Attachment and caregiver-infant interaction: a review of observational-assessment tools

A non-randomized controlled study to assess the impact of the "Appui Parental", an early and intensive support programme for vulnerable families: Study protocol

INTRODUCTION

Early home visit programmes have been developed to help parents build an adequate relationship with their baby and to prevent child developmental delays and affective disorders. The "Appui Parental" programme is an intervention carried out by nursery nurses to provide intensive parental support to vulnerable families. Before extending this programme, it seemed necessary to evaluate its impact objectively.

OBJECTIVES

The main aim is to determine the impact of the "Appui Parental" programme on the change in the child's symptoms. The secondary objectives are to evaluate its effects on mother-child interactions, self-assessed parental competence, perception of social support, primary caregiver's anxiety-depression symptoms, alliance with the nursery nurse, frequency of out-of-home placements, and nursery nurses' stress.

METHOD

This non-randomized prospective multicentre study would include 44 families who receive the "Appui Parental" intervention for a one to 20-month-old child (intervention group) and 44 families with the same vulnerability criteria who receive care as usual by the maternal and child protection services (control group). The child, parents, mother-child interaction, nursery nurse-mother alliance, and nursery nurse's stress will be assessed at month one and month 18 after inclusion. Comparisons between groups will be performed.

CONCLUSION

This study should provide the public authorities with objective data on this programme's impact and allow them to pursue its generalization. For professionals, the study should confirm the interest in close early parental support through home visits or should lead to rethinking some aspects of the programme.

Ecological momentary assessment of parent-child attachment via technological devices: A systematic methodological review

Despite extensive research about parent-child attachment using observational and self-report studies, complementary measures are needed to assess this construct objectively with ecological validity, as well as less obtrusiveness and reactivity than traditional measures. This systematic review describes existing technology-based ecologically momentary assessment (EMA) tools examining attachment-related emotions, cognition, and behaviors between the child and its parents. From the study's inception until March 2021, four databases were searched resulting in 11,910 screened citations. Finally, 18 records were included, characterized by a broad variety of assessment tools, sample characteristics, study designs, and attachment outcomes. Technology-based EMA methods comprised audio, video, diary, and sensory assessment modalities, each occuying its methodological niche. When reported, the psychometric properties of the EMA methods were evaluated as very good; however, the included studies' psychometric data was not completely examined. The main attachment outcomes assessed by EMA were emotional and cognitive reactions and actions of the children, the parents, and the dyad. Cognition was rarely assessed using EMA methods. Future research should focus on the complexity of attachment considering different ethnic backgrounds, multiple caregivers' viewpoints, gender aspects, as well as cognitive and dyadic contents in the naturalistic environment.

A Comparison of Non-verbal Maternal Care of Male and Female Infants in India and the United Kingdom: The Parent-Infant Caregiving Touch Scale in Two Cultures

Differences in infant caregiving behavior between cultures have long been noted, although the quantified comparison of touch-based caregiving using uniform standardized methodology has been much more limited. The Parent-Infant Caregiving Touch scale (PICTS) was developed for this purpose and programming effects of early parental tactile stimulation (stroking) on infant hypothalamic-pituitary adrenal (HPA)-axis functioning (stress-response system), cardiovascular regulation and behavioral outcomes, similar to that reported in animals, have now been demonstrated. In order to inform future studies examining such programming effects in India, we first aimed to describe and examine, using parametric and non-parametric item-response methods, the item-response frequencies and characteristics of responses on the PICTS, and evidence for cross-cultural differential item functioning (DIF) in the United Kingdom (UK) and India. Second, in the context of a cultural favoring of male children in India, we also aimed to test the association between the sex of the infant and infant "stroking" in both cultural settings. The PICTS was administered at 8-12 weeks postpartum to mothers in two-cohort studies: The Wirral Child Health and Development Study, United Kingdom (n = 874) and the Bangalore Child Health and Development Study, India (n = 395). Mokken scale analysis, parametric item-response analysis, and structural equation modeling for categorical items were used. Items for two dimensions, one for stroking behavior and one for holding behavior, could be identified as meeting many of the criteria required for Mokken scales in the United Kingdom, only the stroking scale met these criteria in the sample from India. Thus, while a comparison between the two cultures was possible for the stroking construct, comparisons for the other non-verbal parenting constructs within PICTS were not. Analyses revealed higher rates of early stroking being reported for the United Kingdom than India, but no sex differences in rates in either country and no differential sex difference by culture. We conclude that PICTS items can be used reliably in both countries to conduct further research on the role of early tactile stimulation in shaping important child development outcomes.

