Effective Strategies For Promoting Attachment Between Young Children and Their Parents

NZHTA TECHNICAL BRIEF
March 2007
Volume 6 Number 2

Effective strategies for promoting
attachment between young children and
their parents

Carolyn Doughty

New Zealand
Health Technology Assessment

Department of Public Health and General Practice
Christchurch School of Medicine and Health Sciences
Christchurch, New Zealand

NEW ZEALAND HEALTH TECHNOLOGY ASSESSMENT (NZHTA)

Christchurch, New Zealand

Effective strategies for promoting attachment
between young children and their parents

Carolyn Doughty

NZHTA TECHNICAL BRIEF
March 2007 Volume 6 Number 2

This report should be referenced as follows:

Doughty, C. J. Effective strategies for promoting attachment between young children and their
parents. NZHTA Technical Brief 2005; 6(2)

Titles in this Series can be found on the NZHTA website:
http://nzhta.chmeds.ac.nz/attachment_interventions.pdf

2007 New Zealand Health Technology Assessment (NZHTA)

ISBN 1-877235-96-2 (Print)
1-877235-97-0 (Web)
ISSN 1175-7884

EFFECTIVE STRATEGIES FOR PROMOTING ATTACHMENT BETWEEN YOUNG CHILDREN AND THEIR PARENTS
i
CONTRIBUTIONS BY AUTHORS
It was authored by Dr Carolyn Doughty (Research Fellow), who conducted the critical appraisals,
prepared the report and coordinated the project.
ACKNOWLEDGEMENTS
This Technical Brief was commissioned by the New Zealand Ministry of Health.
The literature search strategy was developed and undertaken by Ms Susan Bidwell (Information
Specialist Manager). Ms Cath Turnbull (Administrator) provided document formatting. Internal peer
review was provided by Dr Robert Weir (Director).
DISCLAIMER
NZHTA takes great care to ensure the accuracy of the information supplied within the project
timeframe, but neither NZHTA nor the University of Otago can accept responsibility for any errors or
omissions that may occur. NZHTA and the University of Otago along with their employees accept no
liability for any loss of whatever kind, or damage, arising from the reliance in whole or part, by any
person, corporate or natural, on the contents of this paper. This document is not intended to be used as
personal health advice; people seeking individual medical advice are referred to their physician. The
views expressed in this report are those of NZHTA and do not necessarily represent those of the
University of Otago, or the New Zealand Ministry of Health.
COPYRIGHT
This work is copyright. Apart from any use as permitted under the Copyright Act 1994 no part may be
reproduced by any process without written permission from New Zealand Health Technology
Assessment. Requests and inquiries concerning reproduction and rights should be directed to the
Director, New Zealand Health Technology Assessment, Christchurch School of Medicine and Health
Sciences, P O Box 4345, Christchurch, New Zealand.
CONTACT DETAILS

New Zealand Health Technology Assessment (NZHTA)
PO Box 4345
Christchurch
New Zealand
Tel: +64 3 364 3696 Fax: +64 3 364 3697

Email: nzhta@chmeds.ac.nz
Website: http://nzhta.chmeds.ac.nz

ii
LEVEL OF EVIDENCE CONSIDERED IN TECHNICAL BRIEFS
Technical Briefs are rapidly produced assessments of the best available evidence for a topic of highly
limited scope. They are less rigorous than systematic reviews. Best evidence is indicated by research
designs which are least susceptible to bias according to the National Health and Medical Research
Councils (NHMRC) criteria (see Appendix 1) Where methodologically acceptable and applicable,
appraised evidence is limited to systematic reviews, meta-analyses, evidence based clinical practice
guidelines, health technology assessments and randomised controlled trials (RCTs). Where not
available, poorer quality evidence may be considered.
CONFLICT OF INTEREST
None.

iii
EXECUTIVE SUMMARY
Objective
To systematically identify and appraise international evidence on the effectiveness of specific
interventions for promoting attachment between young children and their parents.
Data sources
The literature was searched using the following databases: Medline, Embase, Cinahl, Current Contents,
Science/Social Science Citation Index, Cochrane Central Register of Controlled Trials, Index New
Zealand and Te Puna-New Zealand Bibliographic Database. Other electronic and library catalogue
sources searched included the Cochrane Database of Systematic Reviews, Database of Abstracts of
Reviews of Effectiveness, the NHS Economic Evaluation Database, Health Technology Assessment
Database and the ACP Journal Club. Wider searches of the Internet, hand searching of journals and
contacting of authors for unpublished research were not undertaken.
Searches were limited to English language material and published between January 1999 and
December 2006 inclusive.
Study selection
Studies were included if they investigated the effectiveness of an early intervention or intervention
strategy which aimed to promote the development of positive, trusting parent-child relationships.
Clinical and home-based interventions including group-based parent training programmes, other types
of parent training or education, home visiting programmes with a clearly identified parent training
component and relationship-based interventions were considered. Key socio-emotional outcomes,
usually relating to the relationship with the maternal parent must have been reported for either parental
sensitivity or responsiveness to infant needs and/or infant-parent attachment security. Only relevant
systematic reviews, meta-analyses and randomised controlled trials within the timeframe were eligible
for appraisal.
Excluded studies included those that reported on outcomes for specific populations including adoptees,
pre-term infants, and children with severe existing behavioural problems. Children with other serious
mental health issues or developmental problems and mothers with drug dependency were also
excluded. Interventions for preventing family violence, child abuse and neglect including interventions
that target parental attitudes and behaviours around violence were not examined. Studies that focused
on a primary outcome related to child physical health (breastfeeding and nutrition, intention to
vaccinate, sudden infant death, accidental injury, use of medical services), brief postnatal interventions
with the Brazelton Neonatal Behavioural Assessment Scale and early skin-to-skin contact or infant
massage for mothers and infants were not eligible.
Data extraction and synthesis
A systematic method of literature searching, selection and appraisal was employed in the preparation of
this report.
Of more than 517 potentially relevant articles/abstracts identified, 105 articles were retrieved as full
text from which a final group of 20 studies were selected. Of these, two systematic reviews, 18
randomised controlled trials (represented by 24 articles) were identified as eligible for inclusion in this
Technical Brief.

iv
Key results and conclusions
Changes reported in attachment security were generally in a direction consistent with attachment
theory; however effect sizes were relatively modest. Less broad interventions that target sensitive
maternal behaviour are among those that are the most successful both at improving insensitive
parenting and promoting better infant attachment security.
Results suggest that the most effective interventions do not always use a large number of sessions with
families, in fact fewer contacts may be more effective. There is good evidence supporting the use of
behaviourally focused interventions and these types of interventions, with or without video feedback
are effective regardless of the presence or absence of multiple problems in the family. Highly intensive
interventions with numerous sessions focusing on sensitivity, representation and support may not be as
effective as less intensive approaches.
Overall, evidence from primary and secondary research shows that a variety of types of intervention for
enhancing maternal sensitivity and to a lesser extent attachment security are effective, with nearly all of
the studies appraised in this review involving the use of some form of home visiting to deliver the
intervention.
Limitations of this report
The size of included studies ranged from very small pilot trials to larger multi-site studies. Some of the
smaller studies may not be of adequate size to detect an intervention effect, if there is one, whereas the
larger studies that used broader approaches although sufficiently powered may have not resulted in
significant effects for a number of reasons. These types of more general home visiting programmes
may be more likely to show patterns of small pervasive benefits than large effect sizes for specific
outcomes.
Differential attrition may present an issue for these longer term interventions as it may be difficult for
the control group to remain motivated to participate in the face of problems but no active support from
the programme. For studies in which specific populations were targeted, treatment effects found may
hold only for the participants of that specific sample and results may not be generalisable to other
groups. All of the studies considered focused on exclusively mother-infant interaction rather than father
or parent-child interaction which are consistent with previous reviews that have only noted several such
studies.
Within individual studies the aim or objective was often described but without reference to the specific
individual components of the intervention or the process by which intervention goals were achieved.
Although research only trials were in theory excluded from this review, in the absence of
predetermined criteria to ascertain what this meant in practice (eg. laboratory versus community
setting) a small minority of the included studies may be nearer to being efficacy than effectiveness
trials. Efficacy studies may not truly reflect how a therapeutic intervention might be more flexibly
applied in a real world setting as opposed to the research setting but remain informative for considering
what interventions demonstrate potential and therefore what future research might be indicated.
MeSH headings
parent-child relations, object attachment, child-preschool, infant, early intervention (education), family
therapy, intervention studies, prevention
Additional key words
Attachment, resilience, wellbeing, well being, wellness, early intervention, parent$ program$, parent$
train$, parent$, educat$, home visit$, domiciliary visit$, family visit$, multisystemic therapy, healthy
steps, healthy start, early start, healthy famil$, (promot$ and wellbeing or wellness or attachment or
well being).

v
TABLE OF CONTENTS

CONTRIBUTIONS BY AUTHORS.................................................................................................................... I
ACKNOWLEDGEMENTS............................................................................................................................... I
DISCLAIMER............................................................................................................................................... I
COPYRIGHT................................................................................................................................................ I
CONTACT DETAILS ..................................................................................................................................... I
LEVEL OF EVIDENCE CONSIDERED IN TECHNICAL BRIEFS .......................................................................... II
CONFLICT OF INTEREST............................................................................................................................. II
EXECUTIVE SUMMARY.............................................................................................................................III
Objective.................................................................................................................................................................. iii
Data sources ............................................................................................................................................................ iii
Study selection ......................................................................................................................................................... iii
Data extraction and synthesis .................................................................................................................................. iii
Key results and conclusions...................................................................................................................................... iv
Limitations of this report........................................................................................................................................... iv
MeSH headings ......................................................................................................................................................... iv
Additional key words................................................................................................................................................. iv
TABLE OF CONTENTS.................................................................................................................................V
LIST OF TABLES........................................................................................................................................VI
BACKGROUND........................................................................................................................................... 1
SELECTION CRITERIA................................................................................................................................. 3
Study inclusion criteria.............................................................................................................................................. 3
Study exclusion criteria.............................................................................................................................................. 4
MAIN SEARCH TERMS................................................................................................................................ 4
Principal sources of information................................................................................................................................ 4
SEARCH SOURCES...................................................................................................................................... 5
Search methodology................................................................................................................................................... 5
APPRAISAL METHODOLOGY ...................................................................................................................... 5
RESULTS ................................................................................................................................................... 5
OVERVIEW.............................................................................................................................................. 39
Overall quality of evidence ...................................................................................................................................... 39
Summary of evidence for the effectiveness of interventions promoting attachment between young children and
their parents............................................................................................................................................................ 39
Discussion................................................................................................................................................................ 44
Conclusions.............................................................................................................................................................. 47
REFERENCES ........................................................................................................................................... 48
APPENDIX 1: LEVELS OF EVIDENCE......................................................................................................... 52
APPENDIX 2: SEARCH STRATEGY............................................................................................................ 54
APPENDIX 3A: EXCLUDED RETRIEVED PAPERS........................................................................................ 58
APPENDIX 3B: APPRAISED RETRIEVED PAPERS (EXCLUDED) ................................................................... 68
APPENDIX 4: APPRAISED RETRIEVED PAPERS.......................................................................................... 70

vi
LIST OF TABLES

Table 1. Typology of child attachment patterns or responses to the strange situation.......... 1
Table 2. Evidence table of a secondary research appraised relating to effective strategies
for promoting attachment between young children and their parents......................... 7
Table 3. Evidence table of primary research appraised relating to effective strategies
for promoting attachment between young children and their parents....................... 11
Table 4. Summary of aim, mode of delivery, settings and theoretical basis of interventions
appraised in primary studies..................................................................................... 41
Table 5. Summary of direction of observed effect in intervention group by outcome and
the statistical significance/size of the effect ............................................................. 45

1
BACKGROUND
This Technical Brief was requested by Dr Pat Tuohy, Chief Advisor of Child and Youth Health, New
Zealand Ministry of Health and aimed to critically appraise the evidence for effectiveness of a range of
early intervention strategies seeking to promote attachment between young children and their parents.
The scope of this report reflects the Ministry of Healths priority to understand what actions can be
taken or future services developed to ensure healthy socio-emotional development, including secure
attachment in young children before they start school. Healthy child development has been identified as
one of the key determinants of health and resiliency in adulthood. Therefore parent support
interventions aimed at improving the parent-child relationship are indirectly targeting the future
resilience capacity of children for whom healthy development may be at risk.
Research indicates that the quality of the parent-infant relationship creates conditions for establishing
healthy patterns of functioning throughout childhood and adulthood. Early secure attachments with
parents provide a firm basis for secure attachments later in life. Furthermore, insecure attachment prior
to the age of 2 years is associated with a range of poor outcomes that includes conduct problems, low
sociability, poor peer relations, anger, and poor behavioural self-control during the preschool years
(Barlow and Parsons 2006) and beyond. In a classic treatise on attachment Ainsworth and colleagues
(1978) described a method of categorising infants responses using the strange situation. The
categories that result from this procedure are based on the childs behaviours when the child and
mother are alone in the playroom together, when the mother leaves the room, when a strange women
offers comfort, and when the mother returns.
Table 1. Typology of child attachment patterns or responses to the strange situation
Anxious/Avoidant mother and child are left alone together in playroom
the child is more or less indifferent to where their mother is sitting
may or may not cry when their mothers leave the room
if the child becomes distressed, strangers are likely to be as effective as comforting them as their
mothers
when the mother returns these children may turn or look away from her instead of seeking
closeness or comfort.
Securely Attached if the mother is present, the child plays comfortably with the toys in the playroom and reacts
positively to the stranger
the child become visibly and vocally upset when their mothers leave
the child is unlikely to be consoled by a stranger
when the mother reappears, the child climbs into her arms, quickly calms down and resumes
playing
Anxious/Resistant these children have trouble from the start in the strange situation
the child stays close to their mother and appears anxious even when their mother is near
the child becomes very upset when their mother leaves, but is not comforted by her return
the child may seek renewed contact with their mother and resist her efforts to comfort them
the child may cry angrily to be picked up with their arms outstretched, but will struggle to climb
down once they are in their mothers arms
these children do not readily assume playing after their mother returns, instead they keep a wary
eye on her.
After (Ainsworth et al. 1978; Cole and Cole 1997)
Further to this typology, some child-parent attachment relationships appear to be characterised by the
absence or breakdown of an organised strategy, for dealing with the stresses of separations, illness, and
other life threatening events. This has been described as disorganised attachment (Juffer et al. 2005).
The rates of disorganised attachment in low-risk families are about 15% compared to high-risk samples
where elevated rates (up to 80%) have been found. Disorganised attachment in infancy has been shown
to predict problems with stress management, increased externalising behaviour and dissociative
behaviour in adolescence (Juffer et al. 2005b). It is considered to be of clinical importance as it is also
predictive of later psychopathology. It highlights the need to search for determinants of attachment
disorganisation with the goal of developing effective child-parent interventions to mitigate its effect on
normal child development.

2
This Technical Brief focuses on identifying studies that have experimentally evaluated attachment-
based interventions. Experimental intervention studies that aim at changing parental behaviour or
childrens development are important partly because of the dominance of non-experimental research in
the field of parenting and child development. Descriptive, cross-sectional or longitudinal designs are
far more common than experimental studies but a moderate number of experimental studies have been
conducted. Of these, only a minority of studies target low risk parents with healthy children with more
studies being concerned with interventions designed for infants at risk for problematic socio-emotional
development, for parents in adverse circumstances, or for families with both parents and children at-
risk. Studies frequently examine special groups of children including families with premature infants
(Brisch et al. 2003), clinically referred children (Cohen et al. 1999) or mothers (Field et al. 1998;
Suchman et al. 2004), children with developmental disabilities, anxious-withdrawn preschoolers
(LaFreniere and Capuano 1997), or internationally adopted infants (Juffer et al. 1997) but these
particular studies were outside the scope of this report.
Dunst et al. (2004) noted that parental sensitivity has been implicated as a factor influencing and
contributing to variations in child developmental outcomes. Ainsworth (1978) defined sensitivity as the
ability to perceive the childs signals correctly and react to these signals promptly and adequately.
Sensitivity has been proposed to have a causal role in shaping attachment. For this reason, many
interventions that have the goal of promoting childrens emotional and social development, especially
their attachment security attempt to do so by enhancing maternal sensitivity or responsiveness. In these
types of intervention the parents behaviour toward the child is the focus of the intervention.
Attachment-based interventions start at the most basic level of sensitivity and aim to make parents
better perceivers of their childs needs by teaching them observational skills. Intervenors may also
encourage and train parents to perceive their childs behaviour in a more objective way, by explaining
salient issues around child development.
The primary focus of this Technical Brief was to review recent evidence from systematic reviews and
randomised controlled trials about a range of early intervention strategies that seek to promote
attachment between young children and their parents.

3
SELECTION CRITERIA
Study inclusion criteria

Publication type
Studies published between January 1999 and December 2006 inclusive in the English language,
including primary (original) research (published as full original reports) and secondary research
(systematic reviews and meta-analyses) appearing in the published literature.
Context
Studies reporting on effective strategies for promoting attachment between young children and their
parents
Population of interest
Infants and young children aged 0 to 4 years, inclusive.
Parent/s or primary caregivers of sample children.
Setting
Community (home or clinic)
Intervention
Studies that investigate the effectiveness of an early intervention or strategy which aims to promote the
development of positive, trusting parent-child relationships.
Clinical and home-based interventions may be universal or selective and include
group-based parent training programmes
other parent training or education programmes
home visiting programmes with a clearly identified parent training component
relationship-based interventions
Outcomes
Key socio-emotional outcomes, usually relating to the relationship with the maternal parent must have
been reported in either of the following categories:
parental sensitivity or responsiveness to infant needs
infant-parent attachment security
Outcomes measures directly addressing sensitivity and attachment including but not limited to the:
Ainsworth sensitivity rating scales (e.g. strange situation)
Home Observation for Measurement of the Environment (HOME)
Erickson rating scales for maternal sensitivity and supportiveness
Nursing Child Assessment Feeding (NCAFS) and Teaching Scales (NCATS)
Study design
Systematic review or meta-analysis
Randomised controlled trials
Sample size
Studies with samples of at least 10 participants.

4
Study exclusion criteria
Studies were excluded if they:
were non-systematic reviews, letters, editorials, expert opinion articles, comments, book chapters,
articles published in abstract form, and studies on animal subjects,
were not published work or were non-English language articles,
were evidence obtained from comparative studies, case series, either post-test or pre-test/post-test,
(Level III and IV intervention evidence).
reported on programmes that focused on settings where 50% or more of the sample had a mean
age > 5 years
reported only outcomes for specific populations where 50% or more of the sample were
adoptees, pre-term infants, children with severe existing behavioural problems, children with other
serious mental health issues or developmental problems or mothers with drug dependency
other multi-component or comprehensive programmes except where specific outcomes of interest
were clearly reported
focused on specific interventions for preventing family violence, child abuse and neglect including
interventions that target parental attitudes and behaviours around violence
did not clearly describe the methods and results, or where there were significant discrepancies
were implemented only in a research setting
focused on a primary outcome related to child physical health (breastfeeding and nutrition,
intention to vaccinate, sudden infant death, accidental injury, use of medical services)
were on brief postnatal interventions with the Brazelton Neonatal Behavioural Assessment Scale
were on early skin-to-skin contact or infant massage for mothers and infants
were on parental satisfaction with services or programmes
evaluated the process of the early intervention (e.g. uptake of programme) rather than eligible
outcomes

MAIN SEARCH TERMS
MeSH headings (Medline subject headings): parent-child relations, object attachment, child-
preschool, exp infant, early intervention (education), family therapy, intervention studies, pc.fs
(prevention & control as floated subheading)
Embase subject headings (where different from Medline): emotional attachment
PsychInfo subject headings (where different from Medline): attachment behavior, early intervention,
parent training, family intervention, exp multimodal treatment approach, treatment effectiveness
evaluation
Additional free text (used in all databases): attachment, resilience, wellbeing, well being, wellness,
early intervention, (parent$ adj3 program$), (parent$ adj3 (train$ or educat$)), (home adj2 visit$),
domiciliary visit$, (family adj2 visit$), multisystemic therapy, healthy steps, healthy start, early start,
healthy famil$, (promot$ and (wellbeing or wellness or attachment or well being))

Correspondence was excluded from the search and references with vaccination, immunisation or
breastfeeding (or variant forms) in the title of the article were excluded in all databases.
Full details of the search strategies are presented in Appendix 2.
Principal sources of information
Bibliographic databases
Medline
PubMed (last 90 days)
Embase

5
Cinahl
Psychinfo
Current Contents
Cochrane Central Register of Controlled Trials

Review databases
Cochrane Database of Systematic Reviews
DARE database
NHS Economic Evaluation Database
Health Technology Assessment Database
ACP Journal Club

References of all retrieved papers were scanned for further relevant studies.
Extended searching of internet websites, meeting abstracts, hand searching of journals, and contacting
of authors for unpublished data was not undertaken for this Technical Brief.
SEARCH SOURCES
Search methodology
Searches were for material in English published from 1999 onwards. Searches of Medline and
PsychInfo were carried out on 12 October 2006. Other databases were searched on 8 January 2007. A
follow-up search for additional material on home visiting was carried on 26 January 2007 and an
update of the Medline and PsychInfo databases on 8 February 2007.
APPRAISAL METHODOLOGY
Summaries of appraisal results are shown in tabular form (known as Evidence Tables) which detail
study design, study setting, sample, methods, results, reported conclusions and NZHTA reviewer
conclusions/comments based on the limitations and validity of the study. The spelling of the original
article is retained in the Evidence Tables.
The evidence presented in the selected studies were assessed and classified according to the NHMRCs
revised hierarchy of evidence (Appendix 1).
RESULTS
From the above search strategy we identified 517 potentially relevant articles/abstracts of which 108
were retrieved. Of these retrieved articles, 81 were excluded. These papers, annotated with the reason
for exclusion, are presented in Appendix 3a.
primary outcomes of interest were not evaluated at all (n=18)
narrative review or background article (n=17)
attachment interventions and related outcome were not the focus of primary or secondary study
(n=15)
population outside scope (n=10)
descriptive or cross sectional study (n=8)
they focused on home environment (HOME) only and did not examine any other relevant
outcomes (n=6)
case study or pretest/post-test study (n=3)
editorial, commentary or book chapter (n=2)
letter to the editor or conference abstract (n=1)
research focus only (n=1)

6
Two secondary studies and 18 primary studies (from a total of 24 articles) were critically appraised
(listed in Appendix 4). The included papers are presented in the evidence tables on the following
pages. Two systematic reviews that were directly relevant to the present review were identified,
although it is noted that neither of these were exclusively reviews of controlled trials. However the
review by Bakermans-Kranenburg et al. (2003) did establish a core set of randomised controlled trials
on which their principal analyses were based. All of the primary studies selected for inclusion were
level II according to NHMRCs hierarchy of intervention evidence (NHMRC 2005).

