The first metaanalysis on the impact of attachment-focused interventions, by Bakermans-Kranenburg et al., showed an increase in attachment security through enhancing maternal sensitivity, but with a small effect size; indeed, short interventions with precise goals were more effective than interventions nonlimited in time and with no precise focus. At the time, attention was placed on developmental outcomes, namely on increasing infants’ attachment security. However, the mediator role of this security, as well as the developmental impacts of attachment disorganization were key issues that needed to be more widely addressed in future research.
Recent studies have demonstrated that infants and children with disorganized attachment are at particular risk for psychopathology, stress deregulation, and poor cognitive performance [2–4]. As a result, there has been a growing call for the development of interventions programs that target reduction in the prevalence of disorganized attachment among infants and toddlers with a wide range of risk characteristics [5–7].
EARLY INTERVENTION PROGRAMS
Early intervention programs stem from different theoretical backgrounds, such as psychodynamic or cognitive/behavioral. Classically, they focus on prevention of infants’ attachment disturbances by intending to promote optimal infant's attachment and to support infants’ development in a variety of clinical populations and/or high-risk families [8–13,14▪▪].
The Steps Toward Effective, Enjoyable Parenting
The Steps Toward Effective, Enjoyable Parenting (STEEP) was developed in Minnesota by Erickson et al.. This manualized program targeted first-time mothers (17–25 years old), at socioeconomic risk population. The STEEP provides several intervention modalities (e.g., once-a-week visits; twice or once-a-month visits; mother–child groups and follow-up family evenings). The Intervention is manualized and focused on the relationship quality (i.e., respect, authenticity, shared discovery, problem-solving), on reflexive function (i.e., better integrated and applied knowledge, life options otherwise looked at), and on family strengths on which to rely to meet demanding situations. Recent results [16▪] showed, at the end of the intervention (infants’ 12th month), no significant differences between intervention or control groups for attachment security. The program was however efficient on decreasing infants’ attachment disorganization and mother's depressive symptoms; increasing mothers child's development knowledge and responsiveness; as well as family's environment organization. At follow-up assessment (7 months after intervention, as infants’ were 19th month), attachment security was stable in the Intervention Group but had diminished in the Control Group (67–48%).
The Circle Of Security Intervention
The Circle Of Security Intervention (COS) is a manualized early intervention program developed in the United States by Marvin et al.. Several intervention modalities are possible: the COS 20-week group protocol; the COS – Home Visiting 4 Intervention ; the COS perinatal protocol ; and the COS-parenting intervention (COS-P) [20▪▪]. The objectives are to help parents to understand their infant's needs, develop observation and interpretation skills of infants’ behaviors; construct cognitive and emotional responses to her infant's behavior (i.e., recognize them, understand their influence on the interaction, regulate these emotional responses, built new modalities of sensitive responses, and correct insensitive responses). In 2018, Woodhouse et al.[21▪] published a synthesis of their main results. Concerning the COS 20-week, the protocol group  showed, in a low socioeconomic sample (n = 65), in a pre (at infants’ 12th month) – posttest (at infants’ 56th month) assessment, that attachment security had significantly increased and that attachment disorganization had significantly diminished. Data assessed by Hubber et al., in a clinical population (n = 85) of mothers with children aged from 13 months to 7 years, showed a significant increase of children's attachment security and a diminishment of attachment disorganization frequency.
The Minding The Baby
The Minding The Baby (MTB) is a manualized home-visiting program developed at the United States by Slade et al. targeting high-to-medium risk, first time, mothers (14–25 years old). Intervention is given through weekly home visits (pregnancy until infants’ 12th month) and then twice a month (infants’ 12th–24th month). This is a manualized intervention that focuses on the therapeutic alliance as a secure base for emotional regulation and stress management, on family relationships to increase mothers’ sensitivity and secure base behavior, on autoreflexive function to increase secure attachment, as well as on infants’ development and health. Slade et al.[25▪] showed no significant effect for maternal-disruptive behavior (intervention group = 60% and control group = 66%) at 4 months, but in the intervention group, teenager mothers were significantly less disruptive (75%) compared with the control group ones (93.3%). At infants’ 12th month, significant differences were found, with 64.4% of intervention infants being secure compared with 48.4% in the control group. Another significant result was that 26% of the intervention infants had a disorganized attachment compared with 43% of the controls. Finally, significant results were found for maternal reflective function, showing a progression of 1.6 in the intervention group and of 0.2 in the control group, but only for mothers with a reflective function lower than 3 (i.e., low reflective function) at baseline.