Development and validation of the Attachment Relationship Inventory-Caregiver Perception 2-5 years (ARI-CP 2-5): Psychometric structure, external validity, and norms

There is a lack of instruments assessing child–caregiver attachment relationships in early childhood to be used in attachment‐based practice, in particular from a caregiver's perception, which is an important factor of clinical importance to take into account in parenting interventions targeting young children. Therefore, the 48‐item Attachment Relationship Inventory—Caregiver Perception 2–5 years (ARI‐CP 2–5) was developed. Survey data of 446 caregivers of 2‐ to 5‐year‐old children were collected, and a subsample of 83 caregivers participated in an observation study. Confirmatory factor analysis confirmed a four‐factor structure of secure, avoidant, ambivalent, and disorganized attachment relationship. Indications of configural, metric, and scalar invariance were found for caregivers’ and children's sex, children's age, and population (clinical vs. general population). The four scales showed sufficient internal consistency and significant associations with children's psychopathology, caregivers’ general attachment representations, caregivers’ mind‐mindedness, and population type. Moreover, preliminary evidence for convergent validity with observational attachment measures was found. It is concluded that the ARI‐CP 2–5 is a valid instrument that can be used as part of the screening and assessment of insecure attachment relationships.

The Applicability and Performance of Tools Used to Assess the Father-Offspring Relationship in Relation to Parental Psychopathology and Offspring Outcomes

Introduction: Father-infant interactions are important for optimal offspring outcomes. Moreover, paternal perinatal psychopathology is associated with psychological and developmental disturbances in the offspring, and this risk may increase when both parents are unwell. While, the father-offspring relationship is a plausible mechanism of risk transmission, there is presently no "gold standard" tool for assessing the father-offspring relationship. Therefore, we systematically searched and reviewed the application and performance of tools used to assess the father-offspring relationship from pregnancy to 24-months postnatal. Methods: Four electronic databases (including MEDLINE, PsycINFO, Maternity and Infant Care Database, and CINAHL) were searched. Selected articles included evidence of father-offspring relationship assessment in relation to parental perinatal psychopathology and/or offspring outcomes. Data was extracted and synthesized according to the following: (i) evidence supporting the performance of tools in terms of their psychometric properties when applied in the context of fathers, (ii) tool specific characteristics, and (iii) study specific methodological aspects in which the tool was embedded. Results: Of the 30,500 records eligible for screening, 38 unique tools used to assess the father-offspring relationship were identified, from 61 studies. Ten tools were employed in the context of paternal psychopathology, three in the context of maternal psychopathology, and seven in the context of both maternal and paternal psychopathology, while nine tools were applied in the context of offspring outcomes only. The remaining nine tools were used in the context of both parental psychopathology (i.e., paternal, and/or maternal psychopathology) and offspring outcomes. Evidence supporting the psychometric robustness of the extracted observational, self-report and interview-based tools was generally limited. Most tools were originally developed in maternal samples-with few tools demonstrating evidence of content validation specific to fathers. Furthermore, various elements influencing tool performance were recognized-including variation in tool characteristics (e.g., relationship dimensions assessed, assessment mode, and scoring formats) and study specific methodological aspects, (e.g., setting and study design, sample characteristics, timing and nature of parental psychopathology, and offspring outcomes). Conclusion: Given the strengths and limitations of each mode of assessment, future studies may benefit from a multimethod approach to assessing the father-offspring relationship, which may provide a more accurate assessment than one method alone.

Feasibility of training service providers on the AMBIANCE-Brief measure for use in community settings

The Atypical Maternal Behavior Instrument for Assessment and Classification-Brief (AMBIANCE-Brief) was developed to provide a clinically useful and psychometrically sound assessment of disrupted parenting behavior for community practitioners. With prior evidence of this tool's reliability and validity in laboratory settings, this study aimed to determine whether providers from family service agencies could become reliable in the use of the level of disrupted communication following a brief training. Providers (N = 46) from three agency sites participated in a 2-day AMBIANCE-Brief training and, at the end of the training, coded eight videotaped mother-child interactions. Novice participant coding was compared to expert consensus ratings using intraclass correlations. On average, participants' interrater agreement was good (ICC_mean  = .84, SD = 0.10), with 89% meeting the reliability standards of ICC ≥ .70. In response to queries, 100% of participants indicated that they would recommend the AMBIANCE-Brief training to their colleagues, 85% reported that the AMBIANCE-Brief measure would be useful or very useful for their clinical practice, and 56% of participant clinicians believed that parents would find the measure acceptable or very acceptable for integration into intervention or support planning. Altogether, these findings speak to the feasibility of using the AMBIANCE-Brief in community settings. Future studies are needed in diverse clinical and community contexts to evaluate whether use of this assessment tool can inform more targeted interventions tailored to the specific needs of families.

