income: 96% receiving financial assistance CHILDREN: Age (M, SD): 13.31 (0.81) months Sex (male): 46.6%

Methods

STUDY DESIGN: Randomized controlled trial 2 Parallel group Multicenter ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: NO Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 6

STUDY DESIGN: Randomized controlled trial 3 Parallel group Single center ALLOCATION: Progressive block randomization procedure was employed. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: NO Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 6

Cassidy et al. (2011) USA

Cicchetti et al. (2006) USA

Study

TABLE 1. Characteristics of Included Studies Intervention

TARGET: Maternal sensitivity Maternal reflective function LENGTH OF INTERVENTION PHASE: PPI conducted over 2 years IPP conducted over 1 year INTERVENTION GROUP: PPI (maternal representation): Provision of information and knowledge regarding child development, and training in parenting technique, problem solving, and relaxation. Parenting and social skill topics were tailored to each mother’s primary needs. IPP (infant–parent psychotherapy): Joint observation of infant by therapist and mother to allow distorted emotional reactions and perceptions of the infants as they are enacted during mother–infant interaction to be associated with memories and affects from the mother’s prior childhood experiences. The intervention provides the mother with a corrective emotional experience to allow her to differentiate current from past relationships, form positive internal representation of herself, and of herself in relationship to her infants. CONTROL GROUP: Standard services available to maltreating families in the community NORMATIVE COMPARISON GROUP: No intervention CO-INTERVENTION: None listed

Primary Outcome

ATTACHMENT: Strange Situation Procedure

ATTACHMENT: Strange Situation Procedure

None reported

(Continued)

Secondary Outcomes None reported



TARGET: Maternal sensitivity Maternal reflective function LENGTH OF INTERVENTION PHASE: 9 weeks INTERVENTION GROUP: Circle of security, home visiting to help mothers attend to infant attachment and exploratory behaviors, which exploring mother’s cognitive and affective responses to her behavior. Intervention also included video feedback of infant signals and maternal response. CONTROL GROUP: Psychoeducational sessions and reading material addressing caregiving topics. CO-INTERVENTION: None listed

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Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Participants RECRUITMENT CENTER: Peri-urban settlement STUDY POPULATION: Mothers in financial stress with their biological child SIZE OF STUDY POPULTION: 449 mother–child pairs: 220 intervention, 229 control INCLUSION CRITERIA: Live birth Signed consent EXCLUSION CRITERIA: None listed CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS: M (SD) age (years) of mothers: Intervention 25.5 (5.23) Control 26.2 (5.84) Major depressive disorder: Intervention 36 (16%) Control 36 (16%) Unplanned pregnancy: Intervention 89 (40%) Control 83 (36%) Married/cohabiting: Intervention 133 (60%) Control 140 (61%) First child: Intervention: 83 (38%) Control 83 (36%) Male child Intervention: Intervention: 106 (48%) Control: 110 (48%) Housing (shack): Intervention: 185 (84%) Control: 199 (87%) RECRUITMENT CENTER: Adoption agencies STUDY POPULATION: Mothers and their adopted children SIZE OF STUDY POPULTION: 130 mother–child pairs: 30 Book intervention, 50 Book &Video-feedback intervention, 50 control INCLUSION CRITERIA: Child adopted prior to 6 months of age Families with a first adopted children or with birth children and a first adopted child EXCLUSION CRITERIA: Children adopted past 6 months of age CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTSMOTHERS: Income: Upper middle class Ethnicity: 100% Caucasian CHILDREN: Sex (male): 50.8% Ethnicity: 10% Latino, 90% Asian

Methods

STUDY DESIGN: Randomized controlled trial 2 Parallel group Single center ALLOCATION: Description of randomization was not reported. Group allocation was assigned by trial manager situated offsite, by telephone. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: YES Between-group comparison: NO Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: NO Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 6

STUDY DESIGN: Randomized controlled trial 3 Parallel group Single center ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: YES Blinding of therapist: NO Blinding of assessor: NO Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 7

