Effectiveness of interventions in preventing disorganized attachment: A meta-analysis.

Disorganized attachment is associated with a host of negative developmental outcomes, leading to a growing interest in preventative interventions targeting the attachment relationship in infancy. The objective of this meta-analysis was to assess the effectiveness of interventions that aimed to prevent or reduce rates of disorganization among children at risk. We performed a literature search using PsycINFO, MEDLINE, and ProQuest databases for studies published between January 1989 and August 2016. All 16 studies (N = 1,360) included a control condition and reported postintervention rates of organized and disorganized attachments assessed by the Strange Situation Procedure. Results showed that, overall, interventions were effective in increasing rates of organized attachment compared to control conditions (d = 0.35, 95% CI [0.10-0.61]). Moderator analyses demonstrated that interventions were more effective (a) in more recently published studies than in older studies, (b) for maltreated samples than nonmaltreated samples, and (c) as children increased in age. These results have important implications for future development, tailoring, and implementation of attachment-based intervention programs.

[Mentalization and attachment transmission]. / Mentalisierung und Bindungstransmission.

The present study was investigating the predictive role of maternal mentalizing and general as well as depressive symptom burden for attachment security at the end of the first year on a sample of 44 mother-child-dyads from a low-risk community study. Maternal mentalizing was assessed in a multidimensional way as Reflective Functioning (off-line) and Mind-Mindedness (on-line). The design was longitudinal measuring maternal Mind-Mindedness from a videotaped mother-child-play-interaction at the age of three months. General and depressive symptom burden was assessed using the SCL-90-R when the children were nine months old. Maternal attachment and Reflective-Functioning, using the Adult-Attachment-Interview, as well as children's attachment behavior, using the Strange-Situation-Test, were investigated at the age of twelve months. Secure maternal attachment was associated with higher Reflective Functioning, higher frequency of Mind-Mindedness and lower general and depressive symptom burden. A moderation-analysis showed a statistical trend (p = .08) that the interaction of the frequency of mind-related comments, general symptom severity and maternal attachment has a predictive value for infantile attachment security. Results can be tentatively interpreted that mothers with insecure attachment who had a lower general symptom burden and who related to their three-months old babies with a high frequency of mind-related-comments were more likely to have securely attached children. Thus, results may serve as a groundwork for projects aiming to prevent the transmission of insecure attachment by strengthening maternal Mind-Mindedness and working on the reduction of maternal general symptom burden.

Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types.

OBJECTIVE: This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD). METHOD: As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time. RESULTS: As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time. CONCLUSIONS: Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.

Promoting a secure attachment: A primary prevention practice model.

It is increasingly recognized that early sensitive care-giving predicts a secure attachment in infancy and early childhood.This preliminary report details the development, implementation and evaluation of a clinical programme that used a targeted prevention approach following a universally-offered screening of parent-infant interactions. The CARE-Index was used to assign dyads to low, medium and high risk groups, and interventions - featuring reflective videotape-based feedback - were tailored to each risk group in order to increase maternal sensitivity and improve infant attachment status. Results showed improved maternal sensitivity in the intervention conditions compared to comparisons. In addition, infants in the intervention conditions were significantly more likely to be classified as secure, and significantly less likely to be classified as having DMM complex attachment strategies. Methodological shortcomings, however, mean that these findings should be regarded as tentative.

Issues in infant--parent psychotherapy for mothers with borderline personality disorder.

Mothers with Borderline Personality Disorder (BPD) and their infants have been largely neglected in the research literature. This is of concern, given that clinical reports indicate that mothers with BPD have difficulties with sensitive and empathic parenting and that their children are at risk of attachment disorganization. There is little available evidence on the use of interventions with this group of parents despite clinical need. This article describes our experiences in the use of an attachment-focused psychotherapy known as Watch Wait and Wonder for improving the interaction between mothers with a BPD diagnosis and their children. A case example is provided to illustrate one mother's response to the therapy and to highlight specific issues in clinical intervention for this group of parents and possible modifications of approach.

Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: a method to lower the risk of intergenerational transmission of abuse?

Children suffering from insecure attachment due to severe abuse and/or neglect are often characterized by internal working models which, although perhaps adaptive within the original family situation, are inappropriate and maladaptive in other relationships and situations. Such children have a higher probability than the general population of becoming abusing or neglecting parents. Besides the usual goals of psychotherapy, an overall goal is to stop the cycle of abuse in which abused children may grow up to be abusing parents. Therapy with these children is complicated by their distrust in adults as well as difficulties in symbolization due to trauma during the preverbal stage. Animal-Assisted Therapy (AAT) provides avenues for circumventing these difficulties, as well as providing additional tools for reaching the inner world of the client. This article gives a brief background of the connection between insecure attachment and intergenerational transmission of abuse and neglect as well as a brief overview of the principles of AAT in a play therapy setting. A rationale for the use of AAT as a unique therapy technique for children having suffered from abuse and neglect is followed by a number of clinical examples illustrating AAT.

Reaching kids with reactive attachment disorder.

These kids are real. The behavior is real. The work is long and hard, but with patience and perseverance, changes are made. Reactive attachment disorder is a terrible thing. We must never give up on these kids. Every now and then, a success story comes along. The child goes home and in the wake of his or her leaving are letters addressed in uneven script to staff: Deer mister C. I am doing good. School is good. Thank you for helpin me. I luv you.

[Assessment methods and preventive measures focusing on relationships]. / Beziehungsorientierte Diagnostik und Intervention im Kindesalter--Einführung in das Themenheft.

In this contribution relationship-oriented assessment methods and preventive measures during infancy and childhood are founded in an ecological and differential understanding of development in context. Using selected developmental milestones it is demonstrated that relationships as a social context play an important role particularly during early infancy. Criteria for describing well functioning and maladaptive relationships can be derived from theoretical presumptions, empirical longitudinal studies and health related clinical judgements. These criteria may serve as guidelines for interventions, especially in cases of children with a clinical diagnosis of child neglect. Possible procedures to assess the quality of relationships are discussed using methods from contributions in this issue of the journal as examples. Diagnostic and preventive procedures are seen as mutually interacting within continuous feedback loops, where assessment procedures serve to both give evidence for the efficacy of interventions and for specifying further preventive methods.

[Risk assessment of neglect and maltreatment in infants and toddlers. Chances of early preventive intervention]. / Risikoeinschätzung bei Vernachlässigung und Kindeswohlgefährdung im Säuglings--und Kleinkindalter--Chancen früher beziehungsorientierter Diagnostik.

The German child protection system lacks of interdisciplinary and standardized procedures for screening and diagnosing child maltreatment as well as for service delivery. Evidence based assessments of risk-screening in combination with consensus-based models for risk-judgement seem to predict the best possible results. A central part of determining whether an infant is at risk is to evaluate various domains of parental competencies and skills. In particular assessment procedures based on attachment research have proven to be practically and methodologically relevant. These include interactive and video-based observational methods as well as parental representations as sources of information for risk assessment. Attachment based intervention and treatment programs are effective, especially with regard to enhancing paternal sensitive behavior. However, these programs need to be adapted to delivery for specific risk groups. Overall an interdisciplinary approach with regard to the programs as well as to the training of the professionals has to be taken into account.

Long-term developmental, behavioral, and attachment outcomes after international adoption.

Children adopted internationally and their families are a heterogeneous group. Internationally-adopted children have been reported to have a range of developmental and behavioral difficulties. The authors describe the current evidence documenting developmental outcomes for children and common behavioral and mental health concerns including attachment difficulties that may impact children and their families after international adoption. Pediatricians must be thoughtful to individualize the care of adoptive children and not make assumptions shortly after adoption. It is critical to avoid using "standard" parenting advice that may not apply to children who have experienced loss, deprivation, separation, and instability in their early lives. By listening to families, carefully evaluating children, and monitoring progress over time, pediatricians can avoid the pitfall of oversimplifying and underestimating the complexity and challenges that these families face. Instead, pediatric primary care providers can play a key role in maximizing the potential of an internationally adopted child and his or her family.