Measuring bonding or attachment in the parent-infant-relationship: A systematic review of parent-report assessment measures, their psychometric properties and clinical utility

BACKGROUND

Meaningful, valid and reliable self-report measures can facilitate the identification of important parent-infant-relationship factors, relevant intervention development and subsequent evaluation in community and clinical contexts. We aimed at identifying all available parent-report measures of the parent-infant-relationship or bond and to appraise their psychometric and clinimetric properties.

METHOD

A systematic review (PROSPERO: CRD42017078512) was conducted using the, 2018 COSMIN criteria. Eight electronic databases were searched. Papers describing the development of self-report measures of the parent-infant-bond, attachment or relationship from pregnancy until two years postpartum or the assessment of their psychometric properties were included.

RESULTS

Sixty-five articles evaluating 17 original measures and 13 modified versions were identified and reviewed. The studies' methodological quality (risk of bias) varied between 'very good' and 'inadequate' depending on the measurement property assessed; however, scale development studies were mostly of 'inadequate' quality. Although most measures had good clinical utility, the psychometric evaluation of their properties was largely poor. The original or modified versions of the Postpartum Bonding Questionnaire collectively received the strongest psychometric evaluation ratings with high quality of evidence.

CONCLUSIONS

This novel review revealed that only a few antenatal and postnatal measures demonstrated adequate psychometric properties. Further studies are needed to determine the most robust perinatal measures for researchers and clinicians.

Systematic Review: Feasibility, Reliability, and Validity of Maternal/Caregiver Attachment and Bonding Screening Tools for Clinical Use

INTRODUCTION

Infant-caregiver attachment is crucial for an infant's immediate and long-term social-emotional development and health. Despite advocacy by the National Institute of Children's Health Quality for infant social-emotional development screening, there is a lack of identified tools for use in primary care. Therefore, we conducted a systematic review to identify caretaker-infant attachment self-report screening tools that would be feasible, reliable, and valid for use in primary care.

METHOD

A systematic search identified 340 abstracts/articles, which were screened using inclusion and exclusion criteria. Twelve articles and six self-report attachment tools were examined for reliability, validity, and feasibility characteristics.

RESULTS

Six caregiver-infant attachment self-report tools were identified. Establishment of feasibility, reliability, and validity are in the early stages.

DISCUSSION

Potential infant-caretaker attachment screening tools were identified for use in primary care practices. Suggestions for research and practice include informal screening, additional psychometric testing, and development of policies supporting implementation of screening.

Assessment of Parent-Child Interaction Is Important With Infants in Rehabilitation and Can Use High-Tech or Low-Tech Methods

Parents are their infant's first teachers and play a very important role in early development. Early intervention strives to enhance infant participation in the family, and regulations require the engagement of families in assessment and intervention. Infants born preterm or with motor impairments demonstrate altered social engagements that can influence parent-child interaction and the efficacy of therapy services. However, in research focused on the efficacy of interventions or in clinical practice, therapists rarely assess or report on the quality of parent-infant interaction. Understanding these interactions can help determine what perceptual motor opportunities parents provide that can enhance learning. This Perspective article will: (1) present evidence on the need for early assessment and ongoing measurement of parent-infant interaction; (2) describe an example of each of 3 methods for assessment of parent-child interaction-low-tech, low-resource (Dyadic Mutuality Code), low-tech, high-resource (Parent Children Early Relational Assessment), and high-tech, high-resource (customized behavioral coding); (3) compare 3 approaches theoretically highlighting the strengths and weaknesses of each assessment; and (4) reflect on the challenges and value of adding these measures to future research on the efficacy of interventions and clinical practice.

Child Development and Nutritional Status in Ecuador

We assessed the development, nutritional status, and complementary feeding of 12- to 23-month-old children from Cuenca, Ecuador in 2013. Ecuador, an upper-middle-income country, developed a child policy in accordance with World Health Organization (WHO) guidelines. We collected cross-sectional survey data. Child development was assessed using the Integrated Management of Childhood Illness Guide–2011. The nutritional status was defined with WHO Child Growth Standards−2006. We investigated nutrient density, WHO Infant and Young Child Feeding Indicators, and nutrient supplementation intake of the complementary feeding. In all, 11.7% of children had “possible developmental delay,” stunting was identified in 29.4% of the children, and 25.3% faced overnutrition (overweight risk/overweight/obesity). The complementary feeding composition can be summarized as having adequate fat, high energy (MJ/day) and protein, and low iron and zinc. Children with “possible developmental delay” received less iron (P < .05) than children with normal development. Overall, 30.4% of children had minimum dietary diversity. A total of 47.7% of children received nutrient supplementation. This epidemiological profile of infants remains a challenge for Ecuador’s health programs.