The Video-feedback Intervention to Promote Positive Parenting
The Video-feedback Intervention to Promote Positive Parenting (VIPP) is a Netherlands’ program developed by Juffer et al.. This manualized intervention focused on both parental sensitivity (exploration/attachment behavior, speaking for the baby, chain of security, and emotional sharing) and sensible discipline (inductive discipline and distraction, positive reinforcement, sensitive time-out, and empathy for the infant). Juffer et al.[27▪] published a compilation of their main Randomized Controlled Trial (RCT) studies results. Mothers of adopted infants (n = 130; age: 6 months), using a three-session VIPP format Juffer et al., were significantly more sensitive and their infants presented significantly less disorganized behaviors. At follow-up (7 years later) children showed significantly less internalized behaviors. Van Zeijl et al., using a six-session VIPP modality on mothers of infants at risk of externalized behavior (n = 237; age: 1–3 years old) showed that positive parenting was significantly higher in the intervention group, with higher rate of maternal sensitivity and sensible discipline. In the intervention group, there were also lower levels of overreactive behavior of the parental couple. Bakermans-Kranenburg et al. found that, at follow-up (1 year later), intervention group infants, which had a DRD4-7 repeated allele, showed significantly less externalized behavior and had lower levels of day cortisol, but only if their mothers presented higher levels of sensible discipline. In a recent metaanalysis, assessing 12 randomized controlled trials (n = 1116 parents and caregivers), the authors  claim that VIPP proved to be effective in promoting sensitive caregiving, with some positive social–emotional child outcomes.
The program developed by Cowan et al.[32▪] in the United States, distinguished itself from the previous ones by the author's emphasis on Supporting Father Involvement. When trying to answer the question: ‘What is missing in attachment parental intervention?’, authors found several missing key dimensions: fathers involvement; couple relationship (and coparenting capacity); generational insecurity transmission; extrafamily stress management and resource figures’ identification; and level of support for parent's individual vulnerabilities. The authors consider that because couple or coparental relationships are key factors in the therapeutic processes, changes in the couple relationship have a positive impact on the entire family system. The program included groups of 4–7 couples from working or middle class, parents of a school-aged first child. Sixteen sessions of 2 h were implemented. Results showed equal marital conflict levels in the intervention or the control group when the parenting relationship was the focus of the program. However, if the focus was on the quality of the couple relationship, results showed a significant decrease, both in marital conflict and in parenting conflict. Surprisingly, paternal involvement did not increase with fathers’ participation in the study, but a positive intervention effect was obtained with an improvement in positive parenting practices.
RECENT METAANALYSIS ON EFFICIENCY OF EARLY ATTACHMENT-BASED PROGRAMS
Wright et al.[33▪▪] assessed the clinical effectiveness of available parenting interventions for families of children at high risk of developing or already displaying disorganized patterns of attachment. Amongst the 14 studies (n = 3006), the intervention groups showed less disorganized attachment than the controls (OR = 0.50 (0.32, 0.77); P = 0.008). The majority of the interventions targeted maternal sensitivity.
Similarly, Facompré et al.[34▪▪] assessed the effectiveness of interventions aimed at preventing or reducing rates of disorganization among children at risk. All 16 studies (n = 1360) included a control group and reported postintervention rates of organized and disorganized attachments. Overall, interventions were effective in increasing rates of organized attachment compared with controls (d = 0.35; 95% confidence interval 0.10–0.61). Moderator analyses demonstrated that interventions were more effective in more recently published studies than in older studies, for maltreated samples than for nonmaltreated samples, and as children increased in age.
TESTING INTERMEDIATE VARIABLES ON INTERVENTION EFFECTS
The studies presented above were based on a model in which changes within parent–infant interactions were viewed as the mechanism through which infants’ attachment security could be increased and disorganization could be reduced. However, few studies have extended their design to test if, indeed, changes within the parent–infant interactions were the mechanism contributing to changes in the children's outcomes.
The first of such studies, assessing whether changes in maternal sensitivity or maternal representations served as a mediator of intervention effects on secure attachment, showed no significant mediation effect .
More recently, Cassidy et al. implemented a randomized controlled trial of the COS-P, in a low-income sample of 141 children and their mothers. Results showed no intervention main effects on child attachment quality or behavior problems but exploratory follow-up analyses suggested that intervention effects were moderated by maternal attachment style or depressive symptoms. Moderate intervention effects were found for the child's attachment security and disorganization but not for avoidance; the same moderate-effect size was found for inhibitory control, but not for cognitive flexibility, and for child internalizing, but not for externalizing, behavior disorders.
Guild et al.[35▪▪] randomized depressed mothers to receive child–parent psychotherapy (CPP; n = 45) or to be assigned into a control group (n = 55). Results showed higher postintervention rates of secure attachment in the CPP group. At follow-up, children who received CPP were more likely to display secure attachment behaviors after intervention and this was associated with more positive peer relationships, as assessed by teacher's reports, when children were approximately 9 years old.
Attachment researchers also realized that sensitivity is not strictly nor strongly associated with infant disorganized attachment (r = 0.10) [36,37]. This is so because among parents exposed to multiple stressors or traumatic experiences, sensitive or responsive behaviors can mix up the indicators of fear or threat as disorientation, role confusion and role reversal, and withdrawing behavior . Such behaviors are more likely to be found in conditions of poverty, exposure to violence or maltreatment, or in the context of maternal psychopathology. As those disrupted maternal responses are also more strongly associated with infant disorganization (r = 0.35) , the assessment of disrupted maternal behavior might be an important step in evaluating mechanisms of change in at-risk samples. Lyons-Ruth et al. have designed a scale to assess disruptive parental behavior, which has shown to be predictive of attachment disorganization in the exposed child (Atypical Maternal Behavior Instrument for Assessment and Classification - AMBIANCE scale).
