Assessing a change mechanism in a randomized home-visiting trial: Reducing disrupted maternal communication decreases infant disorganization.

Although randomized interventions trials have been shown to reduce the incidence of disorganized attachment, no studies to date have identified the mechanisms of change responsible for such reductions. Maternal sensitivity has been assessed in various studies and shown to change with intervention, but in the only study to formally assess mediation, changes in maternal sensitivity did not mediate changes in infant security of attachment (Cicchetti, Rogosch, & Toth, 2006). Primary aims of the current randomized controlled intervention trial in a high-risk population were to fill gaps in the literature by assessing whether the intervention (a) reduced disorganization, (b) reduced disrupted maternal communication, and (c) whether reductions in disrupted maternal communication mediated changes in infant disorganization. The results indicated that, compared to controls (n = 52), both infant disorganization and disrupted maternal communication were significantly reduced in the intervention group (n = 65) that received regular home-visiting during pregnancy and the first year of life. Furthermore, reductions in disrupted maternal communication partially accounted for the observed reductions in infant disorganization compared to randomized controls. The results are discussed in relation to the societal cost effectiveness of early attachment-informed interventions for mothers and infants, as well as the importance of formally assessing underlying mechanisms of change in order to improve and appropriately target preventive interventions.

Predictors of Study Attrition in a Randomized Controlled Trial Evaluating a Perinatal Home-Visiting Program with Mothers with Psychosocial Vulnerabilities.

OBJECTIVE: Randomised controlled trials evaluating perinatal home-visiting programs are frequently confronted with the problem of high attrition rates. The aim of the present study is to identify predictors of study attrition in a trial evaluating a perinatal home-visiting program in France. MATERIALS AND METHODS: CAPEDP is a French randomized trial comparing a perinatal home-visiting program using psychologists versus usual care (N = 440). The first assessment was at inclusion into the trial at the 27th week of pregnancy and the final assessment when the child reached the age of two. Attrition rates were calculated at 3 and 24 months postpartum. Stepwise logistic regression was used to identify predictors of early (between inclusion and 3 months postpartum) and later (between 3 and 24 months postpartum) attrition among social, psychological and parenting factors. RESULTS: Attrition rates were 17% and 63% at 3 and 24 months respectively. At 24 months, there was significantly more attrition in the control arm (70.6%) compared to the intervention arm (55.2%). Five independent predictors of early attrition were identified: having already had an abortion; having greater attachment insecurity as measured with the Vulnerable Attachment Style Questionnaire (VASQ); having lower global severity of psychiatric symptoms as assessed with the Symptom Check-List (SCL-90) at inclusion, being neither currently employed nor studying; and declaring no tobacco consumption during pregnancy. Being randomized into the control arm, having undergone early parental loss before age 11 and having lower global severity of psychiatric symptoms (SCL-90) at 3 months postpartum were the only variables associated with later attrition. CONCLUSION: This study provides key information for identifying mothers who may require specific support to avoid study attrition in trials evaluating a home-visiting program.

Treatment - mother-infant relationship psychotherapy.

In this chapter, we briefly describe several modes of parent-infant-psychotherapy, an efficient way of treating parent-infant relationship disorders. We then focus on treatment for postnatally depressed mothers. Perinatal depression defines an episode of major or minor depression occurring during pregnancy or the first 12 months after birth. Attachment-based parent-infant interventions are particularly helpful in the context of maternal perinatal depression, as postpartum depression has a special link with unresolved trauma and losses in the mother's childhood. The goal of treatment is to improve the mother's mood but also to prevent or reduce the effects of postpartum depression on the child. Infants of perinatally depressed mothers are at risk for a large array of negative outcomes, including attachment insecurity (particularly disorganised attachment), social-skills deficits, cognitive difficulties, behaviour problems, and later psychopathology. The 'ghosts in the nursery' concept refers to the painful or disturbed early childhood experiences coming from the mother's past, which haunt the present mother-infant relationship. By addressing the mother's unresolved attachment conflicts (in her relationship to her own parents), it is believed that the development of a more adaptive parenting and a more secure and less disorganised attachment between the mother and her infant is facilitated. Changes in parent- infant interaction are not dependent on the port of entry (e.g. child's behaviour, parent's representation or parent-infant relationship). The perspective of attachment is key to install a therapeutic alliance with parents.

