Attachment-based Parenting Intervention Research Articles

EConnect: implementation and preliminary evaluation of a virtually delivered attachment-based parenting intervention during COVID-19

ABSTRACT Connect, an attachment-based and trauma-informed parenting group intervention, has been demonstrated to improve adolescent mental health, parental wellbeing, and family functioning. We report on the online adaptation and delivery of Connect (eConnect) and pre-post treatment changes in parent, family and youth functioning in a clinical sample (N= 190) of parents of youth with serious mental health challenges. Consistent with research evaluating in-person Connect, parents reported significant reductions in youth internalizing and externalizing problems, attachment anxiety and avoidance, and aggression toward parents. Parents also reported significant reductions in caregiver strain and aggression toward their child. Unlike prior research, parent depressed mood did not decline, perhaps due to pandemic stressors. Program completion was remarkably high (84.7%), and parents reported high program satisfaction. Uptake by eConnect program facilitators and host agencies was extremely positive, suggesting good potential for sustainability and broadened program accessibility. Randomized clinical trials and implementation within diverse populations are needed.

Training home visitors in mentalization-based practice: A qualitative case study of clinical supervision in mothering from the inside out.

Attachment-based interventions are important for improving parent-child outcomes. These interventions must be scaled and made available to under-resourced communities. An important part of scaling these interventions is delineating and reproducing high-quality training, including clinical training which often requires the completion of a supervised case. However, descriptions and guidelines for clinical training are frequently broad or not available in the literature. A detailed description of clinical training could lead to further research to improve the effectiveness and dissemination of evidence-based interventions. Mothering from the Inside Out (MIO) is an attachment-based parenting intervention effective at reducing substance use and depression, improving caregiving, and enhancing child attachment. It is now being brought from research to community settings. This paper outlines the didactic and clinical training components of MIO. We then present a qualitative case study of one community-based counselor participating in the clinical training of MIO and employ qualitative methods to describe the main themes that arose during the training. We aim to illustrate how the trainer assisted the counselor in implementing the core components of MIO, which included (a) refining the language used in MIO sessions, (b) making space to explore mental states, and (c) addressing trauma. We conclude by presenting the implications of these findings.

ECONNECT Parent Group: An Online Attachment-Based Intervention to Reduce Attachment Insecurity, Behavioral Problems, and Emotional Dysregulation in Adolescence.

During adolescence, a secure parent-adolescent relationship promotes youths' adjustment and psychological well-being. In this scenario, several studies have demonstrated the effectiveness of the CONNECT program, a 10-session, attachment-based parenting intervention that helps parents understand and reframe their parent-adolescent interactions, reducing adolescents' insecure attachment and behavioral problems. Furthermore, recent years have witnessed a significant increase in the implementation of effective online versions of psychological interventions, emphasizing the opportunity for more agile and easier dissemination of evidence-based protocols. Therefore, this study aims to identify changes in adolescents' attachment insecurity, behavioral problems, and parent-child affect regulation strategies, providing preliminary findings on an online, 10-session, attachment-based parenting intervention (eCONNECT). A total of 24 parents (20 mothers, 4 fathers; Mage = 49.33, SD = 5.32) of adolescents (Mage = 13.83 years, SD = 1.76, 45.8% girls) were assessed on their adolescents' attachment insecurity (avoidance and anxiety) and behavioral problems (externalizing and internalizing), and on their affect regulation strategies in the parent-child interaction (adaptive reflection, suppression, and affect dysregulation) at three time points: before intervention (t0), after intervention (t1), and at a 2-month follow-up (t2). Mixed-effects regression models highlighted a reduction in adolescents' internalizing problems (d = 0.11), externalizing problems (d = 0.29), and attachment avoidance (d = 0.26) after the intervention. Moreover, the reduction in externalizing problems and attachment avoidance remained stable at follow-up. Additionally, our findings highlighted a reduction in parent-child affect dysregulation. Results add preliminary evidence on the implementation suitability of an online attachment-based parenting intervention to change at-risk adolescents' developmental trajectories by reducing attachment insecurity, behavioral problems, and parent-child affect regulation.

Parenting interventions to support parent/child attachment and psychosocial adjustment in foster and adoptive parents and children: A systematic review.

Parenting interventions to support parent/child attachment and psychosocial adjustment in foster and adoptive parents and children: A systematic review.

Maternal Psychological Risk Moderates the Impacts of Attachment-Based Intervention on Mother-Toddler Mutuality and Toddler Behavior Problems: A Randomized Controlled Trial.