7
Table 2. Evidence table of a secondary research appraised relating to effective strategies for promoting attachment between young children and their parents.
Authors
Country
Study Design Scope Methods Results
Authors conclusions
Limitations
Comments

Bakersman-
Kranenburg et
al. (2005)

The
Netherlands.
Systematic
Review/
Meta-Analysis
Scope
Interventions to prevent disorganized
attachment.

Review conducted in Leiden
University.

Setting and participants
Healthy participants, clinically referred
groups, children at risk and mothers at
risk.

Any setting but 87%(n=13/ 15) were
home-based.

Search Strategy
Electronic databases
PsycINFO, Dissertation
Abstracts and Medline were
searched with key terms
attachment, sensitivity (or
responsiveness) and
intervention (preventive or
therapeutic). Citation
searching was undertaken of
retrieved papers, books, book
chapters. Experts in the field
were approached.

Inclusion criteria
any intervention studies
that assessed
disorganized
attachment with
specific coding or
criteria for
disorganization/disorien
tation, or atypical
attachment
middle class families
with healthy infants
clinical and at-risk
populations

Exclusion criteria
case series
unpublished studies
interventions only
reported at meetings or
conferences

Ten studies
1
with 15 preventive interventions
(N=842) were found that included infant
disorganized attachment as an outcome
measure. The effectiveness ranged from
negative to positive, with an overall effect
size of d =0.05 (ns).

Effective interventions started after 6 months
of the infants age (d=0.23). Interventions that
focused on sensitivity only were significantly
more effective in reducing attachment
disorganization (d=0.24) than interventions
that focused on support and parents mental
representations (d=-0.04). Most sample
characteristics that were not associated with
differences in effect sizes, but studies with
children at risk (d=0.29) were more successful
that studies with at-risk parents (-0.10), and
studies on samples with higher percentages
of disorganized children in the control group
were more effective (d=0.31) than studies
with lower percentages of disorganized
children in the control group (-0.18).

Authors conclusions
The meta-analysis shows that disorganized
attachments may change in response to
sensitivity-focused interventions but also
suggests that interventions that specifically
focus on the prevention of disorganization
may be warranted.
Limitations
none of the studies examined an intervention aimed exclusively
at preventing disorganized infant attachment or focused on the
reduction of frightening/frightened parental behaviours
broader interventions dubbed psychotherapy in the kitchen
may require more skilled intervenors, that may be scarce
however more focused programmes may potentially be
delivered by people trained to adhere to an intervention
protocol
professional intervenors appear to be more effective but more
data on this is required to be definitive
only a few studies actually yielded positive effects, those aimed
at promoting sensitivity and infant-parent attachment security
but not more specific attachment security

Comments
four important moderators (age when intervention started, type
of intervention, type of risk of involved families, base rate of
disorganization in control group) were found
while broader approaches may not result in a significant effect
they may be required first to enable multi-problem families to
engage in more focused effective interventions targeting
sensitivity and representations
interactive correlates of disorganization such as frightening/
frightened , non-involved or intrusive parental behaviours may
be important to include in future studies
the current review and meta-analysis suggests that attachment
disorganization can be prevented or changed and that
sensitivity-focused feedback should be an essential part of
future interventions.

1
Gelfand et al. 1996; Cooper et al. 1997; Cohen et al. 1999; Juffer et al. 2005b; Van den Boom et al. 1994; Sajaniemi et al. 2001; Egeland et al. 1993; Heinicke et al. 1999; Lyons-Ruth et al. 1990 and Bakermans-
Kranenburg et al. 1998.

8
Table 2. Evidence table of secondary research appraised relating to the effectiveness of interventions to promote attachment
Authors
Country
Authors conclusions
Limitations
Comments

Bakersman-
Kranenburg et
al. (2005)

The
Netherlands.

Continued

A detailed coding system
was used to rate every
intervention study on design,
sample and intervention
characteristics. Studies were
coded independently by two
raters and intercoder
reliability established.

9
Authors
Country
Authors conclusions
Limitations
Comments

Bakersman-
Kranenburg et
al. (2003)

The
Netherlands.
Systematic
Review/
Meta-Analysis
Scope
Interventions to enhance parental
sensitivity and infant attachment
security.

Review conducted in Leiden
University.

Setting and participants
Healthy participants, clinically referred
groups, children at risk and mothers at
risk.

Any setting but 78%(n=40/ 51) were
home-based.

Search Strategy
Electronic databases
PsycINFO, Dissertation
Abstracts and Medline were
searched with key terms
attachment, sensitivity (or
responsiveness) and
intervention (preventive or
therapeutic). Citation
searching was undertaken of
retrieved papers, books, book
chapters. Experts in the field
were approached.

Inclusion criteria
interventions starting
before childrens mean
age of 54 months
studies using classic
Ainsworth sensitivity
rating scales
studies with posttests
based on the Home
Observation for
Measurement of the
Environment (HOME)
studies using the Nursing
Child Assessment
Teaching Scale (NCATS)
Erickson rating scales for
sensitivity and
supportiveness

Exclusion criteria
case series
unpublished studies
interventions only
reported at meetings or
conferences
Seventy studies were traced including 88
interventions. Data on 9957 children and their
parents were reported. A total of 88
intervention effects on sensitivity (n=7636)
and/or attachment (n=1503) were produced.

To estimate the combined effect size in the
set of studies with the strongest designs only
the intervention studies with randomized
control group design were selected.

A core set of 51 RCTs was established (6282
mothers with their children).

Interventions were moderately effective in
enhancing maternal sensitivity (d=0.33,
p<0.001). Random studies were less effective
than other studies (d=0.61, p<0.001).
Interventions focusing on sensitivity only
(d=0.45, p<.001), combined sensitivity and
support (d=0.27, p<0.001), combined
representation, sensitivity and support
(d=0.46, P<0.001) showed substantial effect
sizes. Interventions focusing on sensitivity only
were more effective (d=.45) than all other
types of interventions combined (d=0.27,
p=0.03). Interventions with video feedback
were more effective (d=0.44) than
interventions without this method (d=0.31,
p=0.04). Interventions with fewer than five
sessions were as effectives (d=0.42) as
interventions with 5 to 16 sessions (d=0.38) but
interventions with more than 16 sessions were
less effective (d=0.21) than interventions with
a smaller number of sessions (p<0.001).
Interventions starting later (d=0.44) were more
effective than interventions starting prenatally
(d=0.32) or in the first 6 months of life (d=0.28,
p=0.04).
Limitations
in general attachment security may be more difficult to change
than maternal insensitivity
small samples may lack power to detect a moderate
intervention effect
randomization with a small number of participants may result in
systematic differences between control and experimental
groups
there may be a ceiling effect when relatively high scores in the
control group prevent any intervention effects from being
detected
sleeper effects (time lag between changes in sensitivity and
attachment) may make it difficult to evaluate program
effectiveness as only long-term effects on deeply rooted
relational or representational characteristics are to be
expected
analyses were limited to maternal sensitivity

Comments
some studies with outlying effect sizes were identified and
excluded from further analysis (Van den Boom 1994 and a
subsample of Zahr 2000)
to avoid excessive influence of the large multisite intervention
study (St Pierre and Layzer) analyses for this study were based in
the windsorized number
only a small number of the interventions were aimed at both
mothers and fathers (three studies in total)
fail-safe n=913, that is it would take more than 900 unpublished
studies without intervention effects to cancel out combined
effect size of randomized studies

10
Authors
Country
Authors conclusions
Limitations
Comments

Bakersman-
Kranenburg et
al. (2003)

The
Netherlands

Continued.
brief postnatal
interventions with the
Brazelton Neonatal
Behavioral Assessment
Scale

A detailed coding system
was used to rate every
intervention study on design,
sample and intervention
characteristics. Studies were
coded independently by two
raters and intercoder
reliability established.
Disagreements were
discussed to consensus.

Authors conclusions
The current meta-analytic data suggest that
interventions with a clear focus and a modest
number of sessions are preferable.
Interventions with an exclusively behavioural
focus on maternal sensitivity appear to be the
most effective not only in enhancing
maternal sensitivity but also in promoting
childrens attachment security.
four studies that did not use personal contact as a means of
intervening (d=0.62, p<.05) had largest effect sizes. These studies
relied on holding infant close (soft baby carriers, snugglies,
kangaroo method etc). It is paradoxical that interventions with
the smallest investment in terms of time and money tended to
be more effective than more elaborate interventions but this
difference was not significant and its important to note the
precision of the estimate was low and the subset of studies
small.

11
Table 3. Evidence table of primary research appraised relating to effective strategies for promoting attachment between young children and their parents.
Authors,
country
Intervention,
setting
Sample characteristics,
inclusion and exclusion
criteria
Study design,
methods
Results Comments/limitations, authors conclusions
Ammaniti et
al. (2006)

Italy

Interventions
Home Visiting
Program (HV)

Control
Scheduled visits
for data
collection only

Participant families were recruited
from maternity and child health
services in the second trimester of
pregnancy.

Home Visiting (HV), n=47
Control (nHV), n=44

Three groups of participants were
selected for inclusion on the basis
of a psychosocial risk interview and
the Center for Epidemiological
Studies-Depression Scale (CES-D)

Inclusion criteria
(1) depressive risk (DR) women with
one or no psychosocial risk factors
(CES-D 20, Psychosocial risk variable
0-1)
(2) a group of psychosocial risk
women (PR) who reported low
levels of depressive symptoms (CES-
D 10, Psychosocial risk variable 3)
(3) low risk women (LR) with one or
no psychosocial risk factor and low
levels of depressive symptoms (CES-
D 10, Psychosocial risk variable 0-1)

Exclusion criteria
None stated.

No significant baseline differences
in depression scores and risk
variables between intervention and
control groups were reported. DR
(n=30), PR (n=28) and LR (n=33)
mothers were equally distributed
across the intervention and control
conditions.

Randomised controlled trial.

Experimental group versus
control, pretest/posttest.
Data were collected at
baseline and at 3, 6 and 12-
month follow-up.

Attrition
n=19 mothers (17.2%of
women who agreed)
dropped out in the first
three months of the
program

Assessment and outcome
measures
Semi-structured interview
about mental
representations and
changes in these (IRMAG
and IRMAN respectively)
Adult attachment interview
(AAI)
Scales of Mother-Infant
Interactional System
CES-D
Strange Situation Procedure
(SSP)

Selected observations of maternal and
infant behavior:

6 months nHV HV p
n=33 n=36
Sensitivity 6.89 (1.20) 7.70 (0.77) 0.002
Cooperation 7.77 (1.17) 8.25 (0.67 0.04
Interference 2.12 (1.32) 1.55 (0.72) 0.03
Affective state
of mother 1.53 (0.74) 1.08 (0.28) 0.003
Self regulation 4.52 (1.68) 4.16 (2.22) n.s.

12 months nHV HV p
n=37 n=45
Sensitivity 6.67 (1.31) 7.25 (1.06) 0.03
Cooperation 7.67 (1.19) 8.11 (0.94) 0.06
Interference 1.52 (0.80) 1.36 (0.81) n.s.
Affective state
of mother 1.39 (0.66) 1.15 (0.44) 0.06
Self regulation 1.96 (0.99) 1.92 (0.95) n.s.

Effects of the home visiting program on
mother-infant interaction tended to persist
until 12 months, although to a lesser
degree. Mothers in the HV group tended to
show more sensitivity (p<.03) and more
cooperation (p<.06) when interacting with
the infant, and their affective state was
inclined to be more positive (p<.06). No
significant differences were found between
the DR and LR groups but mothers in the PR
group who were home visited showed
lower rates on interference (p<.07), and
negative affective state (p<.03). These
mothers showed lower interference
behaviors and a more positive mood than
did the nHV mothers.
Limitations
the process of allocation was not clearly stated though it
was described as being randomly spilt into two subgroups
the authors suggest that compared to the US or UK, home
visiting in Italy is in a very early stage of development and
women are less prone to welcome strangers into their
houses, even if they are health visitors. Program was very
intensive both for the number of visits in the first year and for
the kinds of assessments carried out through interviews and
videotaped observations.
dropouts could also be due to difficulty keeping
engagement they experienced as demanding and
potentially judging
the efficacy of the intervention could be less evident due to
the inverted-U shaped association between the number of
risk factors and efficacy of prevention, where intervention
effects in samples with too-few risk factors, as per this
sample, could be less clear
possibility exists that both groups are biased as the rate of
women who refused to join the program was relatively high
the distribution of mothers in the sample with secure
attachment (65-85%) was higher than previously reported in
clinical samples (55%)

Comments
the primary goal of the study was to investigate whether the
home visiting program would be effective in enhancing the
quality of mother-infant interaction in psychosocial and
depressive risk samples, specifically to enhance the mothers
capacity to read and interpret the signals and behaviours of
the child
intervention was designed specifically to promote child
development, improve parenting practices, and facilitate
positive parent-child relationships and was theoretically
based on attachment theory
it may be that the efficacy of the intervention changes at a
developmental stage of the child during which the mother
faces new developmental tasks of the child that are linked
to autonomy and self-assertion

12
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Ammaniti et
al. (2006)

Italy

Continued
Authors conclusions
The study found that the home visiting intervention was effective in
improving sensitive maternal behaviors toward the child after 6
months of intervention.

13
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Armstrong et
al. (2000)

Australia

Interventions
Child Health
Nurse Visits
(Home-based)

Control
Usual Care
(Centre-based
Visits)

from an inner city obstetric hospital.
All families with a live-born infant
were invited to participate (n=1008).
Child Health Nurse Visits, n=90
Control, n=91
Participants were selected for
inclusion on the basis of risk status (1)
and (2) giving informed consent:
Inclusion criteria
>=1 of the following factors:
physical domestic violence
identified childhood abuse of
either parent
sole parenthood
ambivalence to the
pregnancy (sought
termination, no antenatal
care)
and >=3 of the following factors:
maternal age <18 years
unstable housing (three or
more moves in the preceding
2 years)
financial stress (always
concerned about having
enough food, making ends
meet)
<10 years maternal
education
low family income (<A$16000
per annum)
social isolation
history of mental health
disorder
drug or alcohol abuse (either
parent)
domestic violence other than
physical abuse.


Data was collected at
baseline, at posttest (6
weeks) and at a 4-month
follow-up.

Attrition
n=14 families lost to follow-
up

measures
Edinburgh Post Natal
Depression Scale (EPDS)
Parenting Stress Index (PSI)
Home Observation for
Measurement of the
Environment (HOME)
Parent Satisfaction
Questionnaire (PSQ-18)
At the 4-month follow-up, 160 families (80
intervention, 80 control) were available for
assessment.

All aspects of the home environment,
including the quality of maternal-infant
attachment and mothers relationship with
the child, were significantly enhanced.

A statistically significant difference was
shown between groups on all subscales, as
well as the total HOME score. Intervention
mothers showed greater emotional
responsivity to their infants and more readily
accepted their infants behaviour.

PSI Measure of attachment
Mean (SD)

At baseline
Home Visits 13.29 (3.38)
Usual Care 13.64 (3.73)

At 4-months
Home visits 12.05 (3.47)
Usual care 12.78 (3.67)

Lower scores indicate better quality.

HOME environment quality
For emotional/verbal responsivity
Home Visits 9.69 (1.10)
Control 9.10 (1.68)
F=6.9, p<0.05

Limitations
the control group had also accessed their local community
child health clinic on at least one occasion and 20%had
attended the clinic on seven or more occasions. At 4-
months 35%of the families in the control group were still
regularly attending their child health clinic. As both groups
received some form of intervention this decreases the
likelihood of detecting an effect.
the HOME inventory scale was not measured at baseline
and it is not completely clear whether the figures reported
pertain to data collected at 6 weeks or 4-months (most likely
at 4-months)
short-term follow-up data only so it is not clear whether any
benefits are sustained over time

Comments
clients of the child health service reported greater
satisfaction with service than the comparison group

Authors conclusions
This form of early home-based intervention targeted to vulnerable
families promotes an environment conducive for infant mental and
general health and hence long-term psychological and physical
well-being, and is valued by the families who receive it.

14
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Armstrong et
al. (2000)

Australia

Continued

Exclusion criteria
None stated.

No significant baseline differences
between intervention and control
groups were reported.

15
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Caughy et
al. (2004)

USA

Interventions
Healthy Steps
(Pediatric office
visits plus home
visits).

Control
Usual care

Eligible families were identified and
enrolled either at the hospital
following the birth of their child or at
the pediatric practice following the
birth of their child A total of 758
families enrolled in the National
Evaluation at the two selected sites.
Of these 658

Healthy Steps, n=337
Control, n=321

Were selected to participate in the
direct observation study.

Inclusion criteria
child born within the study
duration
must speak English or Spanish
fluently
planning to live in the same
area and use same
paediatric care for next 6
months or more

Exclusion criteria
their child was to be put up
for adoption or placed in
foster care
their child was too ill to make
an office visit within the first 28
days of life
if the child died
if the study child no longer
lived with the biological
mother
if the family withdrew from
the study, moved out of the
study range (more than 1
hour car travel)
if the child never made a visit
to the paediatric practice
Randomised controlled trial
with cross sectional and
longitudinal analysis.

control. Observational data
were collected at two time
points Time 1 (T1,16-18
months) and Time 2 (T2, 34-
37 months).

Attrition
A total of 378 of the eligible
families (57%) completed at
least first part of home
observation.

At time 2, 604 families were
eligible and of these 233
(39%) completed at least
part of the second home
observation.

measures
The Teaching Scale Score
of the Nursing Child
Assessment by Satellite
Training (NCAST)
The Parent/Caregiver
Involvement Scale (P/ CIS)
Measurement of the
Environment,
Infant/ Toddlers (HOME)
The Attachment Q-Sort
Child Behavior Checklist/2-3
(CBCL)Toddler Behavior
Assessment Questionnaire
(TBAQ)
Results indicated that mothers participating
in Healthy Steps were more likely to interact
sensitively and appropriately than mothers
in the comparison group at the second
assessment point (age 34-37 months) but
not at the first assessment point (age 16-18
months). There were no differences in child
outcomes at either time point when the
cross sectional data were analysed. The
results of the longitudinal analysis that
included families who participated in the
home observations at both time 1 and time
2 indicated that Healthy Steps participation
was associated with greater security of
attachment and fewer child behavior
problems

Mean treatment differences (n=179) were
adjusted by maternal age, race, maternal
education, insurance status during
pregnancy, and marital status.

Post-hoc comparisons indicated mothers in
Healthy Steps group had significantly higher
NCASTtotal scores, F(1132)=4.70, p<.05,
ES=0.18 and children who participated in
Healthy Steps were more securely attached
to their mothers, F(1126)=6.91,p<.01,
ES=0.23.

The maternal behaviors in which
differences between treatment and
comparison group were found indicated
that mothers participating in Healthy Steps
were more likely to interact sensitively and
appropriately than mothers in the
comparison group in that they were more
likely to match their interaction to the
needs of the child. Differences in maternal
sensitivity were observed both in a
structured teaching task as well as during
free play activity.
Limitations
of fifteen participating sites six utilised a randomized design
and nine featured a quasi-experimental design
high rates of attrition in the sample with only 179 mothers of
the original 658 (27%) completing both home observations
effect sizes (ES) were relatively small
program was less intensive than many other intervention
programs in that fewer office and home visits were provided
and center-base care not included as part of the program
low risk sample so results may not generalize to at-risk families

Comments
this analysis presents observational data from two of the sites
that used a randomized treatment design
Healthy Steps is a package of services comprising enhanced
well child visits, home visits, telephone support for
developmental and behavioural concerns, child
development and family health check-ups, written
informational materials for parents (including a child health
and development record), parent groups, and links to
community resources (9 paediatric office visits plus 6 home
visits)
data collected for the study came from a structured
interview with the mother and direct observation of mother
and child
program effects start to emerge and become evident at
later time points which is consistent from a developmental
perspective

Authors conclusions
Findings indicate that child development services can be offered
through pediatric (primary care) practices. Services delivered in this
way can lead to positive changes in mothers interactions with their
young children and are associated with greater security of
attachment and fewer behavioral problems in children in families
characterized as low risk.

16
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Caughy et
al. (2004)

USA

Continued
There were no significant differences
between intervention and control
groups who completed both
observations assessed at time 1. At
time 2, treatment families were more
likely to have used health insurance
to pay for pregnancy and delivery.

17
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Cicchetti et
al. (2006)

USA

Intervention
Infant parent
psychotherapy
(IPP)

Psychoeducatio
nal parenting
intervention
(PPI)

Control/ s
Community
Standard (CS)

Normative
Comparison
(NC)
(from non-
maltreating
families)
Infants in maltreating families and
their mothers were recruited for a
study of the effects of child
maltreatment on infant
development and for an evaluation
study of the efficacy of two
preventive interventions designed to
optimize mother-infant relationships
and improve parenting.

Maltreated, n=137 infants (60 boys,
77 girls) and their mothers.
Nonmaltreated, n=52

IPP, n=53
PPI, n=49
CS, n=35
NC, n=52

During initial assessment
Infant age (SD) =13.31 (0.81)
months
Mothers mean age (SD) =26.8 (5.88)
years
74%were of minority race/ ethnicity

Inclusion criteria
all infants known to have
been maltreated and/or who
were living in maltreating
families with their biological
mothers

Exclusion criteria
infants who had been placed
in foster care who had limited
contact with their mothers


baseline, during the course
of the intervention and at a
one-year follow-up (when
the infants were
approximately 26 months
old).

Attrition
41 families (21.7%) did not
complete post-intervention
assessments.

measures
Child Trauma Questionnaire
(CTQ)
Perceptions of Adult
Attachment Scale (PAAS)
Maternal Behaviour Q-Set
(MBQ)

Follow-up contrasts indicated that no
significant differences existed among the
IPP, PPI and CS groups in their respective
distributions of attachment classifications
but each maltreatment group differed
significantly from the NC group. Post
intervention, all mother-child dyads were
reassessed in the Strange Situation and
significant differences were found that
showed the pattern of differences had
changed, indicating substantial
intervention effects.

