Targeted and high risk approached to supporting parent-infant relationships and attachment security
Promotion of parental sensitivity and attunement to infant needs
Maternal and paternal sensitivity and attunement to their infants have been much researched because of their influence on the development of the infant’s social and emotional brain. A key way in which the latter has been measured in infants is attachment security – observation of the response of the infant or young child to separation from the parent. Long-term studies have also examined the impact of these aspects of parenting on emotional and social development and behaviour, the quality of peer relationships, and mental health more generally.
Attachment-based interventions are diverse and range from parent-infant psychotherapy to interaction guidance (including video feedback). Parent-infant psychotherapy involves specialists (parent-infant psychotherapists) working with both mother and baby using psychotherapeutic methods to treat a range of problems including attachment difficulties and abusive parenting by focusing on the relationship between the parent and infant, parental representations, and parenting practices.
Such interventions are usually delivered on a one to one basis and may be delivered in the home or clinic.
Summary of the evidence:
- It is possible to enhance maternal sensitivity and attunement in these high risk groups with the following approaches.
- Video Interaction Guidance (VIG) can be effective in improving infant symptoms, mother-infant interaction, maternal sensitivity, and maternal representations. There is no evidence about its effectiveness in improving attachment security.
- Parent-infant psychotherapy can be effective in reducing infant-presenting problems, decreasing parenting stress, and reducing maternal intrusiveness and mother-infant conflict, improving maternal sensitivity, responsiveness and reciprocity, and infant attachment.
Several research groups have developed interventions to support the development of sensitivity, attunement and attachment and we identified three reviews which looked specifically at such interventions (Bakermans-Kranenburg, 2003, 2005; Doughty, 2007) Reviews included in other sections (see universal Approached to Supporting Parent-Infant Relationships) which focus on interventions like infant massage, the NBAS and treatment of postnatal depression have included studies with measures of parental sensitivity which are relevant to this section.
One further large narrative review (Barnes 2003) covered a very wide range of interventions to enhance the mental health of children (0-4 years) and families including many interventions relating to attachment security. This review addresses key issues relating to provision and engagement of participants, which meta-analytic reviews do not cover.
Enhancing parental sensitivity and/or infant attachment:
The earliest focused review contained 81 studies, involving 7,636 families and 88 outcomes (Bakermans-Kranenburg, 2003). A wide range of Interventions were included and coded according to their focus as follows:- interventions that aimed to enhance sensitivity; interventions that aimed to enhance sensitivity and maternal representations; and interventions to increase social support; or any combination of the three. For example, interaction guidance with or without video was used to enhance parental sensitivity; psychotherapy was used to transform maternal representations; and in social support interventions, experienced mothers befriended and offered practical help to highly anxious mothers. Several interventions combined different strategies. This review concluded that short-term interventions (with five or fewer sessions) with a clear behaviourally orientated focus on enhancing maternal sensitivity were more effective in increasing maternal sensitivity than those with other orientations (i.e. that focused on support and/or changing maternal representations). Based on a small number of studies, there is some evidence that maternal sensitivity is enhanced in interventions which involve fathers as well as mothers.
Effect of interventions on infant attachment
29 of the studies in Bakermans-Kranenburg (2003) used infant attachment security as the primary outcome and, comparing all insecurely attached infants with securely attached, suggested a small positive impact on attachment security (ES 0.19). Among the 23 randomised studies, interventions focusing on maternal/parental sensitivity were effective whereas those including support and maternal representation focus were not. Interventions were most effective if they started after the age of 6 months. Meta-analysis of 15 randomised studies of families with multiple problems showed that the effect size was comparable to that for families with fewer problems. The authors suggested that infant attachment may be less sensitive to intervention in the short term, and that there may be a ‘sleeper’ effect. It may also be that methods of measuring attachment security are less sensitive to change than those used to measure maternal sensitivity.
This research group undertook a second review (Bakermans-Kranenburg, 2005) which aimed to assess the capacity of interventions to prevent disorganised attachment security (the most disturbed infant response to the Strange Situation test with the poorest prognosis for the future). Overall they found no intervention impact and several interventions with a harmful effect. However, sensitivity focused interventions were effective (ES 0.24). As in the above analyses these were the interventions that started after 6 months of age. Interventions with high risk infants (irritable or preterm) were more likely to be successful than those focusing on high risk mothers. It is likely that low risk mothers are able to respond to these interventions more readily than high risk.