P. Cooper et al. (2009) South Africa

Juffer et al. (2005) Netherlands

Study

TABLE 1. Continued Intervention

Book and video feedback (B&V): Personalized book with information focusing on sensitive parenting, with suggestions for sensitive parenting and playful interactions and video feedback of maternal–child interaction CONTROL GROUP: Received booklet on adoption issues CO-INTERVENTION: None listed

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: 2 sessions INTERVENTION GROUP: Book only (B): Personalized book with information focusing on sensitive parenting, with suggestions for sensitive parenting and playful interactions

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: 16 one-hr sessions over 5 months INTERVENTION GROUP: Encouragement of sensitive and responsive interaction with infants to sensitize mother to her infant’s individual capacities and needs CONTROL GROUP: Standard care CO-INTERVENTION: Provided to both groups: Normal services as provided by the local infant clinic, including assessment of physical and medical progress of mothers and infants, and encouragement of mothers to take their infants to local clinic for physical assessment and immunization.

Primary Outcome

ATTACHMENT: Strange Situation Procedure

ATTACHMENT: Strange Situation Procedure

Secondary Outcomes

(Continued)

MATERNAL–CHILD INTERACTION: Maternal Sensitive Responsiveness

RELATIONSHIP: Quality of maternal engagement with infant DEPRESSION: Maternal Depression

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Participants RECRUITMENT CENTER: Adoption agencies STUDY POPULATION: Asian children placed as infants into White families SIZE OF STUDY POPULTION: 90 mother–child pairs: 30 B intervention, 30 B&V intervention, 30 control INCLUSION CRITERIA: Adopted child was first child in the family and placed before 5 months EXCLUSION CRITERIA: Twins Infants with serious disease CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): 35.2 (3.35) years Education: 12% university; 37% college or trade school, 51 primary education CHILDREN: Age (M, SD): 8 (3.67) weeks Sex (male): 48.9% Ethnicity: 100% Asian Birth order: 100% only child RECRUITMENT CENTER: Hospital setting STUDY POPULATION: Mothers and their first born infant SIZE OF STUDY POPULTION: 54 mother–child pairs; 26 intervention, 28 control INCLUSION CRITERIA: Mothers from intact families, who were primary caregiver to their infants and did not work until children reach 12 months Minimum high-school education Mother scored as insensitive based on play interaction. EXCLUSION CRITERIA: None listed CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): 26.4 (2.94) years Education: 16.8 (SD 2.43) years of education CHILDREN: Age (M, SD): 6 months (12 days) Sex (male): 51.9%

Methods

STUDY DESIGN: Quasi-randomized controlled trial 3 Parallel group Single center ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: NO Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 6

STUDY DESIGN: Randomized controlled trial 2 Parallel group Multicenter ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: YES Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 8

Juffer et al. (1997) Netherlands

Kalinauskiene et al. (2009) Lithuania

Intervention

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: Five 90-min sessions INTERVENTION GROUP: Attachment based video feedback plus baby’s diary CONTROL GROUP: No treatment; were contacted by telephone and asked for information about infants’ development CO-INTERVENTION: None listed

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: 2 sessions for B, 3 session for B&V over the course of 7 months (aged 5 months at baseline; final data collection at 12 months) INTERVENTION GROUP: Book only (B): Personalized book with information focusing on sensitive parenting, with suggestions for sensitive parenting and playful interactions Book and video feedback (B&V): Personalized book with information focusing on sensitive parenting, with suggestions for sensitive parenting and playful interactions and video feedback of maternal–child interaction CONTROL GROUP: Received booklet on adoption issues CO-INTERVENTION: None listed

Primary Outcome

SENSITIVITY: Ainsworth Sensitivity Scale ATTACHMENT: Waters’ Attachment Q-Set

ATTACHMENT: Strange Situation Procedure

Secondary Outcomes

None reported

(Continued)

MATERNAL–CHILD INTERACTION: Maternal Sensitive Responsiveness INFANT COMPETENCE: Infant Exploratory Competence



Study

TABLE 1. Continued

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Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Svanberg et al. (2010) England