Strange Situation attachment post
intervention (%)

Avoidant Secure
IPP 7.1 60.7
PPI 0.0 54.5
CS 18.5 1.9
NC 13.6 38.6

Resistant Disorganised
IPP 0.0 32.1
PPI 0.0 45.5
CS 1.9 77.8
NC 4.5 43.2

Pre-post intervention change pattern
between secure (S) and insecure (IS)
attachment

S to S IS to S
IPP 3.6 57.1
PPI 0.0 54.5
CS 0.0 1.9
NC 20.5 18.2

Limitations
cases randomly assigned to IPP and PPI did not always
comply with the assignment, declining to be involved in the
interventions. As a result those who completed the
interventions are partially self-selected
changes were not found for the constructs hypothesized to
serve as potential mediators of intervention efficacy
the extent to which some mothers did not engage in
interventions, despite active outreach efforts indicating that
additional strategies are necessary to facilitate active
participation
the rates of refusal are problematic for intent-to-treat
analyses because lack of participation could overwhelm
treatment effects

Comments
intent-to-treat analyses examined the group composition
irrespective of whether mothers actually participated. These
indicated that even with cases declining intervention
included in the IPP and PPI groups treatment effects were
nonetheless found.
during baseline both home and center-based sessions were
conducted with mothers and infants
IPP assumes that difficulties in the parent-infant relationship
do not result from deficits in parenting knowledge alone but
that the problems that maltreating mothers have in relating
sensitively and responsively to their infants stem from
insecure representational models evolved in response to the
mothers own experiences in childhood. In IPP the
intervention target is not the mother or the infant but the
relationship between the two
PPI model is based on the work of Olds et al. involving nurse
home visitation. Supplemental cognitive and behavioural
techniques were introduced to address parenting skill
deficits and social-ecological factors
both interventions were manualized with central
components. Therapists participated in weekly group and
individual supervision. Fidelity checks were performed
throughout the course of the intervention.

18
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Cicchetti et
al. (2006)

USA

Continued

Baseline differences between
intervention and control groups in
the maltreatment sample were not
found. Mothers in the NC group had
higher level of education than the
mothers in the IPP and CS groups,
Mothers in the NC group had fewer
children than mothers in each of the
maltreatment groups.

Adult-Adolescent Parenting
Inventory (AAPI)
Social Support Behaviors
Scale (SBS)
Parenting Stress Inventory
(PSI)
(SSP)
S to IS IS to IS
IPP 0.0 39.3
PPI 0.0 45.5
CS 1.9 98.1
NC 18.2 43.2

The majority of cases in the IPP and PPI
groups changed from insecure to secure
attachments.
Authors conclusions
Findings suggest that an attachment-theory informed intervention
(IPP) and an intervention that focuses on improving parenting skills,
increasing maternal knowledge of child development, and
enhancing the coping and social support of maltreating mothers
(PPI) were both successful in altering the predominantly insecure
attachment organizations of infants in maltreating families.

19
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Cohen et al.
(1999)

USA

Intervention
Mother infant
psychotherapy/
Watch, wait and
wonder
program
(WWW)

Control
Psychodynamic
psychotherapy/
usual care (PPT)

Infants and mothers attending a
centre for Childrens Mental Health.
Self referral to the centre by
parents or mental health, medical
or child welfare professionals.

Total sample, n=67
WWW
n=34
61.8%male
Child mean age 21.5 months
Mother mean age 32.2 years
PPT
n=33
57.6%male
Child mean age 19.2 months
Mother mean age 32.4 years

Inclusion criteria
10- to 30-month old infants
parents had to make first
contact to project
mothers and infants both
physically capable of
participating in play
presenting problems
including functional
problems with feeding,
sleeping, and behavioral
regulation or
referrals due to maternal
depression, feelings of
failure in bonding or
attachment

Randomised controlled
trial/Pseudo-controlled trial.

Two thirds of the allocation
was done randomly with
the final one third allocated
by remaining therapist
caseload and time for
treatment. Data was
collected at baseline,
during the course of the
intervention and after the
intervention program was
completed.

Attrition
6 dyads who started
treatment dropped out
early in treatment, 3 due to
life events (e.g. a move)
and three due to
ambivalence to treatment.
These were not included in
the analyses.

measures
(SSP)
Chatoor Play Scale Mental
Scales of the Bayley
Scales of Infant
Development-I or II
Parenting Stress Index (PSI)
Parenting Sense of
Competence Scale (PSCS)
Beck Depression Inventory
(BDI)
Working Alliance Inventory
The majority of infants were classified as
either insecure (A or C, 38%) or
disorganized (D, 39%). The remaining infants
were classified as secure (B, 22%).

At the end of treatment, 20.6%(n=7) in the
WWW group shifted to a secure
attachment compared to 3%(n=1) in the
PPTgroup.
The shift from disorganized attachment to
organized albeit insecure (A or C) was
examined with WWW 14.7%(n=5), PPT9.3%
(n=3).

Attachment Security

Infants in the WWW group were significantly
more likely than infants in the PPTgroup to
move towards either a secure or organized
attachment relationship (WWW 35.2%, PPT
12.5%) (Fishers Exact text, p<.03).
Approximately half of the infants did not
change attachment category from pre- to
post-treatment assessment (WWW=50%and
PPT=59.4%) and a small proportion of infants
became less secure (WWW=14.7%,
PPT=28.1%).

Mother-Infant Interaction

Univariate analyses indicated that
compared to before treatment began
mothers and infants in both groups
exhibited greater reciprocity in play and
less conflict and that mothers became
significantly less intrusive at the end of
treatment. No significant changes were
observed on the unresponsiveness scale.

Limitations
the sample for this study differs from others in that
participants included self-referrals and children with specific
problems were not excluded, the sample may be more
heterogenous and results may be less generalisable
randomization was not complete
small sample size means study may be underpowered when
looking at attachment subgroups
may be selection bias due to the non-systematic method of
recruiting participants however this may also more truly
reflect what happens naturally in clinical settings
clinic-based sample and service delivery so results may not
be comparable with studies using primarily home visitation
application of this treatment may not mirror what would
constitute a flexible, clinical application of the therapy
which might include use of more collateral therapies
analyses were not intent-to-treat

Comments
WWW sessions were in two parts. Infant-led activity with
observed floor time between infant and mother. Therapist did
not intervene or comment. Following this a 20min discussion
exploring what the mother observed and her experience of
the session
PPTinvolved discussion between the mother and therapist
throughout the whole session while mother and infant played
but without any instructions
all clinical interviews, feedback session, and therapy sessions
were videotaped
mothers in the WWW group also had a larger increase in
parenting satisfaction and competence and decrease in
depression compared to mothers in PPTgroup
both interventions were successful in reducing infant-
presenting problems, decreasing parenting stress, and
reducing maternal intrusiveness and mother-infant conflict

Authors conclusions
The watch, wait and wonder group showed a more organized or
secure attachment relationship and a greater improvement in
cognitive development and emotional regulation than infants in
PPTgroup.

20
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Cohen et al.
(1999)

USA

Continued

Exclusion criteria
None stated.
There were no significant baseline
differences between intervention
and control groups on pre-
assessment measures,
demographics, presenting
symptoms or the distribution of
attachment categories.

21
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Constantino
et al. (2001)

USA

Intervention
Socioemotional
development
education
programme

Cohort 1
Families already
involved in
home visitation
(Parents as
Teachers)

Cohort 2
Families not
previously
enrolled in
home visitation

Control
No education
programme.

from the waiting rooms of health
clinics (pediatrics, family practice,
and obstetrics and gynecology).
Once enrolled families were
randomized into intervention or
control groups (3:2 ratio for Cohort 1
and 2:1 ratio for Cohort 2).
Cohort 1
Recruited, n=190
Enrolled, n=95
Mean age (SD) mother, 26.1 (7.2)
years
Mean age (SD) infant, 8.3 (5.7)
months
Intervention (completed), n=51 (24)
Control (completed), n=34 (21)
Cohort 2
Recruited, n=164
Enrolled , n=63
Mean age (SD) mother, 26.3 (6.6)
years
Mean age (SD) infant, 9.3 (6.0)
months
Intervention (completed), n=42 (28)
Control (completed), n=21 (18)
Inclusion criteria
women with 3 to 18 month
infants
resident in St Louis (with zip
code of 63104 or 63118).
Exclusion criteria
not willing to participate in
programme that would be
allocated by lottery
intervention and control groups were
not reported.

Data was collected at
baseline and at a 6-month
follow-up.

Attrition
Cohort 1
n=27 (53%) intervention
n=13 (38%) control

Cohort 1
n=14 (33%) intervention
n=3 (14%) control

measures
IFEEL Pictures (standardized
set of 30 pictures of infants
with ambiguous facial
expression)
Adult Play Scale
Child Behavior Checklist
Cohort 1 (Home visitation)

Parents in intervention group made greater
gains in the number of categories of
emotion for which the number of IFEEL
picture cards attributed fell with 1 SD from
population mean (p=.08). This suggests an
increase in the appropriateness of their
emotional cues communicated by infants
facial expression. None of the specific
changes reached statistical significance.

Cohort 2 (No previous home visitation)

Six months following the intervention period,
14 mothers in the intervention group were
enrolled and actively participating in a
home visitation program.

There was a trend for improvement in
parents ability to interpret infants
emotional cues but no clear evidence that
the group intervention itself positively
influences childrens development
independent of the increase in
participation in home visitation.
Limitations
in both cohorts, those with higher levels of education and
income were more likely to complete the study high attrition
rates were a significant problem in all aspects of the
intervention including recruitment, enrolment, treatment and
follow-up. These rates were inversely associated with
parental income and level of income
the magnitude of attrition may have compromised the
ability of the study to detect an effect
Comments
the geographical areas represented by specific zip codes
represent an ethnically heterogenous stressed,
disadvantaged urban population with elevated rates of
child abuse and neglect and crime
completed study was deemed to be the number of subjects
who completed at least 7 intervention sessions and the 6
month follow-up research assessment (for intervention
group) and the number of subjects who completed the 6
month follow-up research assessment (for the control group)
analyses for Cohort 1 were controlled for maternal
education level and infant age at follow-up
the intervention was a 10-session curriculum (completed
over 10 weeks for Cohort 1 and 20 weeks for Cohort 2. It
sought to provide parents with practical experience of
interactive play and provide support for young adults in their
role as parents. Structured 40min sessions were run with
infants present. Sessions included free play, brief review of
topic, mentored practice of play techniques and group
discussion
availability of a registry for enrolment in the statutory home
visitation program allowed participation or nonparticipation
in home visitation to be ascertained for every participant

Authors conclusions
Group meetings designed to promote parents practical
understanding of childrens earliest social relationships may be an
effective means of engaging hard-to-reach families in home
visitation.

22
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Fraser et al.
(2000)

Australia

Intervention
Home visitor
program

Control
Usual care
comparison
(see comments
section for
further detail)
Intervention, n=90
Comparison, n=91

Women in the immediate postnatal
period were selected on the basis of
two criteria sets listed below.

Inclusion criteria
they had at least one live
born infant
were literate and able to
complete questionnaires in
English with some assistance
planned to reside in
Brisbanes northern suburbs
respondent reporting one or
more of the following four risk
factors
sole parenthood
ambivalence to pregnancy
(sought termination, no
antenatal care)
physical forms of domestic
violence
child abuse of either parent
respondents reporting three
or more of the following risk
factors:
maternal age <18 years
instable housing (three or
more moves in 2 years,
homelessness)
financial stress (often
concerned about enough
food or making ends meet)
<10 years of maternal
education
low family income (<A$16000
per annum)
social isolation
history of mental health
disorder (either parent)


baseline and post
intervention at a 12-months
and an 18-month follow-up.

Attrition
Between recruitment to the
trial and 12-month follow-
up over three-quarters
(76.24%) of the sample was
retained. Of the home
visiting group (75.5%)
compared to the
comparison group (76.9%).

Retained to 12-months
Intervention, n=68
Comparison, n=70

measures
Edinburgh Postnatal
Depression Scale (EPDS)
Measurement of the
Environment (HOME)
Child Abuse Potential
Inventory
Parenting Stress Inventory

Maternal interactions, stimulation and
home safety standards were observed and
measured in participating family homes
where natural behavior between parent
and infant could be observed. In this study,
inter-rater reliability of the HOME Inventory
was checked by having two research
assistants visit 23%of the homes at the
same time at 12 months. Each made an
independent assessment. A correlation
between observers of 0.79 for assessing
emotional and verbal responsivity to infant
was obtained.
Maternal-infant interactions were more
likely to be positive, with significantly higher
(better) scores in aspects of the home
environment related to optimal
development in children, particularly
maternal-infant attachment in the
intervention group.
Parent attachment in intervention group,
mean (SD)
Primiparas Multiparae
Baseline 14.00 (3.23) 12.96 (3.47)
6-week 12.45 (3.71) 12.00 (3.40)
12-month 12.14 (3.68) 11.96 (2.88)
Parent attachment in comparison
group, mean (SD)
Primiparas Multiparae
Baseline 14.35 (3.39) 13.66 (4.02)
6-week 13.20 (3.65) 13.64 (3.84)
12-month 11.50 (2.95) 13.33 (4.08)
There was a significant main effect for time
for parent-infant attachment (p<.05) but no
statistically significant group effect for this
subscale.

Limitations
limited evaluation of infant attachment status (Strange
Situation Procedure) as an outcome although this may be
addressed if subsequent follow-ups are conducted when
the infants are older
teenage mothers and mothers with insecure housing were
more likely to withdraw from the study in first 12-months
short-term outcomes reported and longer follow-up may be
required to program (sleeper) effects that present much
later.

Comments
this article had more of an emphasis on prevention of child
abuse and neglect but attachment outcome was reported
the home visiting programme was designed to establish a
relationship of trust between the professional home visitors
and the family; to promote maternal-infant attachment; to
improve parental adoption of health promoting behaviours;
promote positive parenting practices; reduce parental stress
and improve maternal mood; reduce child abuse potential,
and promote the use of community and neighbourhood
support systems to assist families
families allocated to comparison received information
about community child health services as part of routine
discharge planning at the recruiting hospital. Standard
community child health care services involve the choice of
one home visit by the local child health nurse with more
extensive home visiting provided to those with specific
problems.

Authors conclusions
The evaluation did not demonstrate a sustained positive impact on
the quality of the home environment which included measures of
parent-child interaction.

23
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Fraser et al.
(2000)

Australia

Continued

alcohol or drug abuse
domestic violence other than
physical abuse

Exclusion criteria
None stated.

rigorously assessed and adjusted for
where appropriate.
The schedule of visiting
included weekly visits until
the infant was 6 weeks old,
fortnightly visits until 3
months, then monthly visits
until the age of 12 months.
The minimum number of
nurse-visits per family was
18.
No overall intervention effect was
demonstrated at 12 or 18-month follow-up
with no significant differences between
intervention and comparison groups.

24
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Goodson et
al. (2000)

USA

Intervention
Home visitor
program,
Comprehensive
Child
Development
Program
(CCDP)

Control
Usual care (but
no CCDP
services)
Participants were 4410 families within
21 CCDP projects who were
followed for five years.
CCDP Program, n=1369
Control, n=1430
Demographics
African-American (43%), Hispanic
(26%), White (26%), American Indian
(3%), Asian/Pacific Islander (1%)
Not graduated from high school at
baseline (51%)
Income <$10000 at baseline (85%)
Teenagers when the first gave birth
(35%)
Inclusion criteria
family income below the
Federal poverty guidelines
families included a pregnant
woman or child under age one
willing to participate in CCDP
activities for five years if
selected for the program
group
Exclusion criteria
None stated.
not found on demographic
characteristics.
Nine of 147 tests (seven variables in
21 sites) looking at attrition showed
statistically significant differences
between program and control
families (p<.05). Though this was
slightly higher than chance there
was no consistent pattern so the
samples were considered
comparable by the investigators.

baseline and at 12 and 18
month posttests and then
annually at 2, 3, 4 and 5
year follow-ups.

Attrition
The analytic sample
included 3961 families or
original 4410 families had
been assessed at least
once. At the five-year
assessment, 74%of
program families and 78%
of control families
participated in the
evaluation

measures
Bayley Scales of Infant
Development (BSID)
The Mental Development
Index
Kaufman Assessment
Battery for Children (K-ABC)
(CBCL)
Adaptive Behavior
Inventory (ABI)
Measurement of the
Environment (HOME)
Nursing Child Assessment

In the structured observation of
parent/child interaction using the NCATS
program and control mothers were nearly
identical in their scores.

For child at age 3 years:

Parent Behavior-Total Score
Program Control
Mean 40.20 40.30
SD (5.59) (6.05)

Child Behavior-Total Score
Program Control
Mean 14.66 14.65
SD (3.33) (3.53)

The total score for parent behavior includes
scores for sensitivity, responsiveness,
fostering cognitive growth and fostering
socio-emotional growth.

The regression analysis showed there were
no significant differences between the
groups on maternal behaviors sensitivity
to cues, response to child distress, fostering
of socio-emotional growth, or on total
maternal score, nor was there a significant
difference in the observed behavior of the
program and control children.

Limitations
based on studies of only 21 of 24 of the CCDP project as one
project was not able to randomly assign families, a second
project was not able to maintain appropriate records about
families which were recruited and assigned and a third
project joined a year late
CCDP may not have provided a sufficient amount of
parenting education to effect changes in parent behaviour
large site-to-site differences in the amount of center-based
care received by children though on average program
children received more than control children (3 projects
average time was equivalent to halftime care whereas in 10
projects average time <2 hours per day)

Comments
sample n reported in this table is only for sub-analyses based
on the NCATS, for other measures not of direct relevance to
this report the reader should refer to the original article
control families could not use CCDP services but could use
other locally available services
each site recruited twice as many families as could be
served by the CCDP project
stratified random assignment by independent contractor
using stratifiers such as ethnicity, age of mother, and service
sites (i.e. more than one for a project)
no more than 25%of the sample could be recruited from
existing programs, the majority were recruited door-to-door
in order to include the hardest-to-serve families from the
catchment area
this program is related to the Early Head Start (EHS) Program
in that CCDP provided the original intervention model for
EHS however EHS provides services directly to children.

Authors conclusions
Overall the study suggested that the combination of case
management and parenting education, delivered through home
visits, is not an effective means of improving developmental
outcomes for low-income children.

25
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Heinicke et
al. (1999,
2000 and
2001)

USA

Intervention
Home visiting,
relationship
based program
(UCLA Family
Development
Project)

Control
Pediatric follow-
up
All families receiving prenatal care
at the UCLA Ob/Gyn and pediatric
clinics. In total 70 families were
recruited to the study.

Home-visited (HV), n=31 (52%girls)
Pediatric follow-up (PF), n=33 (48%
girls)

Mean age mother (bothgroups) =24
years

Inclusion criteria
having first child
live within a 20-min drive of
the hospital
families who had four or more
risk factors from social
interview
mother is poor and receiving
aid
mother lacks support
(partner, family, friends)
pregnancy not wanted
mother victim of childhood
physical or sexual or
emotional abuse
mother victim of childhood
rape or violence
mother experienced suicidal
thoughts in the past
mother referred for
mental/ health counselling in
the past
mother treated for drug
and/ or alcohol addiction in
the past, and
mother homeless


baseline and at 12- and 24-
month follow-ups.

Attrition at 12-month follow-
up
4/70 intervention families
and
2/ 70 non-intervention
families

measures
Wechsler Adult Intelligence
Scale
Maternal Support Interview
Cutrona Support Inventory
Spielberger Anxiety
Inventory
Locke-Wallace Marital
Inventory
Parent-Child and Child
Global Ratings
Caldwell HOME Scales
Bayley Scales of Infant
Development/Bayley Scale
Test Situation
Attachment Q-set
(SSP)

Mother responsiveness and child security of
attachment were assessed at 6, 12 and 24
months.

Impact of intervention on mother
responsiveness to need and indices of child
security (mean value shown on a seven
point rating scale)

other responsive to need
6Mos 12Mos 24Mos
HV 4.29 5.22 5.29
PF 4.90 4.30 4.00
Effect size -.42 .97 1.63
p-value .03 .0003 .0001

Mother affectionate response to reunion
6Mos 12Mos 24Mos
HV 3.45 3.90 3.81
PF 3.57 3.45 2.88
Effect size -.11 .47 1.00
p-value .65 .07 .0003

Mother positive affect
6Mos 12Mos 24Mos
HV 4.32 4.90 4.87
PF 4.64 4.30 4.18
Effect size -.19 .54 .58
p-value .30 .03 .02

Secure response to separation
6Mos 12Mos 24Mos
HV 5.10 6.32 6.10
PF 6.06 4.61 4.21
Effect size -.61 1.30 1.31
p-value .02 .0001 .0001

Limitations
on the basis of trends seen at 12 months it was anticipated
that intervention families would show further differential
gains in adaptation however this was not realized
may lack generalisability due to the detailed inclusion and
exclusion criteria
inadequate resources prevented completion of the three
and 4-year follow-up

Comments
this table combines results from three articles, two of which
reported outcomes after the first and second year of life
three socio-emotional transactions were focused on as key
outcomes (1) parental responsiveness to the needs of her
infant as related to the development of his or her security of
attachment; (2) parental encouragement of infant
autonomy and (3) parental encouragement of her childs
task involvement as related to the development of her task
orientation. This evidence table focuses on (1).
the primary goal of the intervention is to offer the mother
experience of a stable trustworthy relationship that conveys
understanding of the situation, and that promotes her sense
of self efficacy through specific interventions
specific intervention included enhancing the mothers
communication and personal adaptation, providing
alternative approaches for relating to her child, direct
affirmation and support

Authors conclusions
Findings suggest that the intervention made a significant impact on
three critical socio-emotional mother-infant transactions in the first
year of life. Children receiving the intervention were more secure
and their mothers more responsive to their needs in the first and
second year of life.

26
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Heinicke et
al. (1999,
2000 and
2001)

USA

Continued

Exclusion criteria
any DSM-IV Axis I diagnosis
currently using drugs
do not speak English
any member of the family
suffering from serious health
complications

No statistically significant differences
in demographic characteristics
including IQ between intervention
and control groups were reported at
baseline.

Child positive affect
6Mos 12Mos 24Mos
HV 3.77 4.58 4.87
PF 3.91 4.33 3.91
Effect size -.11 .21 .74
p-value .66 .41 .004

For standard deviations (SD) refer to original
article.

27
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Letourneau
et al. (2001a
and 2001b)

USA

Study 1

Interventions
Keys to
Caregiving
program

Control
Home visits with
nurse social
support

Two studies were conducted on two
different interventions both with a
focus on parent and infant
interactive behavior. Study 1 is
reported here.