In this line of thought, the CAPEDP (Compétences parentales et Attachement dans la Petite Enfance, that is, Parental Skills and Attachment in Early Childhood) study, a randomized home-visiting program controlled trial, was developed in Paris, between 2006 and 2011, by Guedeney et al.. This was a multifocal program, which aimed to recruit a multirisk, vulnerable French sample from pregnancy until the child was 2 years old. CAPEDP-attachment focused on the increase of maternal sensitivity and mentalizing skills and of infants’ security, as well as on the decrease of disrupted maternal communication and infant disorganized behavior. The need to address maternal trauma-related symptomatology was frequent. Results showed no significant difference between the intervention group and the control group in the infant's attachment security . However, they indicated that, compared with controls, both infant disorganization, disrupted maternal communication [43▪] and infants’ withdrawal  were significantly reduced in the intervention group, through video guidance during home visits. But this improvement was not related to an increase in the mother's insightfulness. The effect of the intervention on disorganized attachment was mediated by the disrupted maternal communication (25% of the variance) [45▪▪], even though the level of postnatal depression was not reduced with the intervention .
THERAPEUTIC APPROACHES FOCUSED ON MATERNAL PSYCHOPATHOLOGY
In a first metaanalysis evaluating the treatment of perinatal depression (PPD), Bledsoe  showed that antidepressant medication with cognitive behavioral therapy (CBT) reported the largest effect size (d
= 3.87, P < 0.001), compared with medication alone (d
= 3.05, P < 0.001), group therapy (d
= 2.05, P < 0.001), interpersonal psychotherapy (d
= 1.26, P < 0.001), or CBT alone (d
= 0.64, P < 0.001).
Postpartum antidepressant medication, as selective serotonin-reuptake inhibitors, with a 12-week course of therapy (i.e., biweekly sessions providing support and education), has been associated with improvements in the quality of mother–infant interaction and infant play . New treatment implicated in γ-aminobutyric acid modulation of synaptic and extrasynaptic receptors are also being studied. In this line, the brexanolone has been associated with rapid and durable antidepressant effects in PPD . Transcranial magnetic stimulation (TMS) is also proposed for patients who do not tolerate antidepressants. Right-sided, low-frequency TMS has shown efficiency in reducing depressive symptoms in a randomized controlled trial of pregnant women .
Maternal posttraumatic stress disorder (PTSD) is also frequent in women with PPD, especially in ones with childhood maltreatment histories and is usually associated with their infants’ disorganization . Trauma-focused therapy, integrated in infant–parent programs, provides an opportunity for women to explore the influences of early trauma, including maladaptive cognitive schemas and biological stress response, on their mood and anxiety . Mindfulness-based CBT has also shown promising results in reducing PTSD symptoms by improving cognitive–emotional attachment processes in women with childhood trauma .
Increasing the infant's secure attachment is possible through increasing maternal sensitivity. Recent reviews also show that some early intervention programs are able to decrease infant's disorganized attachment by reducing the frequency of maternal-disruptive behaviors. Such interventions are also likely to affect a range of social, developmental, and health outcomes, as well as increase the potential of parental competences. However, reducing parental psychopathology seems important but does not ensure that children's developmental outcomes are better. Brief and focused therapeutic solutions seem to work better, particularly if the theoretical background of the intervention is clear. A key issue in all these intervention studies is the building of a working alliance relationship . Professionals who are able to establish positive working alliances will achieve much better outcomes for children and their families . Although most of the studies were performed focusing on mother–infant relationship, Cowen and Cowen [32▪] emphasize that the parental couple relationships should be involved in the therapeutic process. The key issue then is what works for whom, or how and on which grounds should one choose a specific therapeutic of preventive approach?
In an attempt to answer these questions, several aspects are to be considered. First, preventive approaches should be implemented right away for children with specific attachment needs (e.g., international adoption, severe prematurity, trauma-exposed children). In the case of previous parental psychopathology, or in the presence of a severe parental conflict, a longer therapeutic scheme of intervention could be acknowledged.
As far as the duration and intensity of treatment are concerned, opinions seem to be plural. Bakermans-Kranenburg et al. sustain the idea that ‘Less is more,’ with the salient points being to start at the earliest when the baby is 6 months old or even younger and focusing on maternal sensitivity. On the contrary, the study conducted by Egeland et al. seems to sustain that ‘More is better,’ at least for multirisk families. For these families, interventions that are more intensive, and with broader goals, seem to be more effective. So, following Fonagy et al. and Cassidy et al.[20▪▪], the question issue is not ‘Which intervention modality to choose’ but ‘What works for whom’, based on controlled longitudinal studies.
Financial support and sponsorship
CAPEDP-A was supported by research grants from the French Ministry of Health (Hospital Clinical Research Programme: PHRC AOM05036), the French National Institute for Promotion and Health Education (INPES), the French National Institute of Health and Medical Research (INSERM), and the French Public Health Research Institute (IReSP, PREV0702). The Foundation Pfizer funded CAPEDP-A phase II. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the current manuscript.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
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