Institutional caregiver experiences in child care

ABSTRACT Objective: to know the experience of institutional caregivers in child care. Method: qualitative research that used the Attachment Theory and the Symbolic Interactionism. Fifteen caregivers were interviewed, in 2015, in a child care institution based in a municipality in the south of Brazil. Data were analyzed through content analysis. Results: two categories emerged from the study: Embracing the children in the institution; Helping children adapt to institutionalization. Institutionalization imposes several social ills, such as abandonment and violence. These must be faced by caregivers, generating sadness and revolt. In addition, institutionalization leaves a mark on the child’s life, which belongs to no one, nor has his individuality and subjectivity preserved. Conclusion and Implications for practice: it is necessary to provide caregivers psychological support and Permanent Education so that they are supported in the work, improving the conditions of care offered to the child.

Maternal reflective functioning, interpersonal violence-related posttraumatic stress disorder, and risk for psychopathology in early childhood

The aim of this study was to examine associations between maternal mentalization, interactive behavior, and child symptoms in families in which mothers suffer from interpersonal violence-related posttraumatic stress disorder (IPV-PTSD). Fifty-six mothers and children (aged 12-42 months) including mothers with a diagnosis of IPV-PTSD were studied. Mentalization was measured by the Parental Reflective Functioning (PRF) Scale. Interactive behavior during free-play was measured via the CARE-Index. Child symptoms were measured by the Infant-Toddler Social and Emotional Assessment (ITSEA). Data analyses included non-parametric correlations and multiple linear regression. Results showed that lower IPV-PTSD and higher Maternal Reflective Functioning (MRF) were related to greater maternal sensitivity. Lower MRF and greater controlling behavior were related to child dysregulation. MRF was found to be lower in the subgroup of IPV-PTSD when the child's father was the perpetrator of IPV. Both MRF and interactive behavior are thus likely to be important targets for intervention during sensitive periods of early social-emotional development.

Formation and disruption of bonds between caregivers and institutionalized children

OBJECTIVE

to understand the perspective of caregivers about the formation and disruption of bonds with institutionalized children.

METHOD

a qualitative research that used as a theoretical framework the Attachment Theory and the Symbolic Interactionism, and the Grounded Theory as methodological framework. Participating in the study were 15 female caregivers of children aged zero to three years, from a child care institution in the south of Brazil, from April to July 2015.

RESULTS

three categories were elaborated: "Experiencing the formation of bond and attachment"; "Disrupting with the established bonds and detaching"; "Learning how to work with formation and disruption of bond".

FINAL CONSIDERATIONS

we need to think of ways to minimize the negative effects formation and disruption of bonds. In this sense, active listening and the offer of psychological support favor the sharing of experiences and the emotional strengthening of the female caregivers.

A New Therapeutic Group To Help Women With Borderline Personality Disorder and Their Infants

OBJECTIVES

Few treatments have been described to treat the population of women with borderline personality structure who present in a dysregulated state with their infants. Therefore, a new treatment program was developed for this target group.

METHODS

A total of 45 women, who were identified clinically as meeting full or partial diagnostic criteria for borderline personality disorder (BPD) and having an infant younger than 3 years of age, were offered entry with their infant(s) into specialized dialectical behavior therapy groups, adapted to focus on parenting and the mother-infant relationship. Outcomes measured included maternal mood and anxiety, BPD functioning, parenting sense of competence, parental reflective functioning, and caregiver-infant interaction (CARE Index). Infants received high-quality child care while mothers attended each group, with dyadic reunions a further therapeutic focus each week.

RESULTS

A total of 29 women who met clinical or self-report measures for BPD and were offered group therapy began the program, 21 (72%) of whom completed the 24-week group program, with complete premeasures and postmeasures available for 20 dyads. Of the 20 women, 15 met full diagnostic criteria for BPD and 5 met partial criteria. Significant improvements were noted in maternal mood, with positive changes on 2 subscales of the Parental Reflective Function Questionnaire (prementalizing and increased curiosity in mental states); significant reductions in anxiety and BPD symptomatology were also observed. Only a medium effect size was found for parenting sense of competence, and in smaller numbers of participants as this scale was introduced later. It should particularly be noted that 15 dyads showed substantial change on the CARE Index, indicating improvement in dyadic relationships.