Study 1
n=15 (time 1), n=16 (time 2)
Mothers mean age=18 years (SD=1)
50%partners

Inclusion criteria
adolescent parents
at risk due to low income,
educational attainment and
single parent status

Exclusion criteria
None stated.

not found for any of the
demographic or descriptive
variables examined, including
gestational age, birth weight,
educational level, age, partner
status, ethnicity, socioeconomic
status, depression or life stress.

No significant differences could be
found between those who
completed and those who dropped
out though only limited data were
available.


control, two posttests only.
Interactive behavior was
assessed at the baseline
pretest and 6 months
posttest. Data were
collected and mother-child
interactions videotaped
posttest only, at 7 to 9 (time
1) weeks and at follow-up,
11 to 13 (time 2) weeks old.

Attrition
Study 1
Of 24 mothers recruited 18
completed two follow-ups
(75%), only 13 of 24
completed all of the
intervention and outcome
measurement.

measures
Feeding (NCAFS) and
Teaching Scales (NCATS)
Preschool-Parent
Interactive Behavior (PPIB)
Coding System

Feeding Scale Effects
Parent time 1 time 2
Sensitivity to cues 1.07 0.87
Response to distress 0.86 0.61
Socioemotional growth 1.09 1.08
Cognitive Growth 0.86 1.19
Infant
Clarity of cues 0.38 -
Responsiveness 0.69 -

Teaching Scale Effects
Parent time 1 time 2
Sensitivity to cues 1.02 0.47
Response to distress 0.66 0.45
Socioemotional growth 0.88 0.32
Cognitive Growth 0.35 1.03
Infant
Clarity of cues - 1.24
Responsiveness 0.21 0.63

Larger effect sizes greater than 0.8 are
noted for 11 of 16 comparisons in the
subscales relating to parental behavior
change suggesting mean change scores
approaching 1 standard deviation were
achieved for most subscale measures.

Anovas were computed by using those
participants who completed all measures
of NCAFS and NCATS.

For NCAFS, there was a significant main
effect (p=.028) and for NCATS on the total
score (p=.027) and parent subscale
(p=.036).Further tests were conducted that
are not reported here. Group differences
were observed in the overall quality of the
interaction, the parents contributions to
the interaction, and the proportion of
contingently responsive parent-infant
interactions.
Limitations
pilot study (study 1), very small sample size problematic for
statistical analysis however effect size calculation were
presented, a separate article presents some analyses
support processes were not documented as per intervention

Comments
the Keys to Caregiving program delivered via six home visits
introduces five key concepts 1) infant states, 2) infant
behaviour, 3) infant cues, 4) how to modulate states, and 5)
interacting during feeding
social support for the control group included informational
resources, affirmation or reinforcement of parents
perspectives or behaviours, and listening and responding to
parents (emotional support)
a second trial was reported in the same article however this
is not reported here as to qualify for inclusion children had to
have exhibited a 6-month developmental delay in two or
more areas
mean intrarater reliability of 95%for the feeding scale and
94%for the teaching scale were achieved
intervention integrity was monitored through regular
debriefing sessions, field not taking, and selected audio
recordings of intervention sessions

Authors conclusions
Results suggested that parent-child relationships were enhanced.

28
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Klein and
Rye. (2004)

Israel

Intervention
Mediational
Intervention for
Sensitising
Caregivers/ Mor
e Intelligent and
Sensitive
Children (MISC)

Control
Home visits from
community
workers who
focused on
basic health
and nutrition
issues with a
general focus
on child
development
Families with infants and very young
children living in two of the poorest
communities in Addis Ababa,
Ethiopia participated in the study. 49
out of 893 families from Kebele 18
and 47 of 1997 families from Kebele
15 were randomly selected for the
intervention and comparison groups
respectively.

MISC, n=49
Control, n=47

Inclusion criteria
children aged from 1 to 3
years
resident in the Kechene
community (Kebelle 15 and
Kebele 18)

Exclusion criteria
None stated.

Baseline differences between groups
not reported.


baseline (6 months) and
within 3 months of
termination of the
programme at 12-month
and 6- year follow-ups.

Attrition
Of the 96 children who
were initially selected as
participants 84 (87.5%, 42
from each group)
participated in the 6-year
follow-up.

measures
The Rutter Scale of
Emotional and Social
Development
Observing Mediational
Interaction (semi-structured
questionnaire for parents)
The MacArthur
Communicative
Development Inventory
The effects of the intervention on the
participating mothers and their children
were assessed and findings were consistent
with stable effects of the intervention over
time. A clear improvement in the quality of
mother-child interactions was noted
following the MISC intervention. These
findings persisted over time and were
noted in the 6-year follow-up study.

The change in the interactive behavior of
the intervention group mothers and their
children was clearly apparent in
comparison to their own behavior prior to
the intervention as well as in comparison to
the behavior of mothers in the comparison
group. A clear increase in frequency of
parental mediation was found and
included interaction initiated by mothers
and by children. The latter was rare at
outset and remained rare in comparison
group. Mothers and children initiated more
eye contact as well as physical contact,
responded more fully to each others
communicative signals and had more and
longer shared attention episodes. The
emotional climate of the parent-child
interactions became more positive in the
intervention group, with high frequencies of
positive affect and turn taking in the
intervention group and nearly none in the
comparison group.

Limitations
study conducted in a very specific population so may not
be generalisable to other populations
statistical analyses although performed were not explicitly
reported but are reported elsewhere in a unpublished
doctoral dissertation and a book chapter
2

Comments
the intervention with the families was carried out by 21
paraprofessionals, selected from the site of the project as
well as from neighbouring communities, all of them were
already employed by the community as health and social
workers and other positions
this community was among the poorest and most
congested urban slum areas in the city with little or no
sanitation and extreme poverty
training materials were adapted for use in Ethiopia in a pilot
study constructed a year prior to the current intervention
study
home-based and institution-based intervention however this
article focuses on the home-based intervention (5 individual
meetings of 1-1.5hours and 5 group meetings of 2-3 hours)
parent-child interactions were videotaped and analyzed
this program has been evaluated cross culturally in other
settings

Authors conclusions
One year following the intervention, mothers in the intervention
group were more sensitive, more responsive, and optimistic about
their potential to affect their childs development than were
mothers in the comparison group. Six years later significant changes
were still noted in the quality of the adult-child interactions and
developmental measures of the children.

2
Melese, F. (2001) Early psychosocial intervention in Ethiopia [Doctoral Dissertation]. Norway: University of Bergen; Melese, F. (2001) The More Intelligent and Sensitive Child (MISC). In P.S. Klein (Ed.), Seeds of
hope: Twelve years of early intervention in Africa (pp. 131-158). Oslo: University of Oslo, Unipub, Forlag. Neither of these were retrieved for the current Technical Brief.

29
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Klein and
Rye. (2004)

Israel

Although no statistically significant
intervention effects were found for
childrens socioemotional development,
there was a consistent trend showing that
more children in the intervention group
reached developmentally higher
landmarks of socioemotional development
compared to others.
Findings confirmed that the intervention resulted in an increase in
age-appropriate, sensitive and affective interactions had a positive
effect on childrens cognitive and socioemotional development.

30
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Koniak-
Griffin et al.
(2003)

USA

Intervention
Home visiting
program (Early
Intervention
program, EIP)

Control
Usual care
(Traditional
public health
nursing care,
TPHNC)

Adolescent mothers and their infants
were recruited into this study.

EIP, n=56
TPHNC, n=45

Mothers mean (SD) age =16.8 (1.13)
years

Inclusion criteria
adolescents 14-19 years of
age
at 26 weeks gestation or less
having their first child
planning to keep the infant

Exclusion criteria
those dependent on narcotic
or injectable drugs
documented serious medical
or obstetric problem

not found on sociodemographic
characteristics (age, ethnicity/ race,
socioeconomic status).


baseline (6 weeks after
birth) and at 6,12, 18 and
24- month postpartum
follow-ups.

Attrition
At 24 months n=101/ 144
participated an attrition
rate of 30%.

measures
Measurement of the
Environment (HOME)
Rosenberg Self-Esteem
Inventory (RSEI)
Perlins Sense of Mastery
Scale (PSMS)
Center for Epidemiological
Studies Depression Scale
(CED-S)
Perceived Stress Scale (PSS)
Community Life Skills Scale
(CLSS)
Social Skills Inventory (SSI)

Repeated measures ANOVA revealed no
significant group differences in the change
in NCATS mother, child or total scores over
time. Significant time effects were found for
all three measures from 6 weeks to 24
months postpartum. For both groups the
scores markedly increased from birth to 12
months and then showed little change in
the 2
nd
year of life. Similarly, a main effect
for time was found for the total HOMES
scores, without significant differences
between groups in the pattern of change.
Scores increased for both groups from 1 to
2 years postpartum.

Adolescents receiving the EIP showed a
slightly greater gain over time in internal
social competence (p=0.057). No
differences were noted for the external
social competence measure.

Limitations
hard to determine whether improvements in scores over
time reflect benefits of intervention or normal maturational
changes of adolescents
difficulties encountered collecting medical records from
multiple sources, some infant health data collected by
maternal report only
control group may have received active intervention in the
form of telephone contact
article not focused on mother-child interaction

Comments
experimental group received preparation-for-motherhood
classes plus intense home visitation by public health nurses;
control group received traditional public health nursing care
videotape instruction and feedback was used

Authors conclusions
The EIP improved selected areas of infant and maternal health but
no specific improvement was reported for mother-child interaction.

31
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Moran et al.
(2005)

Canada

Intervention
Home visiting
program

Control
Minimal
intervention
(one home visit
only)
A total of 100 adolescent mothers
and their infants were recruited into
a longitudinal study.

n=99 dyads (50 girls, 49 boys)

years

Inclusion criteria
mothers with postpartum stay
in hospital associated with
study
less than 20 years of age
uneventful delivery
infants born at full term with
no medical complications

Exclusion criteria
None stated.

not reported.


baseline (6 months) and at
12- and 24- month follow-
ups.

Attrition
Attrition rate of 2%(n=1/50).
Of the original 100
recruited, 99 dyads
completed the assessments
at 12 months and 90 dyads
remained in the study
through the 24-month
assessments.

measures
Adult Attachment Interview
(AAI)
(SSP)
Maternal Behavior Q-Sort
(MBQS)
Fifty-seven (58%) of the 99 dyads were
classified as Disorganized in the SSP
reflecting the high-risk nature of the sample.

Mothers participating in the intervention
program were more likely than comparison
mothers to be in secure attachment
relationships with their infants at 12 months.

Twenty-eight of the 49 dyads were secure
(57%) compared to 19 of the 50 (38%)
dyads in the comparison group. The
difference in attachment security was
significant, p<.05 with an effect size of 0.25
but the overall effect was modest.

Maternal sensitivity scores assessed with the
Maternal Behavior Q-set in observations in
the home fell for mothers in the comparison
group from 0.38 to 0.12 between 6 and 12
months; at 24 months sensitivity had
recovered to an average value of 0.24.
Mothers in the intervention group displayed
similar levels of maternal sensitivity to the
comparison group at 6 months (0.34),
dropped less in sensitivity at 12 months (0.2)
and recovered to a substantially higher
level at 24 months (0.49).

Overall the brief intervention had a positive
effect on the quality of mother-infant
interactions but a quarter of mothers
participating in the intervention did not
appear to benefit.
Limitations
small sample size in subgroups may mean the study lacked
power to detect an effect
participants were all young mothers so results may not be
generalisable to other age groups
there was an age by group interaction but there were no
significant differences between group means at each age
problems were encountered with scheduling visits with 20%
requiring rescheduling due to mothers not being at home
when home visitor called
funding constraints limited the number of visits to eight
compared with 12 to 16 visits in a previous study

Comments
home visits lasted one hour and were carried out by two
mature women who had raised their own families and who
were knowledgeable about infant development and
attachment theory/research
dyads in intervention group received eight home visits
between 7 and 12 months; comparison group received one
visit at 9 months; SSP was conducted at approximately 12
months
the intervention procedure was designed to promote
sensitivity, a behaviour theoretically unrelated to
disorganization
the differential effectiveness of the intervention was
attributed to the impact of the intervention on the sensitivity
of the mothers. The intervention was only effective in
promoting a secure mother-infant attachment relationship
only when the mother was not classified as
unresolved/disoriented on the AAI.

Authors conclusions
Results showed that interaction-focused intervention in the first year
of life can improve the quality of the relationship between
adolescent mothers and their infants and that the improvement in
interactions persists at least into the second year of the childs life.

32
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Murray et al.
(2003)

UK

Interventions
Non-directive
counselling

Cognitive
Behavioural
Therapy

Psychodynamic
Therapy

Control
Routine primary
care
A community sample of 206 women
with major depressive disorder was
identified. Of these 193 were
randomly assigned to one of three
intervention groups or routine care.

Inclusion criteria
primiparous
living within a 15-mile radius
of the maternity hospital
women with post-partum
depression (Edinburgh
Postnatal Depression Scale)
English as first language

Exclusion criteria
women who had delivered
prematurely (before 36 weeks
gestation)
if their infant had any gross
congenital abnormality
if they had not had a
singleton birth
if they were intending to
move out of the area within
the period of the intervention

not found for background
demographic factors and negative
orientation to motherhood. More
women in the control group had
experienced high levels of adversity
(35%) and fewer women in the
psychodynamic therapy group
(10%).

Experimental groups versus
baseline, immediately after
treatment (4.5 months
postpartum) and at 18-
months and 5-year
postpartum.
Therapy was conducted in
the womens own homes
on a weekly basis from 8 to
18 weeks post-partum.
Mother-infant interaction
was videotaped before
and after treatment and
independently rated.
Attrition
Of the eligible participants
83%(n=171) completed
therapy. Nineteen dropped
out of treatment early or
moved away from the
study area. Of those
successfully assigned 10%
did not complete the trial.
measures
(SSP)
Behavioural Screening
Questionnaire
Mental Development Index
of the Bayley Scales of
Infant Development
Rutter A
2
Scale
Preschool Behaviour
Checklist
Maternal sensitivity at 2 and 4.5 months
postpartum
The three treatments were found to be
comparable with the control condition
after level of maternal sensitivity at 2
months was controlled for. For women with
low levels of social adversity those in the
control condition had higher levels of
sensitivity than women in the CBTor PT
groups. No significant difference was found
between the control condition and non-
directive counselling. For women with high
social adversity, women who received non-
directive counselling were found to have
higher levels of maternal sensitivity than
women in the control condition. There were
no treatment effects for CBTor PT.

Maternal sensitivity at18 months postpartum
Compared with the control group, after
controlling for social adversity and the
significant effect of maternal age, the
effect of treatment was significant for non-
directive counselling (p=.001), with PT
(p=.03) and CBT(p=.06) showing some
improvement compared to control.

Infant attachment
The rates of secure (B) and insecure (A, C
and D) attachment were similar for all four
groups and no significant differences were
found between the treated groups and the
control condition.

Limitations
the sample was one that was generally low risk, and
comprised of first time mothers so the generalisability to high-
risk and multiparous populations is unknown
the sample was underpowered to detect differences
between the treatment groups
although the efficacy of the interventions has been
demonstrated for some outcomes, effectiveness studies are
required to establish whether such benefits would be
obtained in routine practice
indications of a positive benefit were limited
despite symptomatic improvement underlying maternal
vulnerabilities persisted and to prevent longer-term
difficulties in child functioning more prolonged interventions
may be required.

Comments
routine care involved normal care provided by the primary
health team (GP plus health visitors) with no input from
research team
cognitive-behavioural therapy (CBT) with a focus on
problems identified by mother in management of her infant
psychodynamic therapy promoting an understanding of the
mothers representation of her infant and her relationship
with her infant by exploring aspects of the mothers own early
attachment history
non-directive counselling where women were given the
opportunity to air their feelings about current concerns

Authors conclusions
Findings indicated that the treatments had no significant impact on
security of infant-mother attachment but in mothers who
experience social adversity, whose interactions with their infants
were particularly poor, non-directive counselling produced a more
sensitive pattern of mother-infant interaction.

33
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Olds et al.
(2002)

USA

Intervention
Nurse home
visitation.

Paraprofessional
home visits.

Control.

A total of 1178 consecutive women
from 21 antepartum clinics were
invited to participate (Denver). Of
these, 735 were randomized.

Nurse home visits, n=235
Paraprofessional home visits, n=245
Control, n=255

Nurses (paraprofessionals) home visit
average was 6.5 (6.3) during
pregnancy/21 (16) visits from birth to
2
nd
birthday.

Ethnicity
Caucasian 35-37%
Hispanic (Mexican American) 44-46%
African American 16-17%.

Inclusion criteria
no previous live births
qualified for Medicaid or had
no private health insurance
enroll any time prior to
delivery
informed consent.

Exclusion criteria
none stated.

The treatment groups were similar at
baseline.

control, assessment at
baseline with follow-ups at
6, 12, 15, 21 and 24 months.

Attrition for interviews
6 mths 17.7%
12 mths 16.7%
15 mths 23.8%
21 mths 12.7%
24 mths 14.3%
Rates of attrition were
slightly higher for the child
assessments.

measures:
Mental Development
Inventory,
Mother-reported behavior
problems
Mother-infant interaction
(NCAST)
Measurement of the
Environment (HOME)

Data were modeled statistically using
treatments (3 levels), maternal
psychological resources (high vs low) and
the interaction between these
classifications. In addition a number of
covariates were included in model.
Addition of the covariates did not alter the
model greatly.

Nurse-visited mother-child pairs interacted
with each other more responsively than
those in the control group (p=0.05). At 6
months, nurse-visited infants were less likely
to exhibit emotional vulnerability to fear
stimuli and nurse-visited infants born to
women with low psychological resources
were less likely to exhibit low emotional
vitality in response to joy and anger stimuli.
At 21 months nurse-visited children were
less likely to exhibit language delays and at
24 months exhibited superior mental
development. There were no program
effects on womens use of prenatal
services, educational achievement or
childrens temperament or behavior
problems.
Limitations
absence of statistical significance probably due to limited
statistical power to detect small effects
higher rates of refusal among women who smoked may limit
generalisability to smokers and probably users of other
substances
higher study attrition among the nurse-visited women
women visited by nurses and paraprofessionals may have
altered their interview responses and behaviour during the
observations to coincide with what they thought was
expected of them
given the large number of dependent variables, some
findings may be spurious
several of the outcome measures are not independent of
one another.

Comments
no specific measures of attachment status were reported
mother-infant interaction was videotaped either in the
laboratory or home at all postpartum assessments using 2
validated procedures
infants home environments were rated at 12 and 21 months
more of a difference was noted between groups with the
subsample of women classed as having low psychological
resources

Authors conclusions
When trained in a model program of prenatal and infancy home
visiting, paraprofessionals produced small effects that rarely
achieved statistical or clinical significance. Nurses produced
significant effects on a wide range of maternal and child outcomes
including more responsive mother-infant than those visited by non-
nurses.

34
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Toth et al.
(2006)

USA

Interventions
Toddler-Parent
Psychotherapy
(DI)

Control groups
Depressed
mothers (DC)

Nondepressed
mothers (NC)
A total of 202 mothers with a history
of major depression were recruited.
Of these 130 were eligible and were
randomly assigned to one of two
intervention groups. A group of 89
mothers were recruited for the NC,
of which 21 were not eligible.

DI, n=66
DC, n=64
NC, n=68

Inclusion criteria
mothers with and without a
history of major depressive
disorder since the childs birth
child aged approximately 20
months
mother met DSM-III-R criteria
for major depression

Exclusion criteria
low socioeconomic status
determined by reliance on
public assistance
parents without high school
education
diagnosis of bipolar disorder
other prior or current
psychiatric disorder (for
second control group only)

Baseline differences in pre-
intervention attachment
classification were found between
intervention and control groups,
based on Strange Situation
Procedure (p<0.001).


baseline (on average child
aged 20 months), and at
the 16-month (on average
child aged 36 months)
follow-up.

Attrition
Of the original sample of
198, DI, n=20 (30%); DC,
n=10 (15.6%); and C, n=5
(7%) did not complete the
post-intervention
assessments. However no
significant differences due
to completion status were
found for baseline maternal
scores, demographic
characteristics and a range
of other variables. Therefore
no specific evidence of
selection bias in the
retained sample was found.

measures
The Diagnostic Interview
Schedule (DIS-III-R)
(BDI)
(SSP)
The pattern of secure versus insecure
classification at post-intervention shifted in
agreement with the predicted effect of the
intervention.

The overall distributions of post-intervention
attachment differed significantly (p<.001).
The pattern of the groups had also
changed markedly.

Maternal depression was found to be
related to insecure attachment. Prior to the
initiation of the intervention, offspring in the
DI and DC groups both had higher rates of
attachment in security than the NC group.
The same was true of disorganized
attachment.

Following completion of the TPP
intervention, offspring in the DI group
showed increased attachment security
compared with offspring in both the DC
and NC groups. Thus offspring with
depressed mothers who had participated
in TPP actually had more secure
attachment relationships than did offspring
of well mothers.

In intervention effect size for difference in
proportions between DI and DC group was
1.084, indicating a large treatment effect
associated with the intervention.
Furthermore there was a greater degree of
change from insecure to secure
attachment in the DI group relative to the
DC group with a large effect size of 1.11.

For further detail see the original article
which lists a variety of comparisons.

Limitations
a significant amount of attrition occurred during the study,
though this was a largely self-referred sample and that
motivation to participate was not enhanced or encouraged
by any external service providers
because only one intervention was provided it is not possible
to demonstrate whether the improvement in outcomes was
specific to an attachment-theory informed mode of
intervention
sample was predominantly low risk (married, well educated,
financially comfortable) so results may not be generalisable
to high risk populations, therapists could focus on mother-
child relationship rather than issues associated with poverty,
substance abuse and domestic violence
efficacy trial where co-occurring risk factors were minimized
rather than effectiveness (real world) study, possible that
participants received a purer dose of attachment-focused
intervention and this could account for the positive results

Comments
mothers in the DI and DC groups were not restricted from
being involved in other mental health treatment during the
course of the study and 75%(DI) and 67%(DC) respectively
were engage in some form of intervention
although this is a research trial some of the assessment
sessions were conducted in the home
all therapists received extensive training and supervision, the
intervention was manualized, and the fidelity of the
intervention was monitored closely by videotaping and
reviewing taped sessions
the efficacy of TPP in modifying disorganized attachment is
consistent with findings that suggest treating parental
depression is insufficient to improve parenting behaviours
the presence of fewer risk factors enabled therapists to focus
on implementation of TPP in the absence of crisis situations
that would require departure from the therapeutic protocol
the authors note that where populations have more extreme
needs, a more multifaceted and less focused intervention
may be necessary

35
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Toth et al.
(2006)

USA

Continued

The groups were comparable on a
range of demographic
characteristics.

