Attachment state of mind and childhood experiences of maltreatment as predictors of sensitive care from infancy through middle childhood: Results from a longitudinal study of parents involved with Child Protective Services

Interventions from pregnancy to two years after birth for parents experiencing complex post-traumatic stress disorder and/or with childhood experience of maltreatment

BACKGROUND

Acceptable, effective and feasible support strategies (interventions) for parents experiencing complex post-traumatic stress disorder (CPTSD) symptoms or with a history of childhood maltreatment may offer an opportunity to support parental recovery, reduce the risk of intergenerational transmission of trauma and improve life-course trajectories for children and future generations. However, evidence relating to the effect of interventions has not been synthesised to provide a comprehensive review of available support strategies. This evidence synthesis is critical to inform further research, practice and policy approaches in this emerging area.

OBJECTIVES

To assess the effects of interventions provided to support parents who were experiencing CPTSD symptoms or who had experienced childhood maltreatment (or both), on parenting capacity and parental psychological or socio-emotional wellbeing.

SEARCH METHODS

In October 2021 we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, together with checking references and contacting experts to identify additional studies.

SELECTION CRITERIA

All variants of randomised controlled trials (RCTs) comparing any intervention delivered in the perinatal period designed to support parents experiencing CPTSD symptoms or with a history of childhood maltreatment (or both), to any active or inactive control. Primary outcomes were parental psychological or socio-emotional wellbeing and parenting capacity between pregnancy and up to two years postpartum.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of trials for inclusion, extracted data using a pre-designed data extraction form, and assessed risk of bias and certainty of evidence. We contacted study authors for additional information as required. We analysed continuous data using mean difference (MD) for outcomes using a single measure, and standardised mean difference (SMD) for outcomes using multiple measures, and risk ratios (RR) for dichotomous data. All data are presented with 95% confidence intervals (CIs). We undertook meta-analyses using random-effects models.

MAIN RESULTS

We included evidence from 1925 participants in 15 RCTs that investigated the effect of 17 interventions. All included studies were published after 2005. Interventions included seven parenting interventions, eight psychological interventions and two service system approaches. The studies were funded by major research councils, government departments and philanthropic/charitable organisations. All evidence was of low or very low certainty. Parenting interventions Evidence was very uncertain from a study (33 participants) assessing the effects of a parenting intervention compared to attention control on trauma-related symptoms, and psychological wellbeing symptoms (postpartum depression), in mothers who had experienced childhood maltreatment and were experiencing current parenting risk factors. Evidence suggested that parenting interventions may improve parent-child relationships slightly compared to usual service provision (SMD 0.45, 95% CI -0.06 to 0.96; I2 = 60%; 2 studies, 153 participants; low-certainty evidence). There may be little or no difference between parenting interventions and usual perinatal service in parenting skills including nurturance, supportive presence and reciprocity (SMD 0.25, 95% CI -0.07 to 0.58; I2 = 0%; 4 studies, 149 participants; low-certainty evidence). No studies assessed the effects of parenting interventions on parents' substance use, relationship quality or self-harm. Psychological interventions Psychological interventions may result in little or no difference in trauma-related symptoms compared to usual care (SMD -0.05, 95% CI -0.40 to 0.31; I2 = 39%; 4 studies, 247 participants; low-certainty evidence). Psychological interventions may make little or no difference compared to usual care to depression symptom severity (8 studies, 507 participants, low-certainty evidence, SMD -0.34, 95% CI -0.66 to -0.03; I2 = 63%). An interpersonally focused cognitive behavioural analysis system of psychotherapy may slightly increase the number of pregnant women who quit smoking compared to usual smoking cessation therapy and prenatal care (189 participants, low-certainty evidence). A psychological intervention may slightly improve parents' relationship quality compared to usual care (1 study, 67 participants, low-certainty evidence). Benefits for parent-child relationships were very uncertain (26 participants, very low-certainty evidence), while there may be a slight improvement in parenting skills compared to usual care (66 participants, low-certainty evidence). No studies assessed the effects of psychological interventions on parents' self-harm. Service system approaches One service system approach assessed the effect of a financial empowerment education programme, with and without trauma-informed peer support, compared to usual care for parents with low incomes. The interventions increased depression slightly (52 participants, low-certainty evidence). No studies assessed the effects of service system interventions on parents' trauma-related symptoms, substance use, relationship quality, self-harm, parent-child relationships or parenting skills.