Santelices et al. (2010) Chile

Study

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: Variable depending on the intervention INTERVENTION GROUP: Reflective videotape-based feedback tailored to each risk group (sensitive enough; struggling; and high risk) to increase maternal sensitivity; based on outcome of video-based baseline evaluation of maternal sensitivity using the CARE-Index, one of three interventions were offered: 1 session of positive feedback, guidance on emotional development in infancy, and a leaflet on early child development for “Sensitive-enough” 4 sessions accentuating positive elements of maternal–child interaction, improving reading, and responding to infant cues; and increasing mother’s understanding of her representation of herself and her infants for “Struggling” Same intervention as “struggling” group as well as psychotherapy and couples or family therapy is needed for “High-risk.” CONTROL GROUP: Standard health visiting practices, including a home visit 2-weeks’ postpartum, and routine monitoring of development in regular clinics CO-INTERVENTION: None listed

RECRUITMENT CENTER: Family support center (Sure Start Programme) STUDY POPULATION: Mothers in financial stress and their biological children SIZE OF STUDY POPULTION: 323 mother–child pairs: 241 intervention, 82 control INCLUSION CRITERIA: New mothers EXCLUSION CRITERIA: None listed CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): 26.1 (5.7) years Father or other adult present in home: 74% Working status: (working) 58% (nonworking) 42% CHILDREN: Sex: (male) 52% (female) 48%

Intervention TARGET: Maternal sensitivity Maternal reflective function LENGTH OF INTERVENTION PHASE: Six 2-hr weekly sessions followed by four 1-hr sessions INTERVENTION GROUP: Facilitation of a link between mother and her unborn child, contention and reflection, followed by Secure Attachment Promotion Program group workshop offering psychoeducational feedback designed to improve mother’s sensitivity to infant response. CONTROL GROUP: Educational lecture during 3rd trimester about attachment and the affective life of the newborn CO-INTERVENTION: None listed

Participants RECRUITMENT CENTER: Clinics STUDY POPULATION: Stable mothers and their biological children SIZE OF STUDY POPULTION: 72 mother–child pairs: 43 intervention, 29 control (at end of trial) INCLUSION CRITERIA: Pregnant, middle-lower class women who sought prenatal care Primipara mothers aged 18 to 40 years old EXCLUSION CRITERIA: Presentation of serious psychiatric diagnosis CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTSMOTHERS: Age (M, SD): 26.4 (4.82) years CHILDREN: 12 to 18 months at posttest

Methods

STUDY DESIGN: Randomized controlled trial 2 Parallel group Multicenter ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: NO Adequacy of follow-up: NO Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 5 STUDY DESIGN: Quasi-randomized controlled trial 2 Parallel group Multicenter ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: NO Concealed allocation: NO Between-group comparison: NO Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: NO Adequacy of follow-up: NO Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 3

TABLE 1. Continued Primary Outcome

ATTACHMENT: Strange Situation Procedure

ATTACHMENT: Strange Situation Procedure

Secondary Outcomes

(Continued)

SENSITIVITY: Child-Adult Relationship Experimental (CARE) Index

None reported

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Participants RECRUITMENT CENTER: Therapist referrals, advertisements STUDY POPULATION: Depressed mothers and their biological child SIZE OF STUDY POPULTION: 85 mother–child pairs: 43 intervention, 42 control INCLUSION CRITERIA: Mothers meeting criteria for major depressive episode or dysthymia and/or exhibited levels of depressive symptoms and who were receiving concurrent outpatient treatment for their depression EXCLUSION CRITERIA: Psychotic disorder, manic depression, and substance dependence CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Age (M, SD): not available Ethnicity: 85% Caucasian, 15% Other CHILDREN: Age (M, SD): 5.5 months Birth Order: 60% Firstborn, 40% Second-born RECRUITMENT CENTER: University Hospital, midwives STUDY POPULATION: Mothers and their irritable infants SIZE OF STUDY POPULTION: 79 mother–child pairs: 39 intervention, 40 control INCLUSION CRITERIA: Families were considered eligible for the project if their clinic records indicated the following: (a) the pregnancy would result in the mother’s firstborn child, (b) there were no serious complications of pregnancy, (c) the families were lower class, (d) the infants were irritable as indicated on two separate Brazelton exams. EXCLUSION CRITERIA: Not listed CHARACTERISTIC OF INCLUDED STUDY PARTICIPANTS-MOTHERS: Information not available