Authors conclusions
Results demonstrated the efficacy of toddler-parent psychotherapy
in fostering secure attachment relationships in young children of
depressed mothers.

36
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Van Zeijl et
al. (2006)

The
Netherlands

Intervention
Video-
feedback
based on
positive
parenting and
sensitive
discipline (VIPP-
SD)

Control
No explicit
intervention but
mothers
received six
telephone calls
where they
were invited to
talk about the
general
development of
their child

Participants were recruited from
community records of several cities
and towns. Parents of 4615 eligible
children born between May 2001
and December 2002 were sent
screening questionnaires of which
2408 were returned (52%). Of 438
selected families parents of 246
children (56%) agreed to participate.
VIPP-SD, n=120
Control, n=117
Mothers mean (SD) age =33 years
56%boys
children with siblings (59%)
Inclusion criteria
children living with two
parents (biological mother as
primary caregiver and father
figure, biological or
stepfather as second
caregiver)
children with scores above
the 75
th
percentile on the
Child Behavior Checklist/1.5-5
Externalizing Problems scale
(age 1year: scores >=13; age
2 years: scores>=19; age 3
years: scores >=20)
Exclusion criteria
twins
serious medical condition in
mother or child
children with both a non-
Dutch first name and non-
Dutch surname
No significant differences between
groups regarding initial level of child
externalizing problems, parental
educational level, child and
maternal age or presence of siblings.

Video observation data
were collected at baseline
and at a one year follow-
up.

Attrition
During the intervention
phase, 9 families withdrew
from the study, either
directly after the pretest
and before randomization
took place (4 families) or
before the posttest (1
intervention family and 4
control group families).

Selection, assessment and
outcome measures
(CBCL/1.5-5)
Maternal sensitivity (7 pt
scale)
Maternal Discipline
Strategies
Infant Characteristics
Questionnaire (ICQ)
Cantrill Ladder (Mothers
sense of wellbeing).
Dutch Family Problems
Questionnaire

Repeated measures multivariate analysis of
variance (MANOVA) were used to measure
intervention effects.
A MANOVA on attitudes towards sensitivity
and attitudes towards sensitive discipline
showed that the dependent variables were
significantly affected by the intervention,
F(2,234)=11.0, p<.01. Univariate tests
revealed that after receiving the
intervention, mothers in the intervention
group had more favorable attitudes
towards sensitivity, F (1, 235)=18.9, p<.01
and towards sensitive discipline
F(1,235)=4.5, p<.05.
Treatment effectiveness was not related to
child characteristics (sex, age,
temperament) family characteristics (level
of daily hassles, marital discord and
maternal wellbeing), or professional training
level of intervenor.
Univariate tests showed that especially in
families with more marital discord, the
intervention was effective in decreasing
overactive child behavior F(1,229)=8.11,
p<.01. In families with more daily hassles,
the intervention was effective in decreasing
overactive child behavior F(1,229)=6.79,
p<.05. Treatment effectiveness was not
related to child characteristics, maternal
wellbeing, or the training level of intervenor.
The change in maternal attitudes toward
sensitivity and towards sensitive discipline
and the change in sensitive discipline
behaviors did not mediate the change in
childrens overactive problem behavior,
given the posttest assessments of these
parenting variables were not associated
with this child outcome variable. Similarly,
attitudes towards sensitive discipline did not
mediate the change in sensitive behaviour.
Limitations
no information was known about the nonparticipating
families from the screening phase
higher percentage of girls (51%) in the intervention group
compared with the control group (38%)
response rates were moderate
families from higher socioeconomic backgrounds were over
represented
families with a non-Caucasian background were excluded
although families participating did show higher levels of child
externalizing problems, marital discord, and daily hassles as
well as lower levels of maternal well-being compared with
those initially screened it is not clear whether VIPP-SD
program is similarly effective in more troubled families from
lower socioeconomic backgrounds
the program results may not be generalisable to families
from other cultural backgrounds
to avoid overload to parents and children not all constructs
could be measured at all times plus measures were not
broad enough to capture those changes that caused the
decrease in overactive child behaviours
findings constrained by lack of home observations

Comments
WIPP-SD is a standard, manualised program that describes
structure, themes, tips, and exercises for mother and child
and is delivered in six home visits
a dummy intervention for control group was used to ensure
comparable motivation and attention in both groups and
prevent attrition
authors suggest also finding effects of this home-based
intervention in laboratory assessment strengthens rather than
diminishes results

Authors conclusions
The intervention proved to be effective in enhancing maternal
attitudes toward sensitivity and in promoting actual sensitive
discipline interactions in the intervention group compared with the
control group.

37
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Velderman
et al. (2006a
and 2006b)

The
Netherlands

Intervention
Video-
feedback and
brochures (VIPP)

Video-
feedback,
brochures and
discussion (VIPP-
R)

Control
No explicit
intervention

Mothers with first-born children were
identified by town hall records and
child health center records.

Selected mothers (n=311) were
invited to participate in an interview
about their childhood as part of a
study on the influence of their own
childhood on child development. Of
these 262 AAIs were administered
(16%attrition). From this 84 mothers
tentatively classified as insecure
were included in the study.

VIPP, n=28
VIPP-R, n=26
Control, n=27

years
Mean educational level 2.51 (0.96)

Inclusion criteria
mothers with more than 8 but
less than 14 years of formal
education

Exclusion criteria
None stated.

Control groups were on average
two years older than intervention
mothers (p<.01) but did not differ on
educational level or on intelligence.
No significant differences in
sensitivity between the intervention
and control mothers were found at
pretest.


Video observation data
were collected at baseline
and at a 6-month follow-up.

Attrition
Of 84 mothers, 81
participated in all activities
(3.6%attrition).

Selection, assessment and
outcome measures
Adult Attachment Interview
(AAI)
(SSP)
Infant Behavior
Questionnaire (IBQ)
The AAI was used as a
selection instrument and
mothers were selected on
the basis of their insecure
attachment representation.

Home visitors made video
observations of mother-
infant dyads to assess
sensitive responsiveness
during free play. A further
four home visits were
scheduled with a posttest
video observation
assessment of sensitivity
made by research assistant
unknown to the mother.
At posttest, intervention mothers were
significantly more sensitive than control
mothers (p<0.05, d=0.49). Univariate
ANOVA with pretest as the covariate
showed that sensitivity of intervention
mothers increased significantly more than
control mothers sensitivity (p<0.05, d=0.46).

Mothers posttest sensitivity in both
intervention groups was significantly higher
than in the control group (for the VIPP
group p<0.05, d=0.46 and for the VIPP-R
group p<0.05, d=0.52) and the
effectiveness of the two types of
interventions did not differ.

The intervention was less effective in
changing childrens attachment security.
Although 67%of the intervention groups
developed a secure attachment to their
mothers, the same was true of 56%of the
infants in our control group (p=0.17,
d=0.22). The number of secure infants in
both intervention groups was not
significantly higher than in the control
group. The effectiveness of the two
different interventions did not differ. The
infants of mothers who showed more
increase in sensitivity were more securely
attached (using continuous security
scores).

Mothers of highly reactive infants profited
more from the intervention than others. At
posttest, sensitivity in the highly reactive
intervention group differed significantly
from sensitivity in the highly reactive control
group (p<0.01, d=2.27). There was no
difference between the less reactive
groups.
Limitations
small sample size may be underpowered
even a brief home-based intervention such as this requires
significant resources and effort to implement
a larger sample might have resulted in a significant
interaction effect instead of a trend for intervention effects
on attachment security for highly versus less reactive infants
the use of the IBQ may be less robust than observational
assessment of negative reactivity
there may be a ceiling effect due to the selection of
mothers on the basis of the AAI from audiotape as this may
not have led to a sample of 100%insecure mothers, in a
completely insecure sample the possibility of improvement in
maternal sensitivity and infant attachment security would be
higher
the approach of assigning classifications to AAI from tape
instead of transcript needs to be validated.

Comments
WIPP focused on enhancing mothers sensitive
responsiveness by providing them with video feedback
about their own (in-sensitive) behaviours
VIPP-R aimed to enhance sensitivity and restructure mothers
attachment representation (representational level)
discussions in VIPP-R were of mothers childhood attachment
experiences in relation to their current caregiving
educational level scale ranged from 1 to 4, with 1 =primary
school or junior secondary vocational education and 4 =
senior secondary general education followed by senior
secondary vocational education
the authors suggest the findings are important for mental
health providers planning and implementing intervention or
prevention programs in that is seems promising and possibly
cost effective to implement brief interventions with a clear
focus that may have an effect.

Authors conclusions
Post-intervention, both groups of intervention mothers were found
to be more sensitive than control mothers. The two interventions
were equally effective at enhancing maternal sensitivity but failed
to produce a significant effect on infant attachment security.

38
Authors,
country
Intervention,
setting
criteria
Study design,
methods
Velderman
et al. (2006a
and 2006b)

The
Netherlands

Continued

Finally, mothers were invited
to the Child and Family
Studies Center to
participate in the SSP.
This differential intervention effect cannot
be ascribed to differences in pretest
sensitivity between mothers of highly
reactive infants and mothers of less
reactive infants (p=0.99).
The interventions were most effective for highly reactive children
and their mothers, providing support for theories suggesting that
there may be differential susceptibility to rearing influences.

39
OVERVIEW
Emotional and behavioural problems in infancy are mostly viewed as relational so there is general
agreement that the intervention focus for infants should be on improving the quality of parent-infant
relationships. Within this context most studies are guided by the theoretical framework of attachment to
delineate goals and components of specific interventions (Cohen et al. 1999). Hence this report
summarises the evidence from studies seeking to promote attachment between young children and their
parents. For pragmatic reasons (primarily timeframe) this report was limited to studies conducted in the
last eight years only.
Overall quality of evidence
Of the 27 eligible articles identified, two systematic reviews were appraised (see Table 2, pages 7-10)
and 18 separate primary studies were appraised from a total of 24 articles (see Table 3, pages 11-38).
An additional trial focusing on an eligible form of attachment intervention was originally appraised but
subsequently excluded due to its focus on adoptive children (see Appendix 3b).
Summary of evidence for the effectiveness of interventions promoting attachment between
young children and their parents
Secondary studies
Two secondary studies (see Table 2, pages 7-10) met selection criteria and are summarised below.
Bakermans-Kranenburg et al. (2005) published a systematic review that examined intervention studies
designed to prevent disorganised attachment. Ten studies with 15 preventive interventions (n=842)
were found that included infant disorganised attachment as an outcome measure. The effectiveness of
these interventions ranged from negative to positive, with a non-significant overall effect size (d =
0.05). A meta-analysis showed that disorganised attachment may respond to sensitivity-focused
interventions but the authors suggest that interventions that specifically focus on the prevention of
disorganisation may also be warranted.
An earlier systematic review by the same principal author provides what is the most comprehensive
summary of the relevant literature in this field to date. Bakermans-Kranenburg et al. (2003) identified
seventy relevant studies including 88 interventions effects on sensitivity (n=7636) and /or attachment
(n=1503). Not all of the studies considered used true experimental designs to test intervention
effectiveness so to estimate the combined effect size, a smaller group of studies consisting of only the
intervention studies with randomised control group design were selected.
A core set of 51 randomised controlled trials was established (6282 mothers with their children) and a
meta- analysis of these studies was done. Randomised interventions appeared rather effective in
changing insensitive parenting (d=0.33) and infant attachment insecurity (d=0.20). The results
suggested that interventions with a clear focus and a modest number of sessions may be preferable.
Furthermore interventions with an exclusively behavioural focus on improving maternal sensitivity
appear to be the most effective not only in enhancing maternal sensitivity but also in promoting
childrens attachment security.
Primary studies
Eighteen independent randomised controlled trials were reported from a total of 24 articles. All of these
studies had either a focus on promoting attachment or maternal sensitivity or responsiveness, as either a
primary or a secondary outcome and included studies that satisfied pre-determined selection criteria.
These studies are summarised briefly on the following pages and further detail is provided in Evidence
Tables (see Table 3, pages 11-38) and in an overall summary table (see Table 4, page 41).
In the following sections studies have been grouped either by their risk status or by some other
common identifying feature of the population of interest.

40
Mothers with or at risk of depression
Maternal depression is believed to have an adverse impact on the mother-child attachment relationship
but empirical findings are equivocal. A significant but modest association has been confirmed (Martins
and Gaffan 2000) especially when depression is severe or protracted. In some studies maternal
depression has not been associated with insecure attachment, and in all studies it is clear that a
substantial number of mothers with depression are able to provide a sensitive caretaking environment
for their children (McMahon et al. 2006). Three intervention studies were found that specifically
targeted mothers with or at risk of depression in one of the experimental groups.
A study by Ammaniti (2006) focused on three groups of participants, those at risk of depression (high
or low risk) and an additional group of low risk women who had fewer psychosocial risk factors. The
comparison group received only scheduled visits for data collection. The intervention group women all
participated in a home visiting programme theoretically based on attachment theory that was designed
specifically to promote child development, improve parenting practices, and facilitate positive parent-
child relationships. The intervention was effective at 6 and 12 months post-intervention, as sensitive
maternal behaviours toward their child in the combined group of mothers receiving the intervention
increased significantly.
Murray et al. (2003) recruited mothers with post-partum depression into a treatment study that
compared the effectiveness of non-directive counselling with cognitive behavioural therapy,
psychodynamic therapy and routine primary care. Sensitivity and attachment were both primary
outcomes in this study. Findings indicated that the treatments had no significant impact on security of
infant-mother attachment but in mothers who experience social adversity, whose interactions with their
infants were particularly poor, non-directive counselling produced a more sensitive pattern of mother-
infant interaction.
Mothers with and without a history of major depressive disorder since their childs birth were offered
Toddler-Parent Psychotherapy, a manualised intervention based on attachment theory (Toth et al.
2006). Two control groups, one of depressed mothers, the other of non-depressed mothers received
usual care. In many regards this was an efficacy trial, in that co-occurring risk factors were deliberately
minimised in the sample and the intervention was not delivered in the home. The authors suggest that
their results demonstrate the efficacy of toddler-parent psychotherapy in fostering secure attachment
relationships in young children of depressed mothers but qualify this by stating that it is yet to be
ascertained whether the same magnitude of effect (i.e. large) would be found in more heterogenous
samples or where a lesser amount of therapy was received.
Adolescent mothers
Several researchers have targeted adolescent mothers for intervention. This is because children of
adolescent mothers are at risk for a variety of developmental difficulties. Jaffee et al. (2001) found
compelling evidence that negative outcomes for children of adolescent mothers are associated with
both family circumstances (social influence) and maternal characteristics (social selection). They
concluded that the personal characteristics of adolescent mothers contribute to adverse outcomes for
their children, even when the negative social consequences of early childbirth are taken into account.
Furthermore adolescent mothers have been shown to be less responsive to their infants signals, to use
more intrusive and physical interventions, and to provide less verbal stimulation than adult mothers
(Culp et al. 1991).
Three programmes were identified that sought to intervene with adolescent mothers.
The Keys to Caregiving programme was designed to promote high-quality parent-infant interaction
through improving parents understanding on infant behaviours, cues and needs. Several articles by
Letourneau and colleagues (2001a; 2001b) and Letourneau (2001) provide the results from a small pilot
study of this intervention. Across multiple sample sizes, observers, data coders, testing sessions, types
of analysis, and instruments, significant differences between groups were found. Interpretation of these
results is limited by the small size of the sample however this study does provide tentative support for a
nursing intervention programme to improve parent-infant interactions. A full trial with an adequate
number of participants is required to make stronger conclusions about this particular interventions
effectiveness.

41
Table 4. Summary of aim, mode of delivery, settings and theoretical basis of interventions
appraised in primary studies
Primary study
Country

Aim and mode of service delivery Sample
Theoretical basis
Ammaniti et al. (2006),
Italy

Home visiting programme to enhance the quality
of mother-infant interaction.
Sample at risk of psychosocial problems or
depression.
Intervention based on attachment theory.
Armstrong et al. (2000),
Australia

Home visiting programme to enhance quality of
maternal-infant attachment and mothers
relationship with the child.
Multi- risk sample.
Intervention promoting optimal child
development.
Caughy et al. (2004),
USA

Pediatric office visits plus home visits to enhance
sensitive interaction and attachment security.
Low risk sample.
Intervention promoting optimal child
development.
Cicchetti et al. (2006),
USA

Home and center-based sessions to optimize
mother-infant relationship and parenting.
Multi-risk sample.
Based on nurse home visitation model and
mothers attachment history.
Cohen et al. (1999),
USA

Center-based intervention to improve attachment
security and mother-infant interaction.
Heterogeneous sample, self-referrals.
Based on attachment theory.
Constantino et al.
(2001), USA

Home visitation to promote infants social and
emotional development.
Multi- risk sample.
Fraser et al. (2000),
Australia

Home visitation to determine if home visiting
improves home environment and parent-child
interaction.
Multi-risk sample.
Early intervention model.
Goodson et al. (2000),
USA

Home visitation to improve a wide range of
developmental outcomes for children.
Multi-risk sample.
Heinicke et al. (1999,
2000 and 2001), USA

Home visitation to improve mother-infant
interaction and family functioning.
Multi-risk sample.
Based on attachment theory and early
intervention model.
Letourneau et al.
(2001a and 2001b),
USA

Home visitation to promote high-quality parent-
infant interaction.
Adolescent mothers.
Based on Barnards model which promotes
sensitivity to infant cues.
Klein and Rye. (2004),
Israel/Ethiopia

Home-based visitation and institution-based to
improve quality of adult-child interactions and
promote learning.
Specific ethnic population, at risk.
Based on attachment theory and Feuersteins
theory of mediated learning.
Koniak-Griffin et al.
(2003), USA

Home visitation to improve social and emotional
competence.
Adolescent mothers.
Based on social-learning theory.
Moran et al. (2005),
Canada

Home visitation to increase the probability of a
secure infant-mother attachment relationship.
Adolescent mothers.
Murray et al. (2003)
and Cooper et al.
(2003), UK

Home visitation.
To improve mother-child relationship and child
outcome.
Women with post-partum depression.
Olds et al. (2002 and
2004), USA

Home visitation to improve a wide range of
developmental outcomes for children, including
mother-child responsivity.
Mixed sample (includes multi-risk).
Toth et al. (2006), USA

Home- and lab-based to foster improved
attachment security.
Women with post-partum depression.
Van Zeijl et al. (2006),
The Netherlands

Home-based visitation to enhance sensitive
parenting.
Low-risk sample.
Based on attachment and coercion theory.
Velderman et al.
(2006a and 2006b),
The Netherlands

Home visits and clinic-based assessment to
improve infant attachment security.
Mothers classified with insecure attachment.

42
Two further studies were identified that focused primarily on intervening with adolescent mothers.
Koniak-Griffin et al. (2003) implemented an early intervention programme that started with preparation
for parenting classes pre-birth and incorporated intensive post-birth home visitation from nurses.
Mother-child interaction was only a secondary outcome and no improvements were noted specifically
for this measure.
A trial by Moran et al. (2005) compared another home visiting programme with a minimal intervention
consisting of one home visit only. The latter study had a much stronger focus on attachment and
mother-child interaction was a primary outcome measure. Results showed that an interaction-focused
intervention in the first year of life can improve the quality of the relationship between adolescent
mothers and their infants and that the improvement in interactions persists at least into the second year
of the childs life. The authors also noted that there was a sizeable subgroup (25%) for whom the
intervention appeared to be of no benefit.
Mixed or multi-risk populations
Interventions that focus on mixed or multi-risk populations tend to have a broader focus, although this
is not always the case. A range of studies were found that looked at either home visiting as an
intervention alone or home visiting plus adjunctive education programmes with a relationship focus.
Eight groups of studies (some with more than one publication
3
) were reported in this category.
Armstrong et al. (2000) examined two groups, families who received child health nurse home visits and
families who received usual care which may have included accessing their local community child
health clinic. Both the quality of maternal-infant attachment and the mothers relationship with the
child, were significantly enhanced in the experimental group and intervention mothers showed greater
emotional responsivity to their infants and more readily accepted their infants behaviour.
A recent trial by Cicchetti et al. (2006) compared infant parent psychotherapy (IPP), a
psychoeducational parenting intervention (PPI) to a community control group and a second normative
comparison group (from non-maltreating families). This study was one of only a few to directly
examine the change in attachment pattern from pre intervention to post intervention and to also include
a normative comparison group. Post intervention, all mother-child dyads were reassessed using the
Strange Situation Procedure and significant differences were found that showed the pattern of
differences had changed, indicating substantial intervention effects. The authors suggest that an
attachment-theory informed intervention (IPP) and an intervention that focuses on improving parenting
skills, increasing maternal knowledge of child development, and enhancing the coping and social
support of maltreating mothers (PPI) were both successful in altering the predominantly insecure
attachment organisations of infants in maltreating families.
Another study that also looked at mother-infant psychotherapy was conducted by Cohen and colleagues
(1999). They compared two interventions, the watch, wait and wonder programme and
psychodynamic psychotherapy. A mixed sample of mothers both self-referred and referred by health
professionals were randomly assigned to receive either intervention. Both attachment security and
change in attachment security status were examined along with other measures of mother-child
interaction. Overall the watch, wait and wonder group showed more organised or secure attachment
relationships and a greater improvement in cognitive development and emotional regulation than
infants in the comparison group.
Constantino et al. (2001) investigated the effectiveness of an educational programme which had a
socioemotional-development focus. The intervention was offered as an adjunct to home visitation to a
cohort of families already receiving home visits and to another cohort of families not previously
enrolled in home visits. A further group that acted as a control received no educational programme.
There was no clear evidence from this study that the group education intervention delivered positively
influenced childrens development independent of the increase in participation in home visitation. A
trend for improvement in parental ability to interpret infants emotional cues was noted. The authors
suggest that group meetings designed to promote parents practical understanding of childrens earliest

3
Where multiple publications exist, results from more than one article may have been combined in a single Evidence Table or a
summary article selected for appraisal. For example, for some studies such as the Nurse Family Partnership programme (Olds
and colleagues) only the most relevant publications are listed in the references.