Impact of a manualized multifocal perinatal home-visiting program using psychologists on postnatal depression: the CAPEDP randomized controlled trial.

CONTEXT: Postnatal maternal depression (PND) is a significant risk factor for infant mental health. Although often targeted alongside other factors in perinatal home-visiting programs with vulnerable families, little impact on PND has been observed. OBJECTIVE: This study evaluates the impact on PND symptomatology of a multifocal perinatal home-visiting intervention using psychologists in a sample of women presenting risk factors associated with infant mental health difficulties. METHODS: 440 primiparous women were recruited at their seventh month of pregnancy. All were future first-time mothers, under 26, with at least one of three additional psychosocial risk factors: low educational level, low income, or planning to raise the child without the father. The intervention consisted of intensive multifocal home visits through to the child's second birthday. The control group received care as usual. PND symptomatology was assessed at baseline and three months after birth using the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: At three months postpartum, mean (SD) EPDS scores were 9.4 (5.4) for the control group and 8.6 (5.4) for the intervention group (p = 0.18). The difference between the mean EPDS scores was 0.85 (95% CI: 0.35; 1.34). The intervention group had significantly lower EPDS scores than controls in certain subgroups: women with few depressive symptoms at inclusion (EPDS <8): difference = 1.66 (95%CI: 0.17; 3.15), p = 0.05, adjusted for baseline EPDS score), women who were planning to raise the child with the child's father: difference = 1.45 (95%CI: 0.27; 2.62), p = 0.04 (adjusted); women with a higher educational level: difference = 1.59 (95%CI: 0.50; 2.68) p = 0.05 (adjusted). CONCLUSION: CAPEDP failed to demonstrate an overall impact on PND. However, post-hoc analysis reveals the intervention was effective in terms of primary prevention and in subgroups of women without certain risk factors. Effective overall reduction of PND symptomatology for young, first-time mothers presenting additional psychosocial risk factors may require more tailored interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT00392847 Promoting Parental Skills and Enhancing Attachment in Early Childhood (CAPEDP).

Implementation and assessment of an early home-based intervention on infant attachment organisation: the CAPEDP attachment study in France.

Attachment is a long-term emotional link between infants and their mothers. Attachment quality influences subsequent psychosocial relationships, the ability to manage stress and, consequently, later mental health. Home intervention programmes targeting infant attachment have been implemented in several contexts with varying degrees of efficacy. Within the CAPEDP study (Parental Skills and Attachment in Early Childhood: reduction of risks linked to mental health problems and promotion of resilience), a subsample of 120 families were recruited with the objective of assessing the impact of this home-visiting programme on infant attachment organisation using the Strange Situation Procedure. The present paper describes the methodology used in this ancillary study.

A home-visiting intervention targeting determinants of infant mental health: the study protocol for the CAPEDP randomized controlled trial in France.

BACKGROUND: Several studies suggest that the number of risk factors rather than their nature is key to mental health disorders in childhood. METHOD AND DESIGN: The objective of this multicentre randomized controlled parallel trial (PROBE methodology) is to assess the impact in a multi-risk French urban sample of a home-visiting program targeting child mental health and its major determinants. This paper describes the protocol of this study. In the study, pregnant women were eligible if they were: living in the intervention area; able to speak French, less than 26 years old; having their first child; less than 27 weeks of amenorrhea; and if at least one of the following criteria were true: less than twelve years of education, intending to bring up their child without the presence of the child's father, and 3) low income. Participants were randomized into either the intervention or the control group. All had access to usual care in mother-child centres and community mental health services free of charge in every neighbourhood. Psychologists conducted all home visits, which were planned on a weekly basis from the 7th month of pregnancy and progressively decreasing in frequency until the child's second birthday. Principle outcome measures included child mental health at 24 months and two major mediating variables for infant mental health: postnatal maternal depression and the quality of the caring environment. A total of 440 families were recruited, of which a subsample of 120 families received specific attachment and caregiver behaviour assessment. Assessment was conducted by an independent assessment team during home visits and, for the attachment study, in a specifically created Attachment Assessment laboratory. DISCUSSION: The CAPEDP study is the first large-scale randomised, controlled infant mental health promotion programme to take place in France. A major specificity of the program was that all home visits were conducted by specifically trained, supervised psychologists rather than nurses. Significant challenges included designing a mental health promotion programme targeting vulnerable families within one of the most generous but little assessed health and social care systems in the Western World. TRIAL REGISTRATION: Current Clinical trial number is NCT00392847.