AUTHORS' CONCLUSIONS

There is currently a lack of high-quality evidence regarding the effectiveness of interventions to improve parenting capacity or parental psychological or socio-emotional wellbeing in parents experiencing CPTSD symptoms or who have experienced childhood maltreatment (or both). This lack of methodological rigour and high risk of bias made it difficult to interpret the findings of this review. Overall, results suggest that parenting interventions may slightly improve parent-child relationships but have a small, unimportant effect on parenting skills. Psychological interventions may help some women stop smoking in pregnancy, and may have small benefits on parents' relationships and parenting skills. A financial empowerment programme may slightly worsen depression symptoms. While potential beneficial effects were small, the importance of a positive effect in a small number of parents must be considered when making treatment and care decisions. There is a need for further high-quality research into effective strategies for this population.

Psychoanalytic Interventions with Abusive Parents: An Opportunity for Children's Mental Health

Research has extensively shown that most people who experience maltreatment in their childhood develop mental disorders, psychosocial adjustment problems, and, in many cases, become maltreating adults themselves. Preventing child maltreatment and treating abused children and abusive parents are, therefore, pressing public health issues. As established by the UK Children Act in 1989, child development is enhanced by remaining in the family whenever the child's safety is assured. Thus, developing prevention and intervention programs for the purpose of repairing, whenever possible, the child-parent relationship should be a social priority. This narrative review focuses on the psychoanalytic studies related to intrapsychic dynamics and therapeutic intervention for physically abusive parents. The role of the transgenerational transmission of abuse and parents' narcissistic fragility is crucial. Psychoanalytic interventions focus on helping the parent work through their past painful experiences and narcissistic vulnerability. Parent-child psychotherapy and mentalization-based treatment have been found to be prevalent, while there is scarce literature regarding intensive individual psychoanalytic treatment. Within the framework of attachment theory, brief interventions were developed; however, they did not prove effective for those parents who suffered experiences of maltreatment or severe neglect in childhood and for whom long-term parent-child psychotherapy resulted, which proved to be the most effective.

Identifying Risk and Resilience Factors in the Intergenerational Cycle of Maltreatment: Results From the TRANS-GEN Study Investigating the Effects of Maternal Attachment and Social Support on Child Attachment and Cardiovascular Stress Physiology

Introduction

Childhood maltreatment (CM) is a developmental risk factor and can negatively influence later psychological functioning, health, and development in the next generation. A comprehensive understanding of the biopsychosocial underpinnings of CM transmission would allow to identify protective factors that could disrupt the intergenerational CM risk cycle. This study examined the consequences of maternal CM and the effects of psychosocial and biological resilience factors on child attachment and stress-regulatory development using a prospective trans-disciplinary approach.

Methods

Mother-child dyads (N = 158) participated shortly after parturition (t 0), after 3 months (t 1), and 12 months later (t 2). Mothers' CM experiences were assessed at t 0, attachment representation at t 1 and psychosocial risk and social support were assessed at t 1 and t 2. At t 2, dyads participated in the Strange Situation Procedure (SSP). Children's attachmen status were classified as organized vs. disorganized, including their level of disorganized behavior, and heart rate (HR) and respiratory sinus arrhythmia (RSA) were recorded as stress response measures of the autonomic nervous system. Maternal caregiving during SSP was assessed using the AMBIANCE scale. Child's single nucleotide polymorphisms rs2254298 within the oxytocin receptor (OXTR) and rs2740210 of the oxytocin gene (OXT) were genotyped using DNA isolated from cord blood.

Results

Maternal CM experiences (CM+) were significantly associated with an unresolved attachment status, higher perceived stress and more psychological symptoms. These negative effects of CM were attenuated by social support. As expected, maternal unresolved attachment and child disorganized attachment were significantly associated. Maternal caregiving did not mediate the relationship between maternal and child attachment but influenced children's HR and RSA response and disorganized behavior. Moreover, the rs2254298 genotype of the OXTR gene moderated the stress response of children from mothers with CM. Children carrying the rs2740210 risk allele of the OXT gene showed more disorganized behavior independent from maternal CM experiences.