43
social relationships may however be an effective means of engaging hard-to-reach families in home
visitation.
A home visiting programme delivered to at risk women in Australia by Fraser et al. (2000) reported on
a number of secondary outcome measures related to attachment. No significant differences were
reported between intervention and comparison groups for parental attachment. However maternal-
infant interactions were more likely to be positive, with significantly higher (better) scores in aspects of
the home environment related to optimal development in children, particularly maternal-infant
attachment. Despite some changes that were noted over time in this study, no sustained, overall
intervention effect was demonstrated at the 12- or 18-month follow-up.
In a similar but much larger scale, multisite study Goodson et al. (2000) compared families who
received services from the Comprehensive Child Development Program (CCDP) against families who
received no CCDP services but were able to access other local services. There were no significant
differences between the groups on maternal behaviours including sensitivity to cues, response to child
distress, fostering of socio-emotional growth, or on total maternal score, nor was there a significant
difference in the observed behaviour of the programme and control children. Findings suggest that a
combination of case management and parenting education, delivered through home visits, is not an
effective means of improving developmental outcomes for low-income children.
A series of articles by Heinicke and colleagues (1999; 2000; 2001) reported on a relationship oriented
and home visit-based programme (the UCLA Family Development Project). Children receiving the
intervention were more secure and their mothers more responsive to their needs in the first and second
year of life relative to a group receiving paediatric follow-up. The authors concluded that the
intervention made a significant impact on several socio-emotional mother-infant transactions including
parental responsiveness.
Nurse home visitation was compared to paraprofessional home visits by Olds et al. (2002 and 2004).
Nurse-visited mother-child pairs interacted with each other more responsively than those in the control
group (p=0.05). A very large number of outcomes were studied in this trial. At six months, nurse-
visited infants were less likely to exhibit emotional vulnerability to fear stimuli and nurse-visited
infants born to women classed as having low psychological resources were less likely to exhibit low
emotional vitality in response to joy and anger stimuli. The authors concluded that nurses produced
significant effects on a wide range of maternal and child outcomes including more responsive mother-
infant interaction compared to those visited by non-nurses.
Low-risk populations
Several studies focused on low risk participants. One of the main reasons for focusing on a sample with
a lower level of risk is that it is theoretically easier to deliver a more focused, intensive intervention.
An intervention that combined paediatric office with home visits (Healthy Steps) was compared to
usual care by Caughy et al. (2004). Only two of the original fifteen sites (six of which used a
randomised design) were examined in this report. Results suggested that mothers participating in
Healthy Steps were more likely to interact sensitively and appropriately with their children than
mothers in the comparison group by the second assessment point (age 34-37 months) but not at the first
assessment point (age 16-18 months). From a developmental perspective this is consistent as it may
reflect the fact that programme effects start to emerge and become evident at later time points. Findings
indicate that child development services can be offered through paediatric (primary care) practices.
What remains unclear from this study is whether the observed effect is due primarily to the home
visiting or paediatric visit components of the intervention or whether it is a combined effect.
Van Zeijl et al. (2006) delivered an early intervention programme to low-risk mothers that used video-
feedback and was based on a standard manualised programme. The focus of the programme was on
improving sensitivity and sensitive discipline. While the control group did not receive any explicit
intervention mothers in this group did receive a number of phone calls over the course of the study
where they had the opportunity to talk about the general development of their child. The intervention
proved to be effective in enhancing maternal attitudes toward sensitivity and sensitive discipline and in
promoting sensitive discipline interactions. The change in maternal attitudes toward sensitivity and
towards sensitive discipline and the change in sensitive discipline behaviours did not mediate any

44
changes in childrens overactive problem behaviour. Similarly, attitudes towards sensitive discipline
did not mediate any change in sensitive behaviour.
Other studies
One novel trial reported by Klein and Rye (2004) was conducted in Ethiopia among families in two
very poor communities. This intervention focused on improving the quality of parent-child interactions
including maternal sensitivity and responsiveness. One year following the intervention, mothers in the
intervention group were found to be more sensitive, more responsive, and optimistic about their
potential to affect their childs development than were mothers in the comparison group. Six years later
significant changes were still noted in the quality of the adult-child interactions and developmental
measures of the children. Further interpretation of the results from this article was limited by the lack of
information provided on the statistical analyses
4
but this study stood out as being unique in its
community development approach.
Finally, an intervention study by Velderman et al. (2006a and 2006b) was aimed at breaking the
intergenerational cycle of insecure attachment. Eighty-one first time mothers were randomly assigned
to receive video-feedback and brochures to enhance sensitive parenting. The second intervention
involved additional discussions of mothers childhood attachment experiences in relation to their
current caregiving. By the time of the six-month follow-up, intervention mothers were found to be
more sensitive than control mothers. Furthermore the interventions were most effective for the highly
reactive children and their mothers.
One additional study was appraised (see Appendix 3b) that falls outside of the scope of the current
review (due to the population rather than intervention considered). This trial looked at the effectiveness
of a personal book intervention with and without sessions of home-based video feedback in adopted
children (Juffer et al. 2005b). This short-term preventive intervention program lowered the rate of
disorganized attachment in this specific population. The effectiveness of this intervention documents
the importance of parenting in the development of infant attachment disorganization, particularly in
children with a heightened risk of attachment problems. Although the results of this study may not be
generalisable to children who are not adopted, the intervention approach itself could have application
with non-adopted children and their parents.
Discussion
Thirteen out of the 18 eligible studies (72%) reported a statistically significant improvement on one or
more outcomes of interest by the time any follow-up was completed. Of the remaining studies, three
reported no effect, one study reported a trend to improvement on the primary outcome measure of
interest and one additional study reported a positive effect but did not include data to verify this in the
published report (see Table 5, page 45).
Overall, when all the trials are considered disregarding their methodological differences the evidence is
relatively consistent, suggesting that interventions based on attachment theory and delivered to
different populations, are moderately effective despite the wide range of different intervention
approaches and different comparison groups used.
This body of evidence should however not be considered without due consideration to a number of
methodological issues and limitations.
Methodological Issues
Attachment security is only one factor in a multi-risk model of developmental psychopathology and
only one of a number of variables that contribute to parent-child relationships, it may be that
attachment may serve better as an endpoint or marker of improvement over time rather than an
immediate outcome (Cohen et al. 1999). Moreover, in general attachment security may also be more
difficult to change than maternal insensitivity.

4
Analyses appear to have been done but have been reported elsewhere primarily in an unpublished PhD which was not able to
be retrieved.

45
Table 5. Summary of direction of observed effect in intervention group by outcome and the
statistical significance or size of the effect
Primary Study Improvement shown on outcome
measure for intervention group/s

Significance/Effect Size
Ammaniti et al. (2006)

Sensitive maternal behaviours At 12 months p<.03
Armstrong et al. (2000)

Emotional responsivity At 4 months p<.05
Caughy et al. (2004) Secure attachment
Sensitive interaction
At 37 months p<.01/ES 0.23
Cicchetti et al. (2006) Secure attachment (for IPP and PPI
respectively)
At 26 months p<.001/ES 1.46 and ES 1.51
Cohen et al. (1999)

Secure attachment At approx 30 months p<.03
Constantino et al. (2001)

Interpreting emotional cues Trend only, p=.08
Fraser et al. (2000)

Short-term improvement on maternal-
infant interaction
No effect reported.
Goodson et al. (2000)

No improvement No effect reported.
Heinicke et al. (1999, 2000 and 2001)

Secure attachment
Responsivity
At 24 months p<.0001/ES 1.31
At 24 months p<.0001/ES 1.63
Letourneau et al. (2001a, 2001b)

Responsiveness For parent subscale p=.036
Klein and Rye. (2004)

Maternal-infant interaction Statistics not reported.
Koniak-Griffin et al. (2003)

No improvement No effect reported.
Moran et al. (2005)

Secure attachment
Maternal-infant interaction
At 24 months p<.05
Murray et al. (2003)

Sensitivity (for non-directive counselling) At 18 months p=.001
Olds et al. (2002, 2004)

Responsive interaction At 24 months p<.05
Toth et al. (2006)

Secure attachment At 36 months p<.001/ES 1.08
Van Zeijl et al. (2006)

Attitude towards sensitivity At 12 months p<.01
Velderman et al. (2006a and 2006b)

Sensitivity (for VIPP and VIPP-R
respectively)
At 6 months p<.05/ES 0.46 and ES 0.52
where two effect sizes (ES) are noted, more than one intervention was compared with control
Of the primary studies appraised in this review half of them (n=9) included some measure of
attachment security, predominantly the Strange Situation Procedure (which is usually conducted in a
laboratory playroom). One study used an alternative measure, Caughy et al. (2004) used the
Attachment Q-Sort, results from which have been reported to converge with the Strange Situation
Procedure (van Ijzendoorn et al. 2004). Of the studies directly considering attachment as an outcome,
six studies reported significant change, usually from an insecure or disorganised pattern of attachment
to one that was secure (Caughy et al. 2004; Cicchetti et al. 2006; Cohen et al. 1999; Heinicke et al.
1999; Heinicke et al. 2000; Heinicke et al. 2001; Moran et al. 2005; Toth et al. 2006).
However even if infants shift toward a more secure or organised attachment pattern these types of
results still need to be viewed with caution. Some of the earlier literature that predates this report
involved even younger infants in the birth through pre-attachment stage. It is important to be aware that
the effects of interventions will be dependent on the stage of attachment formation. For this reason
studies that include outcomes that were measured beyond very early infancy are useful as there may

46
well be a time lag between delivery of an intervention and subsequent changes in outcome measures (or
other endpoints).
One of the difficulties is in knowing whether any improvements are due specifically to the intervention
or whether the improvements might have occurred naturally over time. To some extent the use of
studies with an experimental design addresses this but to directly look at this, a normative control is
required in addition to their primary comparison group. A few studies did include a normative group
for comparison (Cicchetti et al. 2006; Toth et al. 2006). Cohen et al. (1999) points out it is always a
possibility that infants with mental health problems may become less symptomatic over time without
treatment, as is observed in some studies with older children. It is also possible, that as mothers mature
and become more confident in their role, that they might also become more sensitive and responsive in
their interactions with their children. Some researchers have suggested that the introduction of an early
intervention actually serves to mitigate a reduction in the number and quality of sensitive and
responsive interactions that may otherwise naturally occur over time due to the increased behavioural
demands of toddlers and other factors such as the arrival of additional children.
Ideally, intervention studies in this field would also include a waiting list or no treatment control group
so that infant behaviour and parent perceptions can be more clearly attributed to the effect of treatment.
This was not always possible in all of the studies considered either for ethical reasons or because it was
impossible to restrict mothers access to services available within their community that might constitute
an intervention. Notably, several of the studies which report no effect (Fraser et al. 2000; Goodson et
al. 2000) were broader studies where comparison mothers received usual care, with no restriction on
other programmes and services they might access during the course of the study.
Nearly without exception all of the studies identified used home visiting as the mode of service
delivery, however the extent to which home visits were used varied by study. In some studies the home
visiting programme constituted the intervention itself, whereas in other studies it was the vehicle for
delivering another specified psychosocial intervention.
Only one study by Cohen et al. (1999) appeared to have not used any home-based sessions. The authors
alluded to this by suggesting the need to further test their variant of mother-infant psychotherapy in
other settings.
Study Limitations
The specific strengths and limitations associated with each study are set out in the limitations and
comments section in the evidence tables. Key points are only very briefly discussed here.
The majority of studies were carried out in the United States (56%), with two studies conducted in the
Netherlands and Australia respectively (11%). The remaining four reports were from studies based in
Canada, Ethiopia, Italy and the United Kingdom.
The studies ranged in size from small pilot trials to large multi-site studies. Studies with smaller sample
size may have lacked sufficient power to detect an intervention effect.
The larger studies that used broader approaches although sufficiently powered may have not resulted in
significant effects for a number of reasons. Those delivering the intervention may be required first to
enable multi-risk families to engage by problem solving and attending to daily hassles before more
focused effective interventions targeting sensitivity and representations could be attempted. These
types of programmes are also more likely to demonstrate a pattern of small pervasive benefits than
large effect sizes for one specific outcome (Fergusson et al. 2005a; Fergusson et al. 2005b; Fergusson
et al. 2006).
For studies where difficulties were experienced with recruitment or retention (particularly those with
multiple risk factors), samples may not be representative and therefore less generalisable to others. In
particular, differential attrition may present an issue for longer term interventions as it may be difficult
for control groups to remain motivated to participate in the face of problems but no active support from
the programme (Goodson et al. 2000). Samples that have high rates of initial refusal may also be biased
as the overall pattern of attachment may be different, with the rate of secure attachment lower and rate
of disorganised attachment higher, in refusers compared to mothers who opted to participate in a

47
programme. Clearly, for studies in which specific populations were targeted treatment effects found
may hold only for that specific group, for example, Klein and Rye (2004).
Few studies addressed how clinicians might identify those mothers for whom the intervention is more
likely to be of benefit. In many articles the aim or objective of the intervention was often described but
without reference to the specific individual components of the intervention or detail of the process by
which intervention goals were achieved. Three groups of investigators specifically referred to their
programme as being manualised (Cicchetti et al. 2006; Toth et al. 2006; Van Zeijl et al. 2006) which
implies more detailed information on the intervention would be readily available.
Several of the included studies may be nearer to being efficacy than effectiveness trials (for example,
watch, wait and wonder- mother-infant psychotherapy) and may therefore may not reflect how a
therapy might be more flexibly applied in a real world setting as opposed to the clinic setting where
few or no collateral therapies were utilised (Cohen et al. 1999; Toth et al. 2006).
Conclusions
The evidence presented in this Technical Brief supports the earlier findings of Bakermans-Kranenburg
et al. (2003) who suggested that the most effective interventions do not always use a large number of
sessions with families, in fact fewer contacts may be more effective. It also reinforces the idea that
behaviourally focused interventions delivered one-to-one with mothers are useful and that these types
of interventions are effective regardless of the presence or absence of multiple problems in the family.
Sample characteristics appear to be unrelated to the effectiveness of interventions, though Bakermans-
Kranenburg et al. (2003) noted two exceptions to this. Firstly, samples with a higher percentage of
insecurity in the control group where interventions may exert a larger effect on infant attachment
compared to normative samples and secondly, clinical groups where interventions also appear to have a
greater effect on parental sensitivity.
Interventions that were more effective when Bakermans-Kranenburg et al. (2003) restricted their meta-
analysis to studies with both random allocation and a control group were also more effective in the
subset of clinical and high-risk samples. More general and long-term support of multi-problem families
in coping with daily hassles may be needed before more focused interventions can be implemented
successfully in this group.
While changes in attachment security reported were generally in a direction consistent with attachment
theory, they are modest. Less broad interventions that target sensitive maternal behaviour are among
those that are the most successful both at improving insensitive parenting and promoting better infant
attachment security. Infant-parent psychotherapy shows some promise while group educational
interventions generally do not.
Overall, evidence from primary and secondary research suggests that a variety of types of intervention
for enhancing maternal sensitivity and to a lesser extent attachment security are effective, with nearly
all of the different approaches involving the use of some form of home visiting to deliver the
intervention.

48
REFERENCES
Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A
psychological study of the strange situation. Hilldale, NJ.: Lawrence Erlbaum.

Ammaniti, M., Speranza, A. M., Tambelli, R., Muscetta, S., Lucarelli, L., Vismara, L., et al. (2006). A
prevention and promotion intervention program in the field of mother-infant relationship. Infant Mental
Health Journal, 27, 70-90.

Armstrong, K. L., Fraser, J. A., Dadds, M. R., & Morris, J. (2000). Promoting secure attachment,
maternal mood and child health in a vulnerable population: a randomized controlled trial. Journal of
Paediatrics & Child Health, 36, 555-562.

Bakermans-Kranenburg, M. J., Juffer, F., & van Ijzendoorn, M. H. (1998). Interventions with video
feedback and attachment discussions: does type of maternal insecurity make a difference? Infant
Mental Health Journal, 19, 202-219.

Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., & Juffer, F. (2005). Disorganized infant
attachment and preventive interventions: a review and meta-analysis. Infant Mental Health Journal, 26,
191-216.

Bakermans-Kranenburg, M. J., van, I. M. H., & Juffer, F. (2003). Less is more: meta-analyses of
sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195-215.

Barlow, J., & Parsons, J. (2006). Group-based parent-training programmes for improving emotional
and behavioural adjustment in 0-3 year old children. Cochrane Database of Systematic Reviews, Issue
3.

Brisch, K. H., Bechinger, D., Betzler, S., & Heinemann, H. (2003). Early preventive attachment-
oriented psychotherapeutic intervention program with parents of a very low birthweight premature
infant: results of attachment and neurological development. Attachment & Human Development, 5,
120-135.

Caughy, M. O., Huang, K. Y., Miller, T., & Genevro, J. L. (2004). The effects of the Healthy Steps for
Young Children Program: results from observations of parenting and child development. Early
Childhood Research Quarterly, 19, 611-630.

Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in
maltreating families through preventive interventions. Development and Psychopathology, 18, 623-
649.

Cohen, N. J., Muir, E., Parker, C. J., Brown, M., Lojkasek, M., Muir, R., et al. (1999). Watch, wait and
wonder: testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental

Cole, M., & Cole, S. (1997). The development of children. New York: W. H. Freeman.

Constantino, J. N., Hashemi, N., Solis, E., Alon, T., Haley, S., McClure, S., et al. (2001).
Supplementation of urban home visitation with a series of group meetings for parents and infants:
results of a "real-world" randomized, controlled trial. Child Abuse and Neglect, 25, 1571-1581.

Cooper, P. J., & Murray, L. (1997). The impact of psychological treatments of postpartum depression
on maternal mood and infant development. In L. Murray & P. J. Cooper (Eds.), Postpartum depression
and child development (pp. 201-261). New York: Guilford Press.

Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-
term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. British
Journal of Psychiatry, 182, 412-419.

49

Culp, R. E., Culp, A. M., Osofsky, J. D., & Osofsky, H. D. (1991). Adolescent and older mothers'
interaction patterns with their six-month-old infants. Journal of Adolescence, 14, 195-200.

Dunst, C. J., & Kassow, D. Z. (2004). Characteristics of interventions promoting parental sensitivity to
child behavior. Bridges Practice Based Research Syntheses, 2, 1-17.

Egeland, B., & Erickson, M. F. (1993). Attachment theory and findings: implications for prevention
and intervention. In S. Kramer & H. Parens (Eds.), Prevention in mental health: now, tomorrow, ever?
(pp. 21-50). Northvale, NJ: Jason Aronson.

Fergusson, D., Horwood, J., Ridder, E., & Grant, H. (2005a). Early start evaluation report.
Christchurch Health and Development Study. Christchurch: Christchurch School of Medicine and
Health Sciences.

Fergusson, D. M., Grant, H., Horwood, L. J., & Ridder, E. M. (2005b). Randomized trial of the Early
Start program of home visitation. Pediatrics, 116, e803-809.

Fergusson, D. M., Grant, H., Horwood, L. J., & Ridder, E. M (2006). Randomized trial of the Early
Start program of home visitation: parent and family outcomes. Pediatrics, 117, 781-786.

Field, T. M., Scafidi, F., Pickens, J., Prodromidis, M., Pelaez-Nogueras, M., Torquati, J., et al. (1998).
Polydrug-using adolescent mothers and their infants receiving early intervention. Adolescence, 33,
117-143.

Fraser, J. A., Armstrong, K. L., Morris, J. P., & Dadds, M. R. (2000). Home visiting intervention for
vulnerable families with newborns: follow-up results of a randomized controlled trial. Child Abuse &
Neglect, 24, 1399-1429.

Gelfand, D. M., Teti, D. M., Seiner, S. A., & Jameson, P. B. (1996). Helping mothers fight depression:
evaluation of a home-based intervention program for depressed mothers and their infants. Journal of
Clinical Child Psychology, 25, 406-422.

Goodson, B. D., Layzer, J. I., St. Pierre, R. G., Bernstein, L. S., & Lopez, M. (2000). Effectiveness of a
comprehensive, five-year family support program for low-income children and their families: findings
from the comprehensive child development program. Early Childhood Research Quarterly, 15, 5-39.

Gowen, J. W., & Nebrig, J. R. (1997). Innovations in practice. Infant-mother attachment at risk: how
early intervention can help. Infants and Young Children 9, 462-478.

Hahn, R. A., Mercy, J., Bilukha, O., & Briss, P. (2005). Assessing home visiting programs to prevent
child abuse: taking silver and bronze along with gold. Child Abuse & Neglect, 29, 215-218.

Heinicke, C. M., Fineman, N. R., Ruth, G., Recchia, S. L., Guthrie, D., & Rodning, C. (1999).
Relationship-based intervention with at-risk mothers: outcome in the first year of life. Infant Mental
Health Journal Vol, 20, 349-374.

Heinicke, C. M., Goorsky, M., Moscov, S., Dudley, K., Gordon, J., Schneider, C., et al. (2000).
Relationship-based intervention with at-risk mothers: factors affecting variations in outcome. Infant

Heinicke, C. M., Rineman, N. R., Ponce, V. A., & Guthrie, D. (2001). Relation-based intervention with
at-risk mothers: Outcome in the second year of life. Infant Mental Health Journal, 22, 431-462.

Jaffee, S., Caspi, A., Moffitt, T. E., Belsky, J., & Silva, P. (2001). Why are children born to teen
mothers at risk for adverse outcomes in young adulthood? Results for a 20-year longitudinal study.
Development and Psychopathology, 13, 377-397.

Juffer, F., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2005a). Enhancing children's
socioemotional development: a review of intervention studies In D. M. Teti (Ed.), Handbook of
research methods in developmental science (pp. 214-232). Malden, MA: Blackwell.

50

Juffer, F., Bakermans-Kranenburg, M. J., & van, I. M. H. (2005b). The importance of parenting in the
development of disorganized attachment: evidence from a preventive intervention study in adoptive
families. Journal of Child Psychology & Psychiatry & Allied Disciplines, 46, 263-274.

Juffer, F., Hoksbergen, R. A., Riksen-Walraven, J. M., & Kohnstamm, G. A. (1997). Early intervention
in adoptive families: supporting maternal sensitive responsiveness, infant-mother attachment, and
infant competence. Journal of Child Psychology & Psychiatry & Allied Disciplines, 38, 1039-1050.

Klein, P. S., & Rye, H. (2004). Interaction-oriented early intervention in Ethiopia: the MISC
approach... More Intelligent and Sensitive Children. Infants and Young Children, 17, 340-354.

Velderman, M. K, Bakermans-Kranenburg, M. J., Juffer, F., & van Ijzendoorn, M. H. (2006a). Effects
of attachment-based interventions on maternal sensitivity and infant attachment: differential
susceptibility of highly reactive infants. Journal of Family Psychology, 20, 266-274.

Velderman, M. K,, Bakermans-Kranenburg, M. J., Juffer, F., Van Ijzendoorn, M. H., Mangelsdorf, S.
C., & Zevalkink, J. (2006b). Preventing preschool externalizing behavior problems through video-
feedback intervention in infancy. Infant Mental Health Journal, 27, 466-493.