Methods

STUDY DESIGN: Randomized controlled trial 2 Parallel group Multicenter ALLOCATION: Computer-generated randomization sequence. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 5

STUDY DESIGN: Randomized controlled trial 4 group factorial design Single center ALLOCATION: Description of randomization was not reported. Whether allocation was concealed was not reported. PEDro QUALITY RATING SCORE: Random allocation: YES Concealed allocation: NO Between-group comparison: YES Blinding of subject: NO Blinding of therapist: NO Blinding of assessor: YES Adequacy of follow-up: YES Intention-to-treat analysis: YES Baseline comparability: YES Point estimates & measure of variability: YES Total PEDro Score: 7

van Doesum et al. (2008) Netherlands

van den Boom 1995 Netherlands

Intervention

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: 3 months INTERVENTION GROUP: Skill-based training program to enhance maternal sensitivity between 6 and 9 months of age. The intervention focused on responsiveness to negative and positive infant cues and was implemented during everyday interactions. Intervention was a mothering/skill-based one. CONTROL GROUP: All pairs received two immediate posttreatment assessments (mother–infant interaction and infant exploration) and a delayed posttreatment assessment CO-INTERVENTION: None-listed

TARGET: Maternal sensitivity LENGTH OF INTERVENTION PHASE: Eight to ten 60- to 90-min home visits over 3 to 4 months INTERVENTION GROUP: Video feedback of mother–child interaction, followed by discussion and teaching of 1 of 4 techniques (modeling, cognitive restructuring, practical pedagogical support, and baby massage) for mothers to practice and learn new, more sensitive interactive behaviors. CONTROL GROUP: Three 15-min telephone calls supporting mothers with practical parenting advice CO-INTERVENTION: Outpatient treatment for depression

Primary Outcome

ATTACHMENT: Strange Situation Procedure Attachment Q-set

ATTACHMENT: Attachment Q-Set Version 3

Secondary Outcomes

MENTAL DEVELOPMENT: Bayley Scales of Infant Development SENSITIVITY: Mother Acceptance Accessibility Cooperation Sensitivity COGNITIVE: McCarthy Scales of Children’s Abilities BEHAVIOR: Child Behavior Checklist

MATERNAL–CHILD INTER-ACTION: Emotional Availability Scale INFANT SOCIOEMOTIONAL FUNCTIONING: Infant–Toddler Social and Emotional Assessment (ITSEA)



Study

TABLE 1. Continued

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TABLE 2. Summary of Main Treatment Effect of Interventions From Included Studies Study & Focus

PEDro Score

Effect on Maternal–Infant Attachment

Cassidy et al. (2011) (Sensitivity & Reflective Function) Cicchetti et al. (2006) (Sensitivity & Reflective Function) P. Cooper et al. (2009) (Sensitivity)

6



6

+

6

+

Juffer et al. (1997) (Sensitivity)

6

+ −

∗ Juffer

et al. (2005) (Sensivitity)

7

+ −

Kalinauskiee et al. (2009) (Sensitivity)

8



Santelices et al. (2010) (Sensitivity & Reflective Function) Svanberg et al. (2010) (Sensitivity)

5



3

+

5

+

7

+

∗ van

Doesum et al. (2010) (Sensitivity)

van den Boom (1995) (Sensitivity)