Video Interaction Guidance (VIG):
VIG is used as an intervention for change with selective families including hard-to-reach. It is also used to train professionals working with general population families t to enhance their sensitivity and effectiveness. VIG is generally delivered in the home setting but can be delivered in Family or Clinic settings. VIG often involves 6 one hour visits( or sessions) over 8 weeks (with a 10 minute video being taken in one session and reviewed in the second) but this can range from 2 hours visits over 2 weeks to 20 hours over 9-12 months depending on the severity of difficulties encountered by parents.
The process begins by helping the family or professional to negotiate theirown goals. Asking them what it is they want to change helps to ensure that they are engaged in the process. Adult-child interactions are then filmed and edited, to produce a short film that focuses on the positive.
In the video review sessions that follow, the family and professional review successful moments, particularly those when the adult has responded in an attuned way to the child’s action or initiative using a combination of non-verbal and verbal responses. They reflect collaboratively on what they are doing that is contributing towards the achievement of their goals, celebrate success and then make further goals for change. These reflections move very quickly from analysis of the behaviour to the exploration of feelings, thoughts, wishes and intentions. By seeing themselves on screen, parents are able to analyse what they were doing when things were going ’better than usual’. In this way they are empowered to make an informed decision about how they would like to improve situations that are more problematic.
The use of the video is also of central importance both as a focus for co-constructing new possibilities and as a trigger for revealing intuitive feelings which can be the key to lasting change. It seems that the video helps troubled families uncover alternative stories about themselves. In this way they can grow in an organic way into their new way of being without having to consciously remember and put in place new skills. There is a deeper level of healing that can take place when relationships are restored where further positive changes can naturally occur.
Three studies (RCTs) were identified from a high quality systematic review (Doughty 2007). One RCT (2 papers) compared three groups who received (i) Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP) and brochures (VIPP-SD), (ii) videofeedback, brochures and discussion groups and; (iii) no-treatment controls. The results showed significant changes for both intervention groups in infant symptoms, mother-infant interactions, maternal intrusive behaviour and maternal representations. Maternal sensitivity post-test in both groups was significantly higher than in the control group and the effectiveness of the two interventions did not differ. No significant effect was found for infant attachment.
One RCT evaluated the effectiveness of a video-feedback intervention in promoting positive parenting and sensitive discipline. VIPP-SD involved families with infants with externalising disorders. Significant improvements were found in maternal sensitivity and sensitive discipline, and a decrease in child overactive behaviours.
One RCT (75 mothers with behaviourally disturbed infants) compared brief (maximum 10 sessions) psychodynamic therapy with interaction guidance. No major difference in outcome was found between the two forms of intervention. Results indicated a significant symptom reduction; dyadic interactions became more harmonious (mothers became less intrusive and infants more cooperative). Maternal self-esteem grew significantly and negative affect decreased.
Doughty (2007) covers promising psychotherapeutic interventions which are not covered by other reviews.
Of the four trials of dyadic psychotherapy, one showed that both psycho-education and parent-infant psychotherapy were effective in improving mother-infant interaction (Cicchetti et al 2006) and that parent-infant psychotherapy resulted in the intervention infants attaining rates of secure attachment that were comparable with those of children in the non-depressed control group (Cicchetti et al 1999). A second less rigorous study (with no control group and a high rate of attrition from the intervention) involving women at high risk of child maltreatment and neglect, found that a combination of mother-infant psychotherapy, psychoeducation and developmental guidance was effective, at 3-year follow-up in improving maternal sensitivity, responsiveness and reciprocity (Osofsky et al 2007).
The third trial, of 67 clinically referred mothers and infants aged 10 – 30 months) compared infant-led psychotherapy (Watch, Wait, and Wonder) with mother-infant psychotherapy (Cohen et al 1999). Both Watch Wait and Wonder and mother-infant psychotherapy were successful in decreasing parenting stress, and reducing maternal intrusiveness and mother-infant conflict. The Watch Weight and Wonder group showed a greater shift toward a more organised or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the mother-infant psychotherapy group. Mothers in the Watch Weight and Wonder group reported a larger increase in parenting satisfaction and competence and decrease in depression compared to mothers receiving mother-infant psychotherapy. These differences had disappeared by the 6-month follow-up.
The fourth relevant RCT evaluated the effectiveness of parent-child psychotherapy with children aged 3 – 5 years who were exposed to marital violence (Toth et al 2006). Seventy-five multiethnic preschool-age child-mother dyads from diverse socioeconomic backgrounds were randomly assigned to (1) dyadic psychotherapy or (2) case management plus community referral for individual treatment. Children were 3 to 5 years old. Results at 6 months indicated a significant symptom reduction; dyadic interactions became more harmonious (mothers became less intrusive and infants more cooperative). Maternal self-esteem grew significantly and negative affect decreased.