CONCLUSIONS

This innovative adaptation of mother-infant dialectical behavior therapy showed promising improvements in maternal BPD symptoms and caregiver-infant relationships. Given that the feasibility and safety of this method have been demonstrated, a more methodologically rigorous trial with further refinements appears warranted to help this troubled cohort of patients.

Mother-infant interaction assessment at discharge and at 6 months in a French cohort of infants born very preterm: The OLIMPE study

Objectives

The principal aim was to investigate the feasibility of assessing mother-infant interactions at discharge and at 6 months infant corrected age in singletons born before 32 weeks of gestation. The secondary aims were to describe these interactions and their disorders, explore the association between maternal emotional state and the interactions, and assess the relationship between disordered interactions and infant social withdrawal behaviour.

Methods

OLIMPE is an ancillary study of the population-based study EPIPAGE 2, which recruited preterm neonates in France in 2011. 163 dyads participated at discharge and 148 at 6 months. Interactions were observed with the Attachment During Stress (ADS) scale, which includes two behavioural subscales, for the mother (m-ADS) and her infant (i-ADS). Two professionals independently completed the ADS scales for one third of the observations. Maternal emotional state was assessed using self-administered questionnaires of depression, anxiety, and stress. Infant’s social withdrawal behaviour at 6 months was measured by the Alarm Distress Baby scale.

Results

At discharge, 15.3% of the m-ADS scales and 43.3% of the i-ADS scales had at least one unobserved component. At 6 months, all items on both scales were noticeable in >90% of the dyads. Reliability, estimated by the kappa coefficient, ranged between 0.39 and 0.76 at discharge, and between 0.21 and 0.69 at 6 months. Disordered interactions were indicated on 48.6% of the m-ADS scales and 36.5% of the i-ADS scales at discharge. At 6 months, these rates were 32.6% and 26.0%. Disordered interactions at 6 months were associated with identified disorder at discharge. Insecure infant attachment was not influenced by maternal mental health but was strongly associated with infant social withdrawal behaviour.

Conclusions

The ADS scale can be used to screen for early interaction disorders after premature birth and may help to target dyads that would most benefit from early intervention.

ASSESSING PARENTING IN THE CONTEXT OF REUNIFICATION OF INFANTS/TODDLERS AND THEIR FAMILIES: HOW TO FACE THE CHALLENGES?

Since a substantial portion of infants and toddlers reenter care after reunification, the question of whether family reunification is feasible needs to be answered very cautiously. How parenting is assessed is of major importance in answering this question, but the quality of these assessments is often poor. With an eye to improving current practice, we conducted an integrative review, in which we analyzed the challenges related to the assessment of parenting vis-à-vis reunification and linked relevant knowledge from research with significant know-how from practice. The challenges appear to be embedded in the struggle to define (especially good enough) parenting and the complex context of child protection. As an answer to the challenges, the integrative review resulted in a framework of four key components required for sufficient parenting-assessment practice: (a) the use and development of expertise; and (b) providing families aiming for reunification with an intervention that is intensive, (c) flexible, and (d) organized as teamwork. Providing families with such an intervention gives them the opportunity to make substantial changes in their parenting and helps professionals assess the capacity of parents to grow to an acceptable level of caretaking for their child. Further implications for research and practice are discussed.

Psychometric Properties of the Parent-Infant Caregiving Touch Scale

Recent work in animals suggests that the extent of early tactile stimulation by parents of offspring is an important element in early caregiving. We evaluate the psychometric properties of a new parent-report measure designed to assess frequency of tactile stimulation across multiple caregiving domains in infancy. We describe the full item set of the Parent-Infant Caregiving Touch Scale (PICTS) and, using data from a UK longitudinal Child Health and Development Study, the response frequencies and factor structure and whether it was invariant over two time points in early development (5 and 9 weeks). When their infant was 9 weeks old, 838 mothers responded on the PICTS while a stratified subsample of 268 mothers completed PICTS at an earlier 5 week old assessment (229 responded on both occasions). Three PICTS factors were identified reflecting stroking, holding and affective communication. These were moderately to strongly correlated at each of the two time points of interest and were unrelated to, and therefore distinct from, a traditional measure of maternal sensitivity at 7-months. A wholly stable psychometry over 5 and 9-week assessments was not identified which suggests that behavior profiles differ slightly for younger and older infants. Tests of measurement invariance demonstrated that all three factors are characterized by full configural and metric invariance, as well as a moderate degree of evidence of scalar invariance for the stroking factor. We propose the PICTS as a valuable new measure of important aspects of caregiving in infancy.