No main treatment effect of intervention that included Circle of Security, home visiting, and video feedback on maternal–child attachment compared to psychoeducational sessions and reading material. Infant–parent psychotherapy that included supportive, nondirective, and nondidactic developmental guidance significantly improved maternal–child attachment as compared to standard community service for maltreating families. Home visits delivered by community residents who encouraged sensitive and responsive interactions between mother and child significantly improved maternal–child attachment as compared to standard community practices. Provision of a book consisting of written information on sensitive parenting combined with video feedback significantly improved maternal–child attachment as compared to standard practice of the provision of booklet on adoption issues. Provision of a book consisting of written information on sensitive parenting alone had no impact on maternal–child attachment as compared to standard practice of the provision of booklet on adoption issues Provision of video feedback and the personal book improved maternal–child attachment, as compared to control group. Provision of a book consisting of written information on sensitive parenting alone had no impact on maternal–child attachment, compared to control group. Home visits that included video feedback and a baby diary had no impact on maternal–child attachment as compared to telephone contact to ask mothers about their infants’ development. The Secure Attachment Promotion Program that included group workshops had no impact on maternal–child attachment as compared to an educational lecture during pregnancy about attachment and the affective life of a newborn. The Sunderland Infant Program consisting of home visits, video feedback, and psychotherapy significantly improved maternal–child attachment as compared to standard health practice. Home visits that included video feedback, discussion, modeling, cognitive restructuring, practical pedagogical support, and baby massage significantly improved maternal–child attachment as compared to parenting support by telephone. Skill-based training program focusing on responsive parenting significant improved maternal–child attachment as compared to no treatment.

+Statistically significant treatment effect on maternal–infant attachment. −No change in maternal–infant attachment. ∗ Not included in meta-analysis because numeric data could not be obtained from the authors.

feedback of infant signals to change maternal representations (Santelices et al., 2010), and infant–parent psychotherapy focused on mothers’ distorted maternal representations and associated emotional reactions and perceptions of their infants (Cicchetti et al., 2006). None of the studies included any measurements of parental reflective functioning as an outcome. Primary Outcome

Maternal–child attachment security. The main outcome for this review was maternal–infant attachment security. In their analyses, four of the papers dichotomized attachment security along the security versus insecurity dimension (Cassidy et al., 2011; Juffer et al., 1997; Santelices et al., 2010; van den Boom, 1995), and four used a fuller spectrum of attachment categorizations (e.g., ABCD) (Cicchetti et al., 2006; P. Cooper et al., 2009; Juffer et al., 2005; Svanberg et al., 2010). Two studies utilized the Attachment Q-set (Waters & Deane, 1985), which assesses the security versus insecurity dimension on a continuum (Kalinauskiene et al., 2009; van Doesum et al., 2008).

Only the seven studies that used the Strange Situation Procedure (Ainsworth et al., 1978) to determine attachment pattern were aggregated and combined in meta-analysis. Because most of the seven studies included in our analysis dichotomized attachment security, we adopted the same approach. This also permitted us to maximize the sample size for meta-analysis. There was a beneficial effect of the interventions aimed at increasing maternal sensitivity alone or in combination with reflective function as compared to no or standard intervention (seven trials; OR = 2.77; 95% CI = 1.69, 4.53, n = 965). The number needed to treat to prevent 1 mother– infant pair from forming an insecure attachment was 4.17 (95% CI = 3.17, 6.05). The fail-safe N test statistic was 85, indicating that 85 trials with no group difference would be needed to reverse these findings. As there was significant heterogeneity across the trials included in the meta-analysis, τ 2 = 0.26; χ 2 = 16.63, df = 7, p = .02; ι2 = 58%, sensitivity analysis was undertaken. First, temporarily eliminating the trial that was deemed to be poor quality (Svanberg et al., 2010) revealed a slight increase in the odds of secure attachment associated with intervention (six trials; OR = 2.86; 95% CI = 1.58, 5.19, n = 804). Second, meta-analysis

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N. Letourneau et al.

FIGURE 2.

FIGURE 3.

FIGURE 4.

All trials.

Higher quality trials.

All trials focused on maternal sensitivity.

of interventions focused on maternal sensitivity alone increased the odds of secure attachment with (five trials; OR = 2.82; 95% CI = 1.65, 4.83, n = 405) or without the low quality trial (four trials; OR = 2.97; CI = 1.37, 6.44, n = 508). Finally, meta-analysis of interventions that focused on increasing both maternal sensitivity and reflective function also revealed beneficial effects (three trials, OR = 3.39; 95% CI = 0.90, 2.74, n = 296) (for details, see Figures 2–6).