Conclusion

We replicated and extended existing CM and attachment models by co-examining maternal attachment, social support, and child genetic susceptibility on child attachment and cardiovascular stress regulation. The findings contribute to an extended understanding of risk and resilience factors and enable professionals to target adequate services to parents and children at risk.

Early life stress and neural development: Implications for understanding the developmental effects of COVID-19

Chronic and/or extreme stress in childhood, often referred to as early life stress, is associated with a wide range of long-term effects on development. Given this, the COVID-19 pandemic has led to concern about how stress due to the pandemic will affect children's development and mental health. Although early life stress has been linked to altered functioning of a number of neural and biological systems, there is a wide range of variability in children's outcomes. The mechanisms that influence these individual differences are still not well understood. In the past, studies of stress in childhood focused on the type of events that children encountered in their lives. We conducted a review of the literature to formulate a new perspective on the effects of early life stress on development. This new, topological model, may increase understanding of the potential effects of the COVID-19 pandemic on children's development. This model is oriented on children's perceptions of their environment and their social relationships, rather than specific events. These factors influence central and peripheral nervous system development, changing how children interpret, adapt, and respond to potentially stressful events, with implications for children's mental and physical health outcomes.

Increasing secure base script knowledge among parents with Attachment and Biobehavioral Catch-up

This study evaluated whether Attachment and Biobehavioral Catch-up (ABC), a parenting intervention, altered the attachment representations of parents (average age of 34.2 years) who had been referred to Child Protective Services (CPS) due to risk for child maltreatment when their children were infants. Approximately 7 years after completing the intervention, parents who had been randomized to receive ABC (n = 43) exhibited greater secure base script knowledge than parents who had been randomized to receive a control intervention (n = 51). Low-risk parents (n = 79) exhibited greater secure base script knowledge than CPS-referred parents who had received a control intervention. However, levels of secure base script knowledge did not differ between low-risk parents and CPS-referred parents who had received the ABC intervention. In addition, secure base script knowledge was positively associated with parental sensitivity during interactions with their 8-year-old children among low-risk and CPS-referred parents. Mediational analyses supported the idea that the ABC intervention enhanced parents' sensitivity 7 years later indirectly via increases in parents' secure base script knowledge.

Intergenerational effects of childhood maltreatment: A systematic review of the parenting practices of adult survivors of childhood abuse, neglect, and violence

A history of maltreatment in childhood may influence adults' parenting practices, potentially affecting their children. This systematic review examines 97 studies investigating associations of parental childhood victimization with a range of parenting behaviors that may contribute to the intergenerational effects of abuse: abusive parenting, problematic parenting, positive parenting, and positive parental affect. Key findings include: (1) parents who report experiencing physical abuse or witnessing violence in the home during childhood are at increased risk for reporting that they engage in abusive or neglectful parenting; (2) a cumulative effect of maltreatment experiences, such that adults who report experiencing multiple types or repeated instances of victimization are at greatest risk for perpetrating child abuse; (3) associations between reported childhood maltreatment experiences and parents' problematic role reversal with, rejection of, and withdrawal from their children; (4) indirect effects between reported childhood maltreatment and abusive parenting via adult intimate partner violence; and (5) indirect effects between reported childhood maltreatment and lower levels of positive parenting behaviors and affect via mothers' mental health. Thus, childhood experiences of maltreatment may alter parents' ability to avoid negative and utilize positive parenting practices. Limitations of this body of literature include few prospective studies, an overreliance on adults' self-report of their childhood victimization and current parenting, and little examination of potentially differential associations for mothers and fathers.

Rethinking Concepts and Categories for Understanding the Neurodevelopmental Effects of Childhood Adversity

Discovering the processes through which early adverse experiences affect children’s nervous-system development, health, and behavior is critically important for developing effective interventions. However, advances in our understanding of these processes have been constrained by conceptualizations that rely on categories of adversity that are overlapping, have vague boundaries, and lack consistent biological evidence. Here, we discuss central problems in understanding the link between early-life adversity and children’s brain development. We conclude by suggesting alternative formulations that hold promise for advancing knowledge about the neurobiological mechanisms through which adversity affects human development.