Although there is robust evidence of the benefits of attachment-based parenting interventions, limited research has examined their impact on dyadic mutuality and toddler behavior problems. Given the central question in prevention research of what works for whom, and the documented relation of maternal psychological risk to parenting and intervention response, it is important to consider the moderating role of maternal psychological risk in the efficacy of attachment-based interventions. The current study extends prior research on a randomized controlled trial of Attachment and Biobehavioral Catch-up (ABC) by examining its impact on dyadic mutuality and the moderating role of maternal psychological risk in ABC's impact on dyadic mutuality and toddler behavior problems. ABC (10 sessions) was provided as a supplement to Early Head Start (EHS) for a sample of predominantly low-income Latinx families. Control families received home-based EHS plus 1 book per week for 10weeks. We administered a psychosocial interview and video-recorded parent-toddler interaction pre- and post-intervention. Using intent-to-treat analyses, we found main effects of ABC on dyadic mutuality. We conducted latent class analysis to identify patterns of interrelationships among indicators of baseline maternal risk exposure to characterize a latent risk factor and used this factor to examine the moderating role of maternal psychological risk in ABC's impact on dyadic mutuality and toddler behavior problems. ABC seemed to be particularly beneficial for the development of positive, synchronous dyadic interactions and for reduction of toddler behavior problems in higher-risk EHS families. Findings are discussed in the context of designing and evaluating preventive interventions, with a specific focus on families at psychological risk.

Effect of a parenting intervention on decreasing adolescents’ behavioral problems via reduction in attachment insecurity: A longitudinal, multicenter, randomized controlled trial

IntroductionSecure attachment in adolescence, related to caregiving quality, is a robust predictor of positive behavioral adjustment in early adulthood and beyond. Nevertheless, few attempts have been made to develop treatments to promote parent–adolescent attachment security. MethodsUsing a longitudinal, multicenter, randomized controlled trial design, two questionnaire-based studies were run in Italy (Study 1: n = 100 mothers of adolescents, 60% boys, Mage = 14.89, SD = 1.58; Study 2: n = 40 mothers and 40 adolescents, 60% boys, Mage = 14.90, SD = 1.91) to test the effectiveness of an attachment-based parenting intervention (i.e., Connect) in reducing adolescents’ behavioral problems and attachment insecurity 2 weeks post-intervention (t2) and at a 4-month follow-up (t3). It was further investigated whether a decrease in avoidant and anxious attachment at t2 would account for changes in externalizing and internalizing problems, respectively, at t3. All adolescents belonged to two-parent intact families. ResultsMothers who completed Connect reported significantly fewer adolescent behavioral problems and lower adolescent attachment insecurity, compared to mothers in the waitlist group, at both t2 and t3 (Study 1). These findings were confirmed in a second subsample (Study 2), considering both mothers' and adolescents’ reports. Controlling for pre-intervention behavioral problems, reductions in internalizing and externalizing problems were observed in both studies at t3 via a decrease in anxious and avoidant attachment, respectively, at t2. ConclusionsThe findings point to the malleability of attachment security in adolescence and highlight the importance of targeting parenting quality to promote adolescent behavioral adjustment.

Parent-Child Interaction Therapy with Toddlers in a community-based setting: Improvements in parenting behavior, emotional availability, child behavior, and attachment.

Parent-Child Interaction Therapy with Toddlers (PCIT-T) is a new attachment-based parenting intervention designed to meet the needs of children aged 12-24 months presenting with challenging behaviors. This study examined outcomes of the first phase of PCIT-T, Child Directed Interaction-Toddler (CDI-T), 4-months post treatment. Participants were 56 toddlers (Child Mage=19.13 months) referred to receive CDI-T over an 8-week period at an Australian community-based child behavior treatment clinic for treatment of difficult toddler behaviors. Participants completed questionnaires and observational measures at baseline (Time 1), post-treatment (Time 2), and 4-month follow-up (Time 3). At both Time 2 and Time 3, there were statistically significant increases in observed positive parenting skills and emotional availability and decreases in negative parenting behaviors and child noncompliance. There were also significant improvements in parent-reported child externalizing and internalizing behaviors, parental stress, and maternal depression. There was a pattern of a shift away from attachment insecurity and attachment disorganization. Results suggest that the CDI-T phase of PCIT-T is a promising intervention for toddlers presenting with behavioral issues. Future studies should be conducted to assess efficacy in other settings, using larger samples and utilizing randomized controlled designs.

Emotion Regulation among Children in Foster Care Versus Birth Parent Care: Differential Effects of an Early Home-Visiting Intervention.