Six of seven interventions that focused on sensitivity resulted in significantly more securely attached infants (P. Cooper et al., 2009; Juffer et al., 2005; Juffer et al., 1997; Svanberg et al., 2010; van den Boom, 1995; van Doesum et al., 2008). Juffer et al. (2005) observed a greater proportion of disorganized infants in the control group. Svanberg et al. (2010) found significant differences in attachment classification using the ABC categories of the DMM, but only on the secure-insecure dimension and not on the avoidant

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Narrative and Meta-Analytic Review of Infant Attachment Interventions

FIGURE 5.

FIGURE 6.



381

Higher quality trials focused on maternal sensitivity.

All trials focused on both maternal sensitivity and reflective function.

(A) or ambivalent (C) categories. P. Cooper et al. (2009) also noted that differences between treatment and control groups were driven by more avoidant infants in the control group postintervention. Of the successful interventions, dosage in these trials ranged from 2 to 4 home visits (Juffer et al., 2005; Svanberg et al., 2010), to 8 to 10 home visits (van Doesum et al., 2008), to weekly sessions over 3 to 7 months (P. Cooper et al., 2009; Juffer et al., 2005; Juffer et al., 1997; Svanberg et al., 2010; van den Boom, 1995). Interventions were timed to begin prenatally and lasted until 6 months’ postpartum (P. Cooper et al., 2009), when infants were between 6 and 9 months of age (Juffer et al., 2005; Juffer et al., 1997; van den Boom, 1995), when infants were up to 12 months of age (van

Doesum et al., 2008), or when infants were 3 months of age, ending at 12 months of age (Svanberg et al., 2010). The most effective trial (i.e., the study with the highest OR) focused on maternal sensitivity was by van den Boom (1995), who provided skills-based training to mothers of 6- to 9-month-old irritable infants. Results revealed that intervention children were over six times as likely to be securely attached as were controls. Two of three intervention trials that focused on both maternal sensitivity and reflective function yielded significantly more securely attached children (Cicchetti et al., 2006; Santelices et al., 2010), and the one unsuccessful trial revealed a significant treatment effect for highly irritable infants (Cassidy et al., 2011).

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

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Santelices et al. (2010) focused on “representations about motherhood and their own experience as daughters [and] imaginary vs. real baby” (p. 206). Cicchetti et al. (2006) focused on “representational models that evolved in response to the mother’s own experiences in childhood [and] unresolved and conflictual feelings that can be projected on to the child” (p. 629). Cassidy et al. (2011) tested a version of Circle of Security (G. Cooper, Hoffman, & Powell, 2000) in which mothers were asked to reflect on their parenting and interveners “modeled reflective functioning” (p. 145). Reflective function is a key component of the Circle of Security program (Powell, Cooper, Hoffman, & Marvin, 2014). Program dosages ranged from six 2-hr, one-on-one sessions followed by four weekly, 1-hr group workshops (Santelices et al., 2010) to 1 year of infant–parent psychotherapy (Cicchetti et al., 2006). Interventions were timed to begin prenatally and continue over the infants’ first year of life (Cicchetti et al., 2006; Santelices et al., 2010; van Doesum et al., 2008). Of all the trials reviewed, the one with the largest OR was Cicchetti et al.’s 2010 evaluation of infant–parent psychotherapy for parents and their maltreated children. They found that intervention children were over 40 times as likely to be securely attached as were controls. Secondary Outcomes

Maternal–child interaction. Seven of the 10 trials included measures of maternal–child interaction, and all found significant differences associated with the intervention. The variety of methods used to assess maternal–child interaction precluded aggregation via meta-analysis. Svanberg et al. (2010) observed intervention infants to be more cooperative, F(1, 184) = 5.3, p < .05, and less compulsive, F(1, 187) = 11.3, p < .001, than were comparison infants on the CARE-Index (Crittenden, 2010). van Doesum et al. (2008) observed that mother–infant interaction was significantly improved on four dimensions of the Emotional Availability Scales (Biringen et al., 2005): maternal sensitivity, F(2, 68) = 13.06, p

NARRATIVE AND META-ANALYTIC REVIEW OF INTERVENTIONS AIMING TO IMPROVE MATERNAL-CHILD ATTACHMENT SECURITY.

Early secure maternal-child attachment relationships lay the foundation for children's healthy social and mental development. Interventions targeting ...
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