Aspects of Parent-Child Interaction from Infancy to Late Adolescence Are Associated with Severity of Childhood Maltreatment through Age 18

Childhood maltreatment (CM) is a pervasive public health problem worldwide, with negative health consequences across the lifespan. Despite these adverse outcomes, identifying children who are being maltreated remains a challenge. Thus, there is a need to identify reliably observable features of parent-child interaction that indicate risk for CM and that can instigate strategically targeted family supports. The aim of this longitudinal study was to assess multiple aspects of observed mother-child interaction from infancy to late adolescence as risk indicators of the overall severity of CM by age 18. Mother-child dyads were assessed in infancy (N = 56), at age 7 years (N = 56), and at age 19 years (N = 56/110). Severity of CM through age 18 was indexed by combined prospective and retrospective assessments. Interactions associated with severity of CM by age 18 included maternal hostility in infancy, maternal withdrawal in infancy and middle childhood, child disorganized attachment behavior in middle childhood and late adolescence, as well as hostile and role-confused interactions in late adolescence. This study identifies new indices of maternal and child behavior as important risk indicators for the severity of CM. These indices could be used to improve early identification and tailor preventive interventions for families at risk for CM.

Maternal adverse childhood experiences, attachment style, and mental health: Pathways of transmission to child behavior problems

BACKGROUND

Investigations have found mothers' adverse childhood experiences (ACEs) confer an intergenerational risk to their children's outcomes. However, mechanisms underlying this transmission have only been partially explained by maternal mental health. Adult attachment insecurity has been shown to mediate the association of ACEs and mental health outcomes, yet an extension of this research to children's behavioral problems has not been examined.

OBJECTIVE

To examine the cascade from maternal ACEs to risk for child behavioral problems at five years of age, via mothers' attachment insecurity and mental health.

PARTICIPANTS AND SETTING

Participants in the current study were 1994 mother-child dyads from a prospective longitudinal cohort collected from January 2011 to October 2014.

METHODS

Mothers retrospectively reported their ACEs when children were 36 months of age. When children were 60 months of age, mothers completed measures of their attachment style, depression and anxiety symptoms, and their children's behavior problems.

RESULTS

Path analysis demonstrated maternal ACEs were associated with children's internalizing problems indirectly via maternal attachment avoidance, attachment anxiety, and depression symptoms, but not directly (β = .05, 95% CI [-.001, .10]). Maternal ACEs indirectly predicted children's externalizing problems via maternal attachment avoidance, attachment anxiety, and depression. A direct effect was also observed from maternal ACEs to child externalizing problems (β = .06, 95% CI [.01, .11]).

CONCLUSIONS

Maternal ACEs influenced children's risk for poor behavioral outcomes via direct and indirect intermediary pathways. Addressing maternal insecure attachment style and depression symptoms as intervention targets for mothers with histories of ACEs may help to mitigate the intergenerational transmission of risk.

Infant Trauma Alters Social Buffering of Threat Learning: Emerging Role of Prefrontal Cortex in Preadolescence

Within the infant-caregiver attachment system, the primary caregiver holds potent reward value to the infant, exhibited by infants' strong preference for approach responses and proximity-seeking towards the mother. A less well-understood feature of the attachment figure is the caregiver's ability to reduce fear via social buffering, commonly associated with the notion of a "safe haven" in the developmental literature. Evidence suggests this infant system overlaps with the neural network supporting social buffering (attenuation) of fear in the adults of many species, a network known to involve the prefrontal cortex (PFC). Here, using odor-shock conditioning in young developing rats, we assessed when the infant system transitions to the adult-like PFC-dependent social buffering of threat system. Rat pups were odor-shock conditioned (0.55 mA-0.6 mA) at either postnatal day (PN18; dependent on mother) or 28 (newly independent, weaned at PN23). Within each age group, the mother was present or absent during conditioning, with PFC assessment following acquisition using 14C 2-DG autoradiography and cue testing the following day. Since the human literature suggests poor attachment attenuates the mother's ability to socially buffer the infants, half of the pups at each age were reared with an abusive mother from PN8-12. The results showed that for typical control rearing, the mother attenuated fear in both PN18 and PN28 pups, although the PFC [infralimbic (IL) and ventral prelimbic (vPL) cortices] was only engaged at PN28. Abuse rearing completely disrupted social buffering of pups by the mother at PN18. The results from PN28 pups showed that while the mother modulated learning in both control and