Infant rhythms versus parental time: promoting parent-infant synchrony.

Traditional psychoanalytic theories of early development have been put into question by developmental psychology, and particularly by attachment theory. Psychopathology appears to be more linked to interpersonal relationship problems rather than to intra-psychic conflict, as hypothesized in Freudian drive theory. Establishing synchrony between parent and infant is probably one of the major tasks of the first year of life. Attachment theory appears to be an effective paradigm to understand how caregiver responses to stressful infant situations give way to different regulatory strategies, which impact on the effectiveness of the stress buffer systems and its physiological impact on emotion and stress regulation. This paper underlines the importance of synchronization between infant and caregiver; it highlights the key concept of attachment disorganization and of its relationship with sustained social withdrawal as a defence mechanism and an alarm signal when synchronization fails, and underlines the importance of early interventions promoting parent-infant synchrony.

Un ensayo de prevención/disminución de la desorganización del vínculo en “París y suburbios” / A trial on prevention/minimization of the disorganization of attachment in “Paris and Suburbs”

El apego está considerado como un componente esencial del desarrollo social y afectivo en la vida temprana y la calidad de las relaciones de apego se consideran como importantes indicadores tempranos de la salud mental del bebé. Este articulo analiza la relevancia del trabajo de prevención temprana como una estrategia de intervención del apego. Se presenta el programa de prevención CAPEDP-Apego, desarrollado en “París y suburbios”. Concluimos con una discusión clínica sobre un video de una situación extraña en un niño con apego desorganizado, para ilustrar la importancia de la terapia de video-feddback, en el contexto de la intervención temprana en el hogar (AU)

Attachment is considered an essential component of social and emotional development in early life, and individual differences in the quality of attachment relationships are regarded as important early indicators for infant mental health. In this article we explore the relevance of the early prevention work as a strategic attachment intervention. The prevention program CAPEDP-Attachment, developed in “Paris an suburbs” is presented here. We conclude with a clinical discussion of a strange situation video of a disorganized attachment enfant, to illustrate the relevance of the video feedback therapy in the context of early home intervention (AU)

The infant protection system in France: How does it work?

The French system for protection of infants and toddlers relies on the collaboration of several different partners for preventing, screening, assessing, intervening in, and treating cases of infant abuse and neglect. This article first provides a brief historic overview and some data about the protection of infants in France, with data focused on the Parisian area. We then describe the tasks and interconnections of these different agencies and administrations, and offer some reflections on the actual functioning of the system. Finally, some suggestions for changes are provided. Discussion should begin on a theoretical level regarding whether we should continue with institutionalization of infants for long periods of time, as is still the case in Paris. Discussion also should take place regarding which is the higher priority when infants and children are in situations of danger, abuse, and/or neglect of infants: (a) the hope of reestablishing parental rights or (b) the need of the infant for a secure and stable attachment relationship. The process of evaluating parental caregiving skills would benefit from more clinical observation as well as structured methods of assessment.

Testing the Working Alliance Inventory (WAI) in a French primary care setting: predictive value and factor structure.

BACKGROUND: Working alliance has shown a predictive value of the outcome in different therapeutic settings but was not yet studied in a non-medical setting. METHODS: The predictive value and the factor structure of the Working Alliance Inventory (WAI) [36-item client version; as reported by Horvath and Greenberg (J Couns Psychol 36:223-233, 1989)] were studied in a French primary care setting on a sample of 130 adults accessing social services. RESULTS: The WAI total score completed after the first meeting was positively predictive of quality of the working alliance 4 months later. An exploratory factor analysis produced two orthogonal factors which explained 45.12% of the total variance: a first factor (23 items) labelled 'positive expectations about the usefulness of help' and a second factor (13 items) labelled 'absence of suspicion about the effects of help'. CONCLUSIONS: The WAI is shown to be applicable to primary care social work settings to measure the working alliance phenomenon and predict disruption of practitioner-client relationship.