Koniak-Griffin, D., Verzemnieks, I. L., Anderson, N. L., Brecht, M. L., Lesser, J., Kim, S., et al.
(2003). Nurse visitation for adolescent mothers: two-year infant health and maternal outcomes. Nursing
Research, 52, 127-136.

LaFreniere, P. J., & Capuano, F. (1997). Preventive intervention as means of clarifying direction of
effects in socialization: anxious-withdrawn preschoolers case. Development & Psychopathology, 9,
551-564.

Letourneau, N. (2001a). Attrition among adolescents and infants involved in a parenting intervention.
Child: Care, Health and Development 27, 183-186.

Letourneau, N. (2001b). Improving adolescent parent-infant interactions: a pilot study. Journal of
Pediatric nursing, 16, 53-62.

Letourneau, N., Drummond, J., Fleming, D., Kysela, G., McDonald, L., & Stewart, M. (2001).
Supporting parents: can intervention improve parent-child relationships? Journal of Family Nursing, 7,
159-187.

Lyons-Ruth, K., Connell, D. B., & Grunebaum, H. U. (1990). Infants at social risk: maternal
depression and family support services as mediators of infant development and security of attachment.
Child Development, 61, 85-98.

Martins, C., & Gaffan, E. A. (2000). Effects of early maternal depression on patterns of infant-mother
attachment: a meta-analytic investigation. Journal of Child Psychology & Psychiatry & Allied
Disciplines, 41, 737-746.

McMahon, C. A., Barnett, B., Kowalenko, N. M., & Tennant, C. C. (2006). Maternal attachment state
of mind moderates the impact of postnatal depression on infant attachment. Journal of Child
Psychology & Psychiatry & Allied Disciplines, 47, 660-669.

Moran, G., Pederson, D. R., & Krupka, A. (2005). Maternal unresolved attachment status impedes the
effectiveness of interventions with adolescent mothers. Infant Mental Health Journal, 26, 231-249.

Murray, L., Cooper, P. J., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-
term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child
relationship and child outcome. British Journal of Psychiatry, 182, 420-427.

National Health and Medical Research Council (2005). NHMRC additional levels of evidence and
grades for recommendations for developers of guidelines. Pilot program 2005-2007 NHMRC.
Available from: http://www.nhmrc.gov.au/publications/_files/levels_grades05.pdf Accessed on
09.03.07

51

Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., Jr., et al. (2002).
Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics, 110, 486-
496.

Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., et al. (2004). Effects of
home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial.
Pediatrics, 114, 1560-1568.

Sajaniemi, N., Makela, J., Salokorpi, T., von Wendt, L., Hamalainen, T., & Hakamies-Blomqvist, L.
(2001). Cognitive performance and attachment patterns at four years of age in extremely low birth
weight infants after early intervention. European Child & Adolescent Psychiatry, 10, 122-129.

St Pierre, R.G., & Layzer, J.I., (1999). Using home visits for multiple purposes: the Comprehensive
Child Development Program. Future of Children, 9, 134-151

Suchman, N., Mayes, L., Conti, J., Slade, A., & Rounsaville, B. (2004). Rethinking parenting
interventions for drug-dependent mothers: from behavior management to fostering emotional bonds.
Journal of Substance Abuse Treatment, 27, 179-185.

Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler-parent
psychotherapy to reorganize attachment in the young offspring of mothers with major depressive
disorder: a randomized preventive trial. Journal of Consulting & Clinical Psychology, 74, 1006-1016.

van den Boom, D. C. (1994). The influence of temperament and mothering on attachment and
exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers
with irritable infants. Child Development, 65, 1457-1477.

van Ijzendoorn, M. H., Juffer, F., & Duyvesteyn, M. G. C. (1995). Breaking the intergenerational cycle
of insecure attachment: a review of the effects of attachment-based interventions on maternal
sensitivity and infant security. Journal of Child Psychology and Psychiatry, 36, 225-248.

van Ijzendoorn, M. H., Vereijken, C. M. J. L., Bakermans-Kranenburg, M. J., & Riksen-Walraven, J.
M. (2004). Assessing attachment security with the attachment Q Sort: meta-analytic
evidence for the validity of the observer AQS. Child Development, 75, 1188-1213.

Van Zeijl, J., Mesman, J., Van Ijzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer, F., Stolk, M.
N., et al. (2006). Attachment-based intervention for enhancing sensitive discipline in mothers of 1- to
3-year-old children at risk for externalizing behavior problems: a randomized controlled trial. Journal
of Consulting & Clinical Psychology, 74, 994-1005.

Zahr, L. K. (2000). Home-based intervention after discharge for Latino families of low-birth-weight
infants. Infant Mental Health Journal, 21, 448-463.

52

APPENDIX 1: LEVELS OF EVIDENCE

Level I Evidence obtained from a systematic review (or meta-analysis) of relevant randomised
controlled trials.
Level II Evidence obtained from at least one randomised controlled trial.
Level III. 1 Evidence obtained from pseudorandomised controlled trials (alternate allocation or
some other method).
2 Evidence obtained from comparative studies (including systematic reviews of such
studies) with concurrent controls and allocation not randomised, cohort studies, case
control studies or interrupted time series with a control group).
3 Evidence obtained from comparative studies with historical control, two or more
single-arm studies or interrupted time series without a parallel control group.
Level IV Evidence obtained from case series, either post-test or pretest/post-test.

From NMHRC 2000

53

54
APPENDIX 2: SEARCH STRATEGY
Medline
1 exp parent-child relations/ (31995)
2 object attachment/ (7085)
3 1 and 2 (2473)
4 attachment.tw. (45934)
5 resilience.mp. (1673)
6 (wellbeing or well being or wellness).mp. (22494)
7 or/3-6 (71358)
8 child, preschool/ or exp infant/ (982779)
9 7 and 8 (4695)
10 "early intervention (education)"/ (670)
11 early intervention.mp. (4831)
12 (parent$ adj3 program$).mp. (1122)
13 (parent$ adj3 (train$ or educat$)).mp. (3313)
14 (home adj2 visit$).mp. (3318)
15 family therapy/ (6150)
16 (family adj2 visit$).mp. (556)
17 multisystemic therapy.mp. (63)
18 or/10-17 (18780)
19 intervention studies/ (3547)
20 pc.fs. (669817)
21 8 and 18 (5485)
22 19 and 20 and 21 (25)
23 (promot$ and (wellbeing or wellness or attachment or well being)).tw. (5374)
24 23 and 8 (225)
25 (healthy steps or healthy start or early start or healthy famil$).tw. (760)
26 9 and 18 (171)
27 22 or 24 or 25 or 26 (1162)
28 limit 27 to english (983)
29 limit 28 to yr=1995-2006 (701)
30 (vaccin$ or immuni$ or breastfeeding or breast feeding).ti. (123620)
31 29 not 30 (687)
32 letter.pt. (581686)
33 31 not 32 (684)

Embase
1 exp child parent relation/ (16863)
2 emotional attachment/ (2235)
3 1 and 2 (770)
5 (resilience or wellbeing or well being or wellness).mp. (22842)
6 or/3-5 (51410)
7 Preschool Child/ (65212)
8 Infant/ (128456)
9 7 or 8 (175620)
10 6 and 9 (845)
11 Early Intervention/ (358)
12 (parent$ adj3 program$).tw. (687)
13 (parent$ adj3 (train$ or educat$)).tw. (2690)
14 (home adj2 visit$).tw. (1922)
16 (family adj2 visit$).tw. (340)
17 multisystemic therap$.tw. (45)
18 or/11-17 (9078)
19 10 and 18 (26)

55
20 exp clinical study/ or intervention study/ (2611468)
21 10 and 20 (520)
22 (promot$ and (wellness or wellbeing or well being or attachment)).tw. (3574)
23 (healthy steps or healthy start or early start or healthy famil$).tw. (499)
24 (22 or 23) and 9 (77)
25 19 or 21 or 24 (586)
27 (vaccin$ or immun$ or breastfeed$ or breast feeding$).tw. (824803)
28 26 not 27 (497)
29 limit 28 to yr=1995-2007 (396)
30 letter.pt. (335288)
31 29 not 30 (396)

Cinahl
1 exp Parent-Child Relations/ (6245)
2 Attachment Behavior/ (663)
3 1 and 2 (265)
4 (infan$ or preschool$ or pre-school$).tw. (21944)
5 3 and 4 (87)
6 limit 3 to (newborn infant <birth to 1 month> or infant <1 to 23 months> or preschool child <2 to 5 years>)
(140)
7 5 or 6 (156)
8 (attachment or resilience or wellbeing or well-being).tw. (9617)
9 4 and 8 (553)
(808)
11 7 or 9 or 10 (1057)
12 early intervention/ or early childhood intervention/ (2283)
13 early intervention.tw. (1638)
14 (parent$ adj3 program$).tw. (574)
15 parenting/ (2420)
16 (parent$ adj3 (training or educat$)).mp. (4437)
17 (home adj2 visit$).tw. (1477)
18 (multi-systemic therapy or multisystemic therapy).mp. (19)
19 intervention$.mp. (61888)
20 Program Evaluation/ (8269)
21 or/12-20 (75019)
22 11 and 21 (327)
23 (healthy steps or healthy start or sure start or healthy famil$).tw. (269)
24 4 and 23 (47)
(100)
26 24 or 25 (114)
27 22 or 26 (438)
29 limit 28 to yr=1995-2007 (388)
30 (autism or autistic).ti. (1322)
31 (vaccin$ or immuni$ or breastfeed$ or breast feed$).ti. (10772)
32 29 not (30 or 31) (373)

56
Psychinfo
1 exp Parent Child Relations/ (39818)
2 attachment behavior/ (8892)
3 1 and 2 (2872)
4 infant$.tw. (38379)
5 preschool child$.mp. (8130)
6 limit 3 to (120 neonatal <birth to age 1 mo> or 140 infancy <age 2 to 23 mo> or 160
preschool age <age 2 to 5 yrs>) (1235)
7 3 and (4 or 5) (1197)
8 6 or 7 (1557)
9 early intervention/ (4948)
10 early intervention.tw. (4552)
11 parent training/ (3968)
12 (parent$ adj3 program$).mp. (3374)
13 (parent$ adj3 (train$ or educat$)).mp. (10798)
14 (home adj2 visit$).mp. (1998)
16 family intervention/ (662)
17 exp Multimodal Treatment Approach/ (1202)
18 multisystemic therapy.tw. (169)
19 (promot$ and (wellbeing or well being or attachment or wellness)).tw. (2492)
20 or/9-19 (37420)
21 8 and 20 (114)
22 limit 21 to yr=1995-2006 (82)
23 limit 22 to all journals (58)
24 from 23 keep (selected references)
25 (3 and 20) not 21 (85)
26 limit 25 to yr=1995-2006 (68)
28 from 27 keep(selected references)
29 exp program evaluation/ (11461)
30 treatment effectiveness evaluation/ (7886)
31 treatment outcome/ (13233)
32 or/29-31 (31282)
33 (8 and 32) not (22 or 26) (0)
35 resilience.tw. (3340)
36 (well being or wellbeing).tw. (21561)
37 or/34-36 (39062)
38 20 and 37 (3284)
39 limit 38 to (120 neonatal <birth to age 1 mo> or 140 infancy <age 2 to 23 mo> or 160 preschool
age <age 2 to 5 yrs>) (326)
40 limit 39 to yr=1995-2006 (223)
44 child abuse/ (15427)
45 20 and 44 (939)
46 limit 45 to (120 neonatal <birth to age 1 mo> or 140 infancy <age 2 to 23 mo> or 160 preschool
age <age 2 to 5 yrs>) (129)
47 limit 46 to yr=1995-2006 (67)
50 (early start or healthy families or sure start or healthy start or healthy steps).tw. (185)
51 limit 50 to yr=1995-2006 (120)

57
Current Contents
1. Attachment
2. Preschool* OR pre-school*
3. Infant OR infants OR infancy
4. #1 AND (#2 OR #3)
5. Parent SAME (train* OR educat* OR program*)
6. #3 AND #5
7. #4 AND #5
8. #6 OR #7
9. #6 AND (trial OR study OR intevention OR program*)
10. #7 OR #9
11. #10 NOT (vaccin* OR immuni* OR breastfeed* OR breast feed*)

Additional cross database search for home visiting Medline, Embase, Cinahl,
PsychInfo
1 home visit$.mp. (7392)
2 domiciliary visit$.mp. (107)
3 1 or 2 (7487)
4 (infant or infants or infancy).mp. (474538)
5 (preschool child$ or young child$).mp. (128133)
6 child$.mp. (1321036)
7 4 or 5 or 6 (1520448)
8 3 and 7 (3403)
10 limit 9 to yr=1996-2007 (2579)
11 random$.mp. (661954)
12 10 and 11 (634)
13 remove duplicates from 12 (374)
14 (breastfeed$ or breast feed$).mp. (27148)
15 asthma$.mp. (108630)
16 (vaccin$ or immuni$).mp. (288546)
17 13 not (14 or 15 or 16) (288)

58
APPENDIX 3a: EXCLUDED RETRIEVED PAPERS
Anderson, G. C., Moore, E., Hepworth, J., & Bergman, N. (2003). Early skin-to-skin contact for
mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, Issue 3.

Systematic review. Intervention outside scope.

Bakermans-Kranenburg, M. J., van Ijzendoorn, M. H., & Bradley, R. H. (2005). Those who have,
receive: the Matthew effect in early childhood intervention in the home environment. Review of
Educational Research, 75, 1-26.

Systematic review. General focus on quality of home environment (responsivity measured by the
HOMES scale) rather than attachment interventions delivered by home visitors.

Barlow, J., Coren, E., & Stewart-Brown, S. S. B. (2006). Parent-training programmes for improving
maternal psychosocial health. Cochrane Database of Systematic Reviews, Issue 3.

Systematic review. Did not focus on outcomes of interest.

Barlow, J., & Parsons, J. (2006). Group-based parent-training programmes for improving emotional
and behavioural adjustment in 0-3 year old children. Cochrane Database of Systematic Reviews, Issue
3.

Systematic review. Focus on child behavioural adjustment rather than attachment. Outcomes of
interest not reported.

Barlow, J., Johnston, I., Kendrick, D., Polnay, L., & Stewart-Brown, S. (2006). Individual and group-
based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database
of Systematic Reviews, Issue 3.

Systematic review. Focus on child abuse and neglect rather than attachment. Outcomes of interest not
reported.

Barlow, J., Parsons, J., & Stewart-Brown, S. (2005). Preventing emotional and behavioural problems:
the effectiveness of parenting programmes with children less than 3 years of age. Child Care Health
and Development, 31, 33-42.

Systematic review. Focus on emotional and behavioural adjustment outcomes rather than attachment,
responsivity and sensitivity.

Barlow, J., & Stewart-Brown, S. (2000). Behavior problems and group-based parent education
programs. Journal of Developmental & Behavioral Pediatrics, 21, 356-370.

Systematic review. Focus on emotional and behavioural adjustment outcomes rather than attachment,
responsivity and sensitivity.

Barnet, B., Duggan, A. K., Devoe, M., & Burrell, L. (2002). The effect of volunteer home visitation for
adolescent mothers on parenting and mental health outcomes - a randomized trial. Archives of
Pediatrics & Adolescent Medicine, 156, 1216-1222.

Randomised controlled trial. Outcomes of interest not reported.

59
Belsky, J., Melhuish, E., Barnes, J., Leyland, A. H., & Romanuik, H. (2006). Effects of Sure Start local
programmes on children and families: early findings from a quasi-experimental, cross sectional study.
BMJ: British Medical Journal, 332.

Cross sectional study.

Benoit, D., Madigan, S., Lecce, S., Shea, B., & Goldberg, S. (2001). Atypical maternal behavior
toward feeding-disordered infants before and after intervention. Infant Mental Health Journal, 22, 611-
626.

Randomised controlled trial Focus on feeding disordered infants.

Bohlin, G., Hagekull, B., & Rydell, A.-M. (2000). Attachment and social functioning: a longitudinal
study from infancy to middle childhood. Social Development, 9, 24-39.

Cohort study. No intervention delivered.

Boris, N. W., Zeanah, C. H., & Work Group on Quality, I. (2005). Practice parameter for the
assessment and treatment of children and adolescents with reactive attachment disorder of infancy and
early childhood. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 1206-1219.

Background.

Bosquet, M., & Egeland, B. (2001). Associations among maternal depressive symptomatology, state of
mind and parent and child behaviors: implications for attachment-based interventions. Attachment &
Human Development, 3, 173-99.

Randomised controlled trial. Specific intervention effects of STEEP (Steps Towards Effective Enjoyable
Parenting) were not clearly reported in this article. The focus of this paper was on reporting
associations between maternal characteristics with regard to attachment status and their relation to
maternal and child behaviour. Research focus.

Brisch, K. H., Bechinger, D., Betzler, S., & Heinemann, H. (2003). Early preventive attachment-
oriented psychotherapeutic intervention program with parents of a very low birthweight premature
infant: results of attachment and neurological development. Attachment & Human Development, 5,
120-135.

Randomised controlled trial. Relevant attachment-based intervention however focused on a population
of interest (preterm infants) that was outside the scope of this report.

Brotman, L. M., Dawson-McClure, S., Gouley, K. K., McGuire, K., Burraston, B., & Bank, L. (2005).
Older siblings benefit from a family-based preventive intervention for preschoolers at risk for conduct
problems. Journal of Family Psychology, 19, 581-591.


Bugental, D. B., Ellerson, P. C., Lin, E. K., Rainey, B., Kokotovic, A., & O'Hara, N. (2002). A
cognitive approach to child abuse prevention. Journal of Family Psychology, 16, 243-258.


60
Carlson, E. A. (1998). A prospective longitudinal study of attachment disorganization/disorientation.
Child Development, 69, 1107-1128.

Background.

Cassidy, J., & Mohr, J. J. (2001). Unsolvable fear, trauma, and psychopathology: theory, research, and
clinical considerations related to disorganized attachment across the life span. Clinical Psychology:
Science and Practice, 8, 275-298.

Background

Chambers, H., Amos, J., Allison, S., & Roeger, L. (2006). Parent and child therapy: an attachment-
based intervention for children with challenging problems. Australian and New Zealand Journal of
Family Therapy, 27, 68-74.

Case study.

Cicchetti, D., Toth, S. L., & Rogosch, F. A. (1999). The efficacy of toddler-parent psychotherapy to
increase attachment security in offspring of depressed mothers. Attachment & Human Development, 1,
34-66.

Randomised controlled trial. Outcomes of interest not reported though intervention based on
attachment theory.

Cooper, P. J., & Murray, L. (1997). The impact of psychological treatments of postpartum depression
on maternal mood and infant development. In L. Murray & P. J. Cooper (Eds.), Postpartum depression
and child development (pp. 201-261). New York: Guilford Press.

Book chapter.

Cooper, P. J., Landman, M., Tomlinson, M., Molteno, C., Swartz, L., & Murray, L. (2002). Impact of a
mother-infant intervention in an indigent peri-urban South African context: pilot study. British Journal
of Psychiatry 180, 76-81.

Comparative study. Used Brazelton Neonatal Behavioural Assessment Scale.

Coren, E., & Barlow, J. (2006). Individual and group-based parenting programmes for improving
psychosocial outcomes for teenage parents and their children. Cochrane Database of Systematic
Reviews, Issue 3.

Systematic review. Broader focus than attachment and sensitivity. This review did identify several
parenting programs (articles published predate the time restriction for this report) that examined
parenting programmes delivered on a one-to-one basis in the home. Results using the NCATS
measure indicated a large but non-significant effect favouring infants in the intervention group on
responsiveness to the parent. No significant difference was apparent for improving the clarity of
interpreting infant cues.

Coren, E., Barlow, J., & Stewart-Brown, S. (2003). The effectiveness of individual and group-based
parenting programmes in improving outcomes for teenage mothers and their children: a systematic
review. Journal of Adolescence, 26, 79-103.

Systematic review. Broader focus than attachment and sensitivity.

61
Cornish, A. M., McMahon, C., Ungerer, J. A., Barnett, B., Kowalenko, N., & Tennant, C. (2006).
Maternal depression and the experience of parenting in the second postnatal year. Journal of
Reproductive & Infant Psychology, 24, 121-132.

Descriptive study.

Craig, E. A. (2004). Parenting programs for women with mental illness who have young children: a
review. Australian and New Zealand Journal of Psychiatry, 38, 923-928.

Narrative review.

Diener, M. L., Nievar, M. A., & Wright, C. (2003). Attachment security among mothers and their
young children living in poverty: Associations with maternal, child, and contextual characteristics.
Merrill Palmer Quarterly, 49, 154-182.

Controlled trial. Random allocation not reported. No intervention effects reported.

Doherty, W. J., Erickson, M. F., & LaRossa, R. (2006). An intervention to increase father involvement
and skills with infants during the transition to parenthood. Journal of Family Psychology, 20, 438-447.


Dunst, C. J., & Kassow, D. Z. (2004). Characteristics of interventions promoting parental sensitivity to
child behavior. Bridges Practice Based Research Syntheses, 2, 1-17.

Meta-analysis. This is a practice-based summary of the systematic review by Bakermans-Kranenburg
et al. (2003).

El-Kamary, S. S., Higman, S. M., Fuddy, L., McFarlane, E., Sia, C., & Duggan, A. K. (2004). Hawaii's
healthy start home visiting program: determinants and impact of rapid repeat birth. Pediatrics, 114,
e317-26.

Randomised controlled trial. Attachment outcomes not the focus of article.

Elkan, R., Kendrick, D., Hewitt, M., Robinson, J. J. A., Tolley, K., Blair, M., et al. (2000). The
effectiveness of domiciliary health visiting: a systematic review of international studies and a selective
review of the British literature. Health Technology Assessment, 4, 1-361.

Systematic Review. Focus on home visiting not attachment intervention. All age focus.

Fergusson, D. M., Grant, H., Horwood, L. J., & Ridder, E. M. (2005). Randomized trial of the Early
Start program of home visitation. Pediatrics, 116, e803-9.


Field, T. M., Scafidi, F., Pickens, J., Prodromidis, M., Pelaez-Nogueras, M., Torquati, J., Wilcox, H.,
Malphurs, J., Schanberg, S., & Kuhn, C. (1998). Polydrug-using adolescent mothers and their infants
receiving early intervention. Adolescence, 33, 117-43.

Controlled trial, method of assignment unclear. Mothers using drugs.

62
Galano, J., Credle, W., Perry, D., Berg, S. W., Huntington, L., & Stief, E. (2001). Developing and
sustaining a successful community prevention initiative: the Hampton Healthy Families Partnership.
Journal of Primary Prevention, 21, 495-509.

Descriptive study of a programme.

Garbers, C., Tunstill, J., Allnock, D., & Akhurst, S. (2006). Facilitating access to services for children
and families: lessons from Sure Start Local Programmes. Child & Family Social Work, 11, 287-296.

Background. Presents models of three types of parental service use.

Guyer, B., Hughart, N., Strobino, D., Jones, A., & Scharfstein, D. (2000). Assessing the impact of
pediatric-based development services on infants, families, and clinicians: challenges to evaluating the
Health Steps Program. Pediatrics, 105, E33.

Randomised controlled trial. Describes evaluation design and study.

Herschell, A. D., Calzada, E. J., Eyberg, S. M., & McNeil, C. B. (2002). Parent-child interaction
therapy: New directions in research. Cognitive and Behavioral Practice, 9, 9-15.

Background to the therapy. Not a study.

Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers' and preschoolers'
attachment classifications: the Circle of Security intervention. Journal of Consulting and Clinical
Psychology, 74, 1017-1026.

Pre-test/post-test study with no control group.

Horowitz, J. A., Bell, M., Trybulski, J., Munro, B. H., Moser, D., Hartz, S. A., et al. (2001). Promoting
responsiveness between mothers with depressive symptoms and their infants. Journal of Nursing
Scholarship 33, 323-329.

Randomised controlled trial. Only one relevant outcome reported. The treatment group did show
significantly higher maternal infant responsiveness after an interactive coaching intervention to
promote responsiveness (as measured by the Dyadic Mutuality Code).

Johnston, B. D., Huebner, C. E., Anderson, M. L., Tyll, L. T., & Thompson, R. S. (2006). Healthy
steps in an integrated delivery system: child and parent outcomes at 30 months. Archives of Pediatrics
& Adolescent Medicine, 160, 793-800.


Juffer, F., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2005). Enhancing children's
socioemotional development: a review of intervention studies In D. M. Teti (Ed.), Handbook of
research methods in developmental science (pp. 214-232). Malden, MA: Blackwell.

Book chapter.

63
Juffer, F., Bakermans-Kranenburg, M. J., & van, I. M. H. (2005). The importance of parenting in the
development of disorganized attachment: evidence from a preventive intervention study in adoptive
families. Journal of Child Psychology & Psychiatry & Allied Disciplines, 46, 263-74.

Randomised controlled trial. Sample of adoptive children outside predetermined scope but included as
a separate appendix.

Kaaresen, P. I., Ronning, J. A., Ulvund, S. E., & Dahl, L. B. (2006). A randomized, controlled trial of
the effectiveness of an early-intervention program in reducing parenting stress after preterm birth.
Pediatrics, 118, e9-19.

Randomised controlled trial. Conference Abstract.

Kendrick, D., Elkan, R., Hewitt, M., Dewey, M., Blair, M., Robinson, J., et al. (2000). Does home
visiting improve parenting and the quality of the home environment? A systematic review and meta
analysis. Archives of Disease in Childhood, 82, 443-451.

Systematic review. General focus on home visiting programmes and quality of home environment
(measured by the HOMES scale) rather than attachment interventions delivered by home visitors.

Klein Velderman, M., Bakermans-Kranenburg, M. J., Juffer, F., & van Ijzendoorn, M. H. (2006).
Effects of attachment-based interventions on maternal sensitivity and infant attachment: differential
susceptibility of highly reactive infants. Journal of Family Psychology, 20, 266-274.

Descriptive study.

Kivijrvi, M., Rih, H., Kaljonen, A., Tamminen, T., & Piha, J. (2005). Infant temperament and
maternal sensitivity behavior in the first year of life. Scandinavian Journal of Psychology, 46, 421-428.

Cross-sectional study. No control group.

Lagerberg, D. (2000). Secondary prevention in child health: effects of psychological intervention,
particularly home visitation, on children's development and other outcome variables. Acta Paediatrica
Supplement, 89, 43-52.

Narrative review. Methods not outlined. Includes sensitivity and attachment interventions.

Landry, S. H., Smith, K. E., & Swank, P. R. (2006). Responsive parenting: establishing early
foundations for social, communication, and independent problem-solving skills. Developmental
Psychology, 42, 627-642.

Randomised controlled trial. Only reported one outcome of interest (responsivity) and did not report
any outcome measures for attachment. The study compared term infants with those born at very low
birth weight with a developmental comparison group. The target group that received the intervention
showed greater increases in responsiveness than the comparison group, with changes in emotionally
supportive behaviours strongest for the low birth weight babies and mothers.

Leitch, D. B. (1999). Mother-infant interaction: achieving synchrony. Nursing Research 48, 55-58.

Quasi-experimental study. Random assignment to intervention group at time of registration. Reports on
a brief prenatal intervention but relevant outcomes only measured 24 hours post-birth.

64
Letourneau, N. (2001). Improving adolescent parent-infant interactions: a pilot study. Journal of
Pediatric Nursing, 16, 53-62.

Randomised controlled trial (pilot study). Only one outcome of interest reported (NCATS).

Love, J. M., Kisker, E. E., Ross, C., Raikes, H., Constantine, J., Boller, K., et al. (2005). The
effectiveness of early head start for 3-year-old children and their parents: lessons for policy and
programs. Developmental Psychology, 41, 885-901.

Randomised controlled trial. This was a high quality trial however this article did not specifically
report outcomes of interest (sensitivity, responsiveness, attachment) although child oucome measures
did include relevant instruments such as the Child Behavior Checklist (CBCL) and the Home
Observation for Measurement of the Environment (HOME). Early Head Start children had lower levels
of aggression and rated higher on engagement with their parents compared with children in the control
group.

Luster, T., Perlstadt, H., McKinney, M., Sims, K., & Juang, L. (1996). The effects of a family support
program and other factors on the home environments provided by adolescent mothers. Family
Relations: Journal of Applied Family & Child Studies, 45, 255-264.


Lynch, K. B., Geller, S. R., & Schmidt, M. G. (2004). Multi-year Evaluation of the effectiveness of a
resilience-based prevention program for young children. Journal of Primary Prevention, 24, 335-353.

Narrative review.

MacLeod, J., & Nelson, G. (2000). Programs for the promotion of family wellness and the prevention
of child maltreatment: a meta-analytic review. Child Abuse & Neglect, 24, 1127-1149.

Meta-analysis. Only one outcome measure (HOME) of interest reported and no detail on sensitivity
subscales.

Martins, C., & Gaffan, E. A. (2000). Effects of early maternal depression on patterns of infant-mother
attachment: a meta-analytic investigation. Journal of Child Psychology & Psychiatry & Allied
Disciplines, 41, 737-746.

Meta analysis but not of intervention studies.

Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002). The Circle of Security project: attachment-
based intervention with caregiver-pre-school child dyads. Attachment & Human Development, 4, 107-
124.

Case study.

McMahon, C. A., Barnett, B., Kowalenko, N. M., & Tennant, C. C. (2006). Maternal attachment state
of mind moderates the impact of postnatal depression on infant attachment. Journal of Child
Psychology & Psychiatry & Allied Disciplines, 47, 660-669.

Longitudinal study. Focus on implications for intervention.

65
Mercer, R. T., & Walker, L. O. (2006). A review of nursing interventions to foster becoming a mother.
JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 568-582.

Systematic review. Focus on brief postnatal interventions (up to 4 months post-partum).

Minkovitz, C. S., Hughart, N., Strobino, D., Scharfstein, D., Grason, H., Hou, W., Miller, T., Bishai,
D., Augustyn, M., McLearn, K. T., & Guyer, B. (2003). A practice-based intervention to enhance
quality of care in the first 3 years of life: the Healthy Steps for Young Children Program. JAMA, 290,
3081-91.

Randomised controlled trial (by site). Attachment outcomes not the focus of article.

Nelson, G., Westhues, A., & MacLeod, J. (2003). A meta-analysis of longitudinal research on
preschool prevention programs for children. Prevention & Treatment, Vol 6, Article 31.

Meta-analysis. Not outcomes of interest. Socioemotional outcomes only reported at a broad level.

Norr, K. F., Crittenden, K. S., Lehrer, E. L., Reyes, O., Boyd, C. B., Nacion, K. W., & Watanabe, K.
(2003). Maternal and infant outcomes at one year for a nurse-health advocate home visiting program
serving African Americans and Mexican Americans. Public Health Nursing, 20, 190-203.

Randomised controlled trial. Only one outcome of interest reported (HOMES).

Nylen, K. J., Moran, T. E., Franklin, C. L., & O'Hara, M. W. (2006). Maternal depression: a review of
relevant treatment approaches for mothers and infants. Infant Mental Health Journal, 27, 327-343.

Narrative review.

O'Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: assessment strategies and treatment
approaches. Attachment & Human Development Vol, 5, 223-244.

Background.

Olds, D. L. (2006). The nurse-family partnership: an evidence-based preventive intervention. Infant

Narrative review.

Onozawa, K., Glover, V., Adams, D., Modi, N., & Kumar, R. C. (2001). Infant massage improves
mother-infant interaction for mothers with postnatal depression. Journal of Affective Disorders, 63,
201-7.

Randomised controlled trial. Not intervention of interest.

Palfrey, J. S., Hauser-Cram, P., Bronson, M. B., Warfield, M. E., Sirin, S., & Chan, E. (2005). The
Brookline Early Education Project: a 25-year follow-up study of a family-centered early health and
development intervention. Pediatrics, 116, 144-152.

Comparative study. Outcomes of interest not reported.

66
Reynolds, A. J., & Ou, S.-R. (2004). Alterable predictors of child well-being in the Chicago
longitudinal study. Children and Youth Services Review, 26, 1-14.

Descriptive summary of cohort study.

Sajaniemi, N., Makela, J., Salokorpi, T., von Wendt, L., Hamalainen, T., & Hakamies-Blomqvist, L.
(2001). Cognitive performance and attachment patterns at four years of age in extremely low birth
weight infants after early intervention. European Child & Adolescent Psychiatry, 10, 122-9.

Pseudorandomised controlled trial. Not population of interest.

Schuler, M. E., Nair, P., Black, M. M., & Kettinger, L. (2000). Mother-infant interaction: effects of a
home intervention and ongoing maternal drug use. Journal of Clinical Child Psychology, 29, 424-31.

Randomised controlled trial. Mothers using drugs

Siddiqui, A., & Hagglof, B. (2000). Does maternal prenatal attachment predict postnatal mother-infant
interaction? Early Human Development, 59, 13-25.

Cross sectional study. Background on maternal responsive behaviour.

Stormshak, E. A., Kaminski, R. A., & Goodman, M. R. (2002). Enhancing the parenting skills of Head
Start families during the transition to kindergarten. Prevention Science, 3, 223-34.

Randomised controlled trial (by site). Attachment outcomes not the focus of article.

Suchman, N., Pajulo, M., DeCoste, C., & Mayes, L. (2006). Parenting interventions for drug-dependent
mothers and their young children: The case for an attachment-based approach. Family Relations, 55,
211-226.

Narrative review. Also describes the development of a pilot randomised controlled trial.


Background. Mothers using drugs.

Sweet, M. A., & Appelbaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic
review of home visiting programs for families with young children. Child Development, 75, 1435-
1456.

Meta analysis. General focus on home visiting programmes rather than attachment interventions
delivered by home visitors.


Comparative study. Population group outside the scope of this report.

67
Tessier, R., Cristo, M., Velez, S., Giron, M., de Calume, Z. F., Ruiz-Palaez, J. G., et al. (1998).
Kangaroo mother care and the bonding hypothesis. Pediatrics, 102, e17.

Randomised controlled trial. Intervention outside the scope of this report.

Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of
two interventions in altering maltreated preschool children's representational models: implications for
attachment theory. Development & Psychopathology, 14, 877-908.

Randomised controlled trial. Outcomes of interest not reported in this article.

Wendland-Carro, J., Piccinini, C. A., & Millar, W. S. (1999). The role of an early intervention on
enhancing the quality of mother-infant interaction. Child Development, 70, 713-21.

Randomised controlled trial. Brief postnatal hospital-based intervention.

Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., et al. (2004). The Social
Support and Family Health Study: a randomised controlled trial and economic evaluation of two
alternative forms of postnatal support for mothers living in disadvantaged inner-city areas. Health
Technology Assessment, 8, 1-139.

Randomised controlled trial. Not outcomes of interest.

Willinger, U., Diendorfer-Radner, G., Willnauer, R., Jorgl, G., & Hager, V. (2005). Parenting stress
and parental bonding. Behavioral Medicine, 31, 63-69.

Background.

Zahr, L. K. (2000). Home-based intervention after discharge for Latino families of low-birth-weight
infants. Infant Mental Health Journal, 21, 448-463.

Pseudo-randomised controlled trial. Focus on low-birth-weight infants.

68
APPENDIX 3b: APPRAISED RETRIEVED PAPERS (EXCLUDED)
Authors,
country
Intervention,
setting
inclusion and exclusion criteria
Study design,
methods
J uffer et al.
(2005b)

The
Netherlands

Intervention
Personal book
group (PB)

Personal book
plus three
sessions home-
based video
feedback (VF)

Control
No intervention
Participants were 90 families with a first
adopted child and 40 families with
birth children and a first adopted child.
All families were randomly recruited
through adoption agencies and not
selected in future problems.

Adopted children were not selected
by, nor matched to, the characteristics
of their future adoptive parents.

n=130 (66 boys, 64 girls)

Inclusion criteria
family with first adopted child
child came into adoptive care
before 6 months of age

Exclusion criteria
None specifically stated.

not found for family background
characteristics, e.g. socioeconomic
status or parents age, the number of
boys or girls, or the adopted childs
health problems on arrival.

There were significant differences with
respect to the association between
country of origin and age on arrival.
Post hoc tests indicated that infants in
the video-feedback group arrived at
an older age than the children in the
book-only or control group.

Randomised controlled
trial.

Experimental group
versus control,
pretest/posttest. Data
was collected and
mother-child
interactions
videotaped in the
home at baseline (6
months) and at follow-
up (12-months).

In addition at 6 and 9
months mother-child
interaction was
videotaped in all
families. In the video-
feedback group,
videotapes were used
in the intervention
whereas in the other
groups they were not.
At 12 and 18-months
infant-mother
attachment was
observed in the
laboratory.

Attrition
There was no attrition
between pre- and
posttests.

Assessment and
outcome measures
Strange Situation
Procedure (SSP)
Dutch Temperament
Questionnaire
Intervention effects were computed using
analysis of covariance (ANCOVA).

Sensitive Responsiveness
The standardized composite score for
sensitive responsiveness at 12 months was
conducted with experimental condition
(video feedback, book-only and control) as
the independent variable and pretest
responsiveness (standardized composite
score) as the covariate.
A significant main effect of the experimental
condition was found (p=.01).

Two further planned comparisons were
examined. The book intervention did not
yield a significant effect compared with the
control (p=.07). However there was a
significant main effect for the video-
feedback intervention (p<.01).

Post hic analyses confirmed that the effects
on sensitiveness responsiveness were in the
same direction and of comparable
magnitude in families with and without birth
children.

Disorganized Attachment
The intervention with video feedback was
effective and lowered the number of
disorganized infants as well as the continuous
disorganization score. A moderate effect size
of d=0.46 for the effect on the disorganized
attachment classification, and a medium to
strong effect size of d =.62 for the effect on
the continuous disorganization ratings. The
book-only intervention did not result in a
significant decrease of infant disorganization,
although infants in this group had lower
ratings than in the control group
Limitations
sample of adopted children who may be a special case
of attachment insecurity, may limit generalisability
the study intervention was not specifically aimed at
changing attachment disorganization but may have
affected aspects of parenting that are important for this

Comments
the intervention was primarily aimed at promoting
sensitive parenting and secure attachment
the authors note that the discovery of a distinct effect of
the video-feedback intervention is important, as a follow-
up study has found that infant disorganized attachment in
combination with difficult temperament is predictive of
less optimal cognitive development and less optimal ego-
control in middle childhood
adoptive families were particularly open to intervention
and eager to receive support (as noted by the zero
attrition rate)
the success of the intervention cannot be explained by
post-adoption support as no such service were available
at the time of the study
sample consists of parents with genetically unrelated,
adopted children who were not selected but placed by
chance so results are not confounded by genetically
transmitted risks or protective factors for attachment
disorganization.

Authors conclusions
A short-term preventive intervention program with video
feedback and a book lowered the rate of disorganized
attachment. The effectiveness of the intervention documents the
importance of parenting in the development of infant
attachment disorganization.

69

70
APPENDIX 4: APPRAISED RETRIEVED PAPERS
Secondary Articles
Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., & Juffer, F. (2005). Disorganized infant
attachment and preventive interventions: a review and meta-analysis. Infant Mental Health Journal, 26,
191-216.
Bakermans-Kranenburg, M. J., van, I. M. H., & Juffer, F. (2003). Less is more: meta-analyses of
sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195-215.
Primary Articles
Ammaniti, M., Speranza, A. M., Tambelli, R., Muscetta, S., Lucarelli, L., Vismara, L., et al. (2006). A
prevention and promotion intervention program in the field of mother-infant relationship. Infant Mental
Armstrong, K. L., Fraser, J. A., Dadds, M. R., & Morris, J. (2000). Promoting secure attachment,
maternal mood and child health in a vulnerable population: a randomized controlled trial. Journal of
Paediatrics & Child Health, 36, 555-62.
Caughy, M. O., Huang, K. Y., Miller, T., & Genevro, J. L. (2004). The effects of the Healthy Steps for
Young Children Program: results from observations of parenting and child development. Early
Childhood Research Quarterly, 19, 611-630.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in
maltreating families through preventive interventions. Development and Psychopathology, 18, 623-
649.
Cohen, N. J., Muir, E., Parker, C. J., Brown, M., Lojkasek, M., Muir, R., & Barwick, M. (1999).
Watch, wait and wonder: testing the effectiveness of a new approach to mother-infant psychotherapy.
Infant Mental Health Journal, 20, 429-451.
Constantino, J. N., Hashemi, N., Solis, E., Alon, T., Haley, S., McClure, S., Nordlicht, N., et al. (2001).
Supplementation of urban home visitation with a series of group meetings for parents and infants:
results of a "real-world" randomized, controlled trial. Child Abuse and Neglect, 25, 1571-81.
Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-
term effect of psychological treatment of post-partum depression. I. Impact on maternal mood. British
Journal of Psychiatry, 182, 412-419.
Fraser, J. A., Armstrong, K. L., Morris, J. P., & Dadds, M. R. (2000). Home visiting intervention for
vulnerable families with newborns: follow-up results of a randomized controlled trial. Child Abuse &
Neglect, 24, 1399-429.
Goodson, B. D., Layzer, J. I., St. Pierre, R. G., Bernstein, L. S., & Lopez, M. (2000). Effectiveness of a
comprehensive, five-year family support program for low-income children and their families: findings
from the comprehensive child development program. Early Childhood Research Quarterly, 15, 5-39.
Heinicke, C. M., Fineman, N. R., Ruth, G., Recchia, S. L., Guthrie, D., & Rodning, C. (1999).
Relationship-based intervention with at-risk mothers: outcome in the first year of life. Infant Mental
Health Journal. Vol, 20, 349-374.
Heinicke, C. M., Goorsky, M., Moscov, S., Dudley, K., Gordon, J., Schneider, C., & Guthrie, D.
(2000). Relationship-based intervention with at-risk mothers: factors affecting variations in outcome.
Infant Mental Health Journal, 21, 133-155.

71
Heinicke, C. M., Rineman, N. R., Ponce, V. A., & Guthrie, D. (2001). Relation-based intervention with
at-risk mothers: outcome in the second year of life. Infant Mental Health Journal, 22, 431-462.
Letourneau, N., Drummond, J., Fleming, D., Kysela, G., McDonald, L., & Stewart, M. (2001a).
Supporting parents: Can intervention improve parent-child relationships? Journal of Family Nursing, 7,
159-187.
Letourneau, N. (2001b). Improving adolescent parent-infant interactions: a pilot study. Journal of
Pediatric Nursing, 16, 53-62.
Klein, P. S., & Rye, H. (2004). Interaction-oriented early intervention in Ethiopia: the MISC
approach... More Intelligent and Sensitive Children. Infants and Young Children, 17, 340-354.
Koniak-Griffin, D., Verzemnieks, I. L., Anderson, N. L., Brecht, M. L., Lesser, J., Kim, S., et al.
(2003). Nurse visitation for adolescent mothers: two-year infant health and maternal outcomes. Nursing
Research, 52, 127-136.
Moran, G., Pederson, D. R., & Krupka, A. (2005). Maternal unresolved attachment status impedes the
effectiveness of interventions with adolescent mothers. Infant Mental Health Journal, 26, 231-249.
Murray, L., Cooper, P. J., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-
term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child
relationship and child outcome. British Journal of Psychiatry, 182, 420-7.
Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., Jr., et al. (2002).
Home visiting by paraprofessionals and by nurses: a randomized, controlled trial.. Pediatrics, 110, 486-
496.
Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., et al. (2004). Effects of
home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial.
Pediatrics, 114, 1560-1568.
Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler-parent
psychotherapy to reorganize attachment in the young offspring of mothers with major depressive
disorder: a randomized preventive trial. Journal of Consulting & Clinical Psychology, 74, 1006-1016.
Van Zeijl, J., Mesman, J., Van Ijzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer, F., Stolk, M.
N., et al. (2006). Attachment-based intervention for enhancing sensitive discipline in mothers of 1- to
3-year-old children at risk for externalizing behavior problems: a randomized controlled trial. Journal
of Consulting & Clinical Psychology, 74, 994-1005.
Velderman, M. K., Bakermans-Kranenburg, M. J., Juffer, F., & van, I. M. H. (2006a). Effects of
attachment-based interventions on maternal sensitivity and infant attachment: differential susceptibility
of highly reactive infants. Journal of Family Psychology, 20, 266-74.
Velderman, M.K, Bakermans-Kranenburg, M. J., Juffer, F., Van Ijzendoorn, M. H., Mangelsdorf, S. C.,
& Zevalkink, J. (2006b). Preventing preschool externalizing behavior problems through video-
feedback intervention in infancy. Infant Mental Health Journal, 27, 466-493.

Effective Strategies For Promoting Attachment Between Young Children and Their Parents

Transféré par

Informations du document

Description originale:

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Effective Strategies For Promoting Attachment Between Young Children and Their Parents

Transféré par

Droits d'auteur :

Formats disponibles

NZHTA TECHNICAL BRIEF

From NMHRC 2000

Vous aimerez peut-être aussi