Children involved with Child Protective Services (CPS) often show worse emotion regulation than non-involved children, with downstream effects on adaptive functioning. The current study uses two randomized control trials, one conducted with foster caregivers and one conducted with birth parents, to investigate the longitudinal effects of caregiver type (foster versus birth parent) and a home-visiting parenting intervention on emotion regulation among young children referred to CPS. Participants were 211 children referred to CPS during infancy or toddlerhood, of whom 120 remained with their birth parents and 91 were placed in foster care. Caregivers were randomly assigned to receive Attachment and Biobehavioral Catch-Up (ABC), a 10-session intervention designed to promote nurturing, sensitive, and non-intrusive caregiving, or a control intervention. Caregiver type moderated the effects of ABC on young children's observed anger dysregulation during a frustrating task at age 2 to 3years. Among children remaining with their birth parents, children whose caregivers received ABC showed lower anger dysregulation than children whose caregivers received the control intervention. Children placed in foster care showed lower anger dysregulation than children with birth parents regardless of parenting intervention, and additionally showed higher adaptive regulation than children remaining with their birth parents. Adaptive regulation was not significantly associated with parenting intervention or the caregiver by intervention interaction. Results suggest that foster care placement may be protective for emerging emotion regulation skills among young children referred to CPS, and an attachment-based parenting intervention buffers risks of remaining in the home for young children's emotion dysregulation.

Improving infants’ stress-induced cortisol regulation through attachment-based intervention: A randomized controlled trial

Attachment-based parenting interventions have shown positive effects on early cortisol regulation, a key biomarker. Evaluations to date have focused on diurnal cortisol production in high-risk infants. It is important to understand whether attachment-based intervention may also improve stress-induced cortisol production in typically developing infants. This randomized controlled trial tested an enhanced model of U.S. Early Head Start (EHS) services that combined home-based EHS with a brief, attachment-based parenting intervention, Attachment and Biobehavioral Catch-up (ABC). The trial included 153 low-income mothers and their infants (M age 12.4 months [SD = 4.1]). Control participants received home-based EHS plus 10 weekly books. Intent-to-treat analyses using multilevel models revealed a significant indirect intervention effect on infants’ rates of cortisol change in response to a series of mild stressors. The intervention increased maternal sensitivity, which in turn improved cortisol regulation, particularly infants’ rates of cortisol recovery. The findings illustrate the efficacy of EHS plus ABC for supporting infants’ stress-induced cortisol regulation and implicate sensitive maternal behavior as the underlying driver of the intervention effect. Findings are discussed in terms of the preventative value of attachment-based parenting interventions that improve both parenting and infants’ physiological regulation.

Parent-child intervention decreases stress and increases maternal brain activity and connectivity during own baby-cry: An exploratory study.

Parental responses to their children are crucially influenced by stress. However, brain-based mechanistic understanding of the adverse effects of parenting stress and benefits of therapeutic interventions is lacking. We studied maternal brain responses to salient child signals as a function of Mom Power (MP), an attachment-based parenting intervention established to decrease maternal distress. Twenty-nine mothers underwent two functional magnetic resonance imaging brain scans during a baby-cry task designed to solicit maternal responses to child's or self's distress signals. Between scans, mothers were pseudorandomly assigned to either MP (n = 14) or control (n = 15) with groups balanced for depression. Compared to control, MP decreased parenting stress and increased child-focused responses in social brain areas highlighted by the precuneus and its functional connectivity with subgenual anterior cingulate cortex, which are key components of reflective self-awareness and decision-making neurocircuitry. Furthermore, over 13 weeks, reduction in parenting stress was related to increasing child- versus self-focused baby-cry responses in amygdala-temporal pole functional connectivity, which may mediate maternal ability to take her child's perspective. Although replication in larger samples is needed, the results of this first parental-brain intervention study demonstrate robust stress-related brain circuits for maternal care that can be modulated by psychotherapy.

The state of evidence-based parenting interventions for parents who are substance-involved.

Approximately 70 million children and adolescents live with at least one parent who abuses or is dependent on alcohol or an illicit substance. Given the negative parenting practices that substance-involved mothers and fathers tend to exhibit as well as the poor outcomes that their children, particularly their young children, experience, evidence-based parenting interventions are an important complement to substance abuse treatments. At this time, there are few studies that compare the efficacy of parenting interventions for these parents, however. Nonetheless, research has begun to examine skill-based and attachment-based parenting interventions for substance-involved families with young children. These parenting interventions should be considered within the context of the neurobiology of substance abuse, which emphasizes the role of dopamine in the reward systems that promote substance use. In the context of these neurobiological connections, parenting interventions that engender repeated intense emotional experiences may stimulate this same reward system and, therefore, may be more efficacious. Attachment-based interventions are particularly promising when such connections are considered. More attention needs to be paid to bringing impactful parenting interventions to substance-involved parents with young children.