- No single approach to mental health promotion is effective with all populations.
- The theoretical approach may be less important than the quality of the relationship established with the practitioner.
- However interventions focusing on the positive – enhancing positive mother-infant interaction and enjoyment and taking a strengths-based, empowering approach were more effective than psychodynamic programmes focusing on problems in the relationship and difficult past life histories.
- Prenatal contact enhances intervention effectiveness enabling practitioners to attend to primary engagement factors and establish a therapeutic alliance.
- Failure to engage and drop out are common especially amongst vulnerable families and both offering incentives (e.g. meals or free transport) and using outreach to understand local issues and circumstances can reduce attrition and participation. These factors make randomised trial designs difficult to apply effectively and the evidence base therefore needs to encompass findings from other designs.
- With regard to level of training, many programmes demand highly skilled professionals. However trained paraprofessionals may have a role to play. They may provide valuable support, community knowledge and outreach. These two groups can work together.
- The optimum approach to supporting the most vulnerable families is still not entirely clear, partly because this is a very difficult group to study particularly in the context of randomised controlled trials. The most effective interventions in the Bakermans-Kranenburg reviews (2003, 2005) were behaviourally orientated and focused on maternal sensitivity delivered in six sessions or less. However, as Barnes (2003) noted, it also seems likely that not all families can respond to such approaches.
- The impact of brief interventions with high-risk families may be short-lived unless families are offered additional, ongoing support. It seems likely that the most vulnerable families, at highest risk, require highly skilled professionals offering multimodal and long-term programmes grounded in ecological theory, responding to the circumstances of individual families and spanning at least two generation. Weekly contact starting antenatally and continuing for the first year appears optimum. This approach enables families to engage with practitioners and to feel safe enough to respond to specific interventions – such as for example the short term behaviourally orientated maternal sensitivity approaches described above. Longer term, more intensive psychodynamic therapies are less effective with young high-risk mothers.
It may be more effective to target high risk areas rather than high risk families. Within this context, offering a small number of high intensity services to a family is likely to be more effective than a large number of low intensity components.
Named programmes in Europe
Video Interaction Guidance:
Video Training in Interaction (VTI)
Video Home Training (VHT)
Video Home Training (VHT)
Video Interaction in Positive Parenting ( VIPP) - University of Leiden, the Netherlands
Video Home Training (VHT) - The Netherlands
Video Training in Interaction (VTI)
Video Training in Interaction (VTI)
Video Enhanced Reflection on Communication (VEROC) - University of Dundee
Video Interaction Guidance UK (VIGuk)
VIG is delivered by VIGuk accredited practitioners and practitioners in training under supervision by VIGuk accredited supervisors.
The list of training providers can be accessed through www.viguk.org
There are 60 fully accredited VIGuk Supervisors spread over the UK and 30 in training. Some supervisors work for government organisations and others work freelance for VIGuk training
The Tavistock and Portman Clinic - Britain's leading provider of multidisciplinary postgraduate training in mental health and social care http://www.tavistockandportman.ac.uk/cpd58
Other relevant links
VIG International Research conference held at University of Dundee 2001, 2006, 2009. Papers available from http://www.cpdeducation.co.uk/veroc
Bakermans-Kranenburg M, van Ijzendoorn M, Juffer F. Less is more: meta-analyses of sensitivity and attachment interventions in early childhood. Psychol Bull. 2003;129:195-215.
Bakermans-Kranenburg M, Van Ijzendoorn M, Juffer F. Disorganized infant attachment and preventive interventions: A review and meta-analysis. Infant Mental Health Journal. 2005;26(3):191-216.
Doughty C. Effective strategies for promoting attachment between young children and infants. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA), 2007.
Cicchetti D, Rogosch FA, Toth SL. Fostering secure attachment in infants in maltreating families through preventive interventions. Development & Psychopathology.2006;18(03):623-649.
Cicchetti D, Toth SL, Rogosch FA. The efficacy of toddler-parent psychotherapy to increase attachment security in offspring of depressed mothers. Attachment & Human Development.1999;1(1):34 - 66.
Cohen N, Muir E, Lojkasek M, Muir R, Parker C, Barwick M, et al. Watch, wait, and wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal.1999;20(4):429-451.
Osofsky J, Kronenberg M, Hammer J, Lederman J, Katz L, Adams S, et al. The development and evaluation of the intervention model for the Florida Infant Mental Health Pilot Program. Infant Mental Health Journal. 2007;28(3):259-280.
Toth S, Rogosch F, Manly J, Cicchetti D. The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: a randomized preventive trial. J of Consulting & Clinical Psychology. 2006;74:1006-1016.