The Impact of Attachment-Based Interventions on the Quality of Attachment Among Infants and Young Children

Introduction

A key biologically-based task for infants and toddlers is developing attachment relationships with caregivers. The quality of attachment that children develop appears largely dependent on caregivers’ availability.¹ When caregivers are responsive, children tend to develop secure attachments, seeking out caregivers directly when distressed.  When caregivers reject children’s bids for reassurance, children tend to develop avoidant attachments, turning away from caregivers when distressed. When caregivers are inconsistent in their availability, children tend to develop resistant attachments, showing a mixture of proximity-seeking and resistance. Although it may be optimal for children in our society to develop secure attachments,^2-4 each of these three attachment types can be seen as well-suited to caregivers’ availability. When caregivers are frightening to children, though, children have difficulty developing organized attachments and instead often develop disorganized attachments, which leave children without a consistent strategy for dealing with their distress.  Attachment quality has been linked with later problem behaviours, with disorganized attachment especially predictive of dissociative symptoms (e.g., seeming spacey, “in a fog” etc.),5 and internalizing and externalizing problems.^6-8 A number of prevention and intervention programs have been developed that aim to improve infant attachment quality. 

Subject

Some attachment-based interventions target parental sensitivity (e.g., following the child’s lead, nurturance to distress, avoidance of frightening behaviours) as the primary mechanism of change. Parental behaviour reflects a proximal intervention target– that is, that parental behaviour drives child expectations of parental availability and thus attachment; thus, changes in parental behaviour should lead to changes in child attachment.  Other interventions target more distal factors, such as parental representations, which reflect how adults process attachment-related thoughts, feelings, and memories. Some would argue that changing parental representations or addressing other distal factors (e.g., parental depression, trauma history, environmental stressors) is necessary to lead to sustained behavioural change.

Problems

Programs that share the goal of enhancing attachment may differ in their focus, in their intervention strategy, and in the populations targeted. Whereas an overall objective may be to enhance attachment quality, other goals of improving quality of life, increasing life skills and reducing symptomatology may differ, depending on the intervention and the population served, as well as the level of fidelity to the treatment model. There is disagreement among experts in the area regarding the nature of what is needed. For example, some⁹ suggest that intensive interventions that start prenatally are essential, whereas others¹⁰ suggest that targeted, short-term interventions are needed. Assessment of treatment process and treatment fidelity is crucial to knowing what is being provided in an intervention. For example, Korfmacher et al.¹¹ found that their intervention, intended to modify parental state of mind, rarely engaged parents in insight-oriented work.

Research Context

In 2003, a meta-analysis reported by Bakermans-Kranenburg, van IJzendoorn and Juffer¹⁰ found 29 studies that included attachment security as an outcome. Of these, 23 were randomized clinical trials, with a total of 1,255 participants. The nature of the interventions, and the populations served, differed widely from one study to another. Nonetheless, meta-analytic results allow assessment of the importance of factors such as intervention intensity and population. 

In the last two decades, many more studies have examined attachment as an outcome. In 2018, Facompre, Bernard, and Waters¹¹ reported in a meta-analysis on the rates of disorganized attachment in 16 experimental studies. Overall, interventions were associated with reduced incidence of disorganized attachment. Effects were larger in more recent studies than in older studies, in maltreated samples versus non-maltreated samples, and among children who were older versus younger. 

Key Research Questions

Key research questions include:

• Do intervention or prevention programs enhance the quality of children’s attachments to their caregivers? 
• What are the characteristics of successful interventions?
• For whom are interventions most successful? 
• What is the process by which intervention programs work?
• Can interventions be disseminated widely with fidelity?

Recent Research Results

In the last decade, the evidence base for many attachment-based interventions has increased.¹³ A number of interventions have been tested through randomized clinical trials and have been found to result in higher rates of security of attachment and/or lower rates of disorganized attachments than control interventions.  Among these are interventions that directly target parenting sensitivity as seen in Attachment and Biobehavioral Catch-up (ABC¹⁴), Video-Feedback Intervention to Promote Positive Parenting  (VIPP¹⁵), and several others, as well as interventions that target parental representations, such as Child-Parent Psychotherapy (CPP¹⁶) and Minding the Baby (MTB¹⁷).

The question of what works for whom is an important one. For the most part, we do not have empirical evidence to suggest different attachment-based interventions for different issues. To this point, there is no support for the idea that lower risk parents will do better with less intensive services and higher risk parents will do better with more intensive services. 

In general, interventions that are efficacious in lab-based trials show diminished effectiveness in the community.¹⁸ One of the culprits for the drop-off in effectiveness is that fidelity is not ensured or is not measured well.¹⁹ Attachment-based interventions with clearly specified fidelity assessments have the best chance for effective implementation. 

Conclusions

1. Interventions are effective in enhancing children’s attachment quality.
2. Interventions that target specific issues, most especially parental sensitivity, appear more effective than interventions with more global goals.
3. Interventions that are brief are at least as effective as those that are of longer duration.
4. Interventions that begin at older ages appear to be more effective than those begun earlier. 

Implications

The research evidence supports the efficacy of interventions to enhance attachment quality.  Interventions that are brief and target parental sensitivity have been shown to be effective, as are other interventions that are time-intensive and target parent representations. 

References

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