Predictors of Treatment Engagement to the Parenting Intervention Mom Power Among Caucasian and African American Mothers

ABSTRACT. It has been well documented that early-intervention programs focused on young children hold the greatest promise to mediating mental, emotional, and behavioral disorders. Parenting programs with young children have yielded favorable outcomes; however, engaging and retaining participants has typically been a challenge. Predictors of treatment engagement, or factors influencing participants’ attendance rates and/or retention in a program, have been routinely studied with outcomes yielding differing results. The present study aims to extend this research by presenting engagement data on 150 mothers and their young children (ages 0–6 years old) in an attachment-based parenting and self-care skills intervention called Mom Power (MP). This study examines the impact of sociodemographic data, and mental and physical health factors on attendance rates of the entire mother–child sample and also compares rates for Caucasian and African American mothers separately. Results show that employment status and physical health impacted attendance for the entire sample and continued to be main predictors among African American mothers. This study has implications for future research specifically pertaining to ethnic and physical health predictors of participants’ retention in intervention programs. Recommendations for engagement and retention strategies are discussed, as are considerations for next steps to test the MP model in a real-world effectiveness trial.

Evidence of Attachment Disorganization and Growth in One Mother's Descriptions of Her Son: A Case Study

This case study analyzes descriptions given by a 21-year-old mother of her 3-year-old son as illustrations of characteristics consistent with attachment disorganization. Descriptions are taken from two sources: the Insightfulness Assessment, an attachment-based interview designed to assess qualities of caregivers' internal working models of their children, and group sessions of an attachment-based parenting intervention, the Circle of Security. Relevant discourse qualities identified include emotional disengagement; contradictory and unintegrated positive and negative perceptions; intrusive, painful memories from her past; blurring of identity boundaries; and feelings of burden mixed with fears of his emotional estrangement from her. Changes in discourse qualities are also identified that appear consistent with changes in attachment security assessed for both mother and child before and after the mother's participation in the intervention. Understanding of attachment disorganization and associated discourse characteristics is important because of its prevalence among maltreating parents and the life-span developmental consequences with which it is associated.

Attachment‐based intervention for substance‐using mothers: A preliminary test of the proposed mechanisms of change

Although randomized controlled trials examining the efficacy of attachment-based interventions have been increasing in recent years, adequate measurement of treatment integrity, integrity-outcome associations, and mechanisms of change has been rare. The aim of this investigation was to conduct a rigorous test of proposed mechanisms of change in the Mothers and Toddlers Program (MTP) treatment model, a 12-session, attachment-based individual therapy for substance-using mothers of children birth to 3 years of age. The MTP aims to improve maternal reflective functioning (RF) and representation quality (RQ) to bring about second-order change in maternal caregiving behavior. Following guidelines from M.K. Nock (2007), it was hypothesized that (a) therapist adherence to unique MTP treatment components would uniquely predict improvement in RF and RQ and that (b) improvement in RF and RQ would function as unique mechanisms of change (when compared with other potential mechanisms-reduction in depression and increase in abstinence from drug use) in the improvement of caregiving behavior. Findings supported each hypothesis, confirming the proposed mechanisms of the treatment model. However, improvement in maternal depression also uniquely predicted improvement in caregiving behavior. Results underscore the potential value of attachment-based parenting interventions for improving mother-child relations and the importance of providing these interventions in clinic settings where mothers have access to comprehensive care (e.g., psychiatric services).

Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes

BackgroundIntegrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes.ObjectivesAs part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes.MethodsLiterature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes.ResultsThere were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, ds = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health.ConclusionsThis is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues.

The mothers and toddlers program, an attachment‐based parenting intervention for substance‐using women: Results at 6‐week follow‐up in a randomized clinical pilot

Previously, we reported posttreatment findings from a randomized pilot study testing a new attachment-based parenting intervention for mothers enrolled in substance-use treatment and caring for children ages birth to 3 years (N.E. Suchman, C. DeCoste, N. Castiglioni, T. McMahon, B. Rounsaville, & L. Mayes, 2010). The Mothers and Toddlers Program (MTP) is a 12-session, weekly individual parenting therapy that aims to enhance maternal capacity for reflective functioning and soften harsh and distorted mental representations of parenting. In a randomized pilot study, 47 mothers who were enrolled in outpatient substance-abuse treatment and caring for children between birth and 3 years of age were randomized to the MTP versus the Parent Education Program (PE), a comparison intervention that provided individual case management and developmental guidance. At the end of treatment, mothers in the MTP condition demonstrated better reflective functioning, representation quality, and caregiving behavior than did mothers in the PE condition. In this investigation, we examined whether the benefits of MTP at posttreatment were sustained at the 6-week follow-up. Recently, we also identified two components of parental reflective functioning: (a) a self-focused component representing the parent's capacity to mentalize about strong personal emotions (e.g., anger, guilt, or pain) and their impact on the child and (b) a child-focused component representing the parent's capacity to mentalize about the child's emotions and their impact on the mother (N. Suchman, C. DeCoste, D. Leigh, & J. Borelli, 2010). In this study, we reexamined posttreatment outcomes using these two related, but distinct, constructs.

The Mothers and Toddlers Program, an attachment-based parenting intervention for substance using women: Post-treatment results from a randomized clinical pilot

This is a report of post-treatment findings from a completed randomized pilot study testing the preliminary efficacy of the Mothers and Toddlers Program (MTP), a 12 week attachment-based individual parenting therapy for mothers enrolled in substance abuse treatment and caring for children ages birth to 36 months. Forty-seven mothers were randomized to MTP versus the Parent Education Program (PE), a comparison intervention providing individual case management and child guidance brochures. At post-treatment, MTP mothers demonstrated better reflective functioning in the Parent Development Interview, representational coherence and sensitivity, and caregiving behavior than PE mothers. Partial support was also found for proposed mechanisms of change in the MTP model. Together, preliminary findings suggest that attachment-based interventions may be more effective than traditional parent training for enhancing relationships between substance using women and their young children.

“Why Don’t You Just Tell Me How You Feel?”: A Case Study of a Young Mother in an Attachment-Based Group Intervention

This paper describes an attachment-based parenting intervention, the Circle of Security, and presents a case study of one participant’s experience as a member of it. The Circle of Security is a group intervention for parents of young children ages 1–5 that teaches parents to recognize and respond to their children’s alternating needs for attachment and exploration. The intervention content in group sessions relies to a great extent on discussions of videotaped vignettes of each parent–child dyad. Ultimately, the intervention focuses on strengthening parents’ capacities for empathic responsiveness to their children’s needs for them. In the second part of the paper, the case study illustrates one mother’s experience in a Circle of Security group designed for parents involved with the child welfare system as a result of substantiated maltreatment. Observations of this parent indicate that her capacity for empathic understanding was greatly strengthened, which appears to be related to important behavior change.

Understanding and Utilizing Parallel Processes of Social Interaction for Attachment-based Parenting Interventions

In an effort to meet both the parenting and treatment needs of substance-abusing women who are parents, residential drug treatment programs have been struggling to find the best approach. A qualitative-quantitative study of the parenting experience of mothers in residential drug treatment programs housing both mothers and their children found that relational processes characterized how these mothers perceived parenting as well as treatment. The findings presented the interplay and mutuality between a mother’s interactions (natural or facilitated) with the external social world that includes her child and those connected to the treatment facility and the internal formation of her sense of herself, her child, and others, along with the changes in both areas that took place in the facility. These findings lend important support to the use of attachment-based parenting interventions in residential drug treatment programs by drawing on these relational processes.

The Mothers and Toddlers Program: Preliminary findings from an attachment-based parenting intervention for substance-abusing mothers.

The authors examined pilot data from an attachment-based parenting intervention for substance-abusing mothers of toddlers (ages 12-36 months). The Mothers and Toddlers Program (MTP) is a 20-week individual therapy intervention that aims to help mothers develop more balanced representations of their children and improve their capacity for reflective functioning (i.e., recognition of the intentional nature of children's behavior). The authors hypothesized that improvement in maternal representational balance and maternal capacity for reflective functioning would correspond with improvements in maternal behavior with toddlers (e.g., sensitivity to cues, responsiveness to distress, and social-emotional growth fostering) and reduction in maternal psychiatric distress and substance abuse. Eight mothers who completed MTP showed moderate improvements in representational balance and reflective functioning, and these changes corresponded with significant improvements in maternal behaviors with toddlers. The authors also compared MTP completers and noncompleters on sociodemographic and psychosocial indexes and examined the validity of the intervention's proposed mechanisms of change. Preliminary findings support the importance of attachment mechanisms and indicate that attachment-based interventions may strengthen substance-abusing mothers' capacities to foster their toddlers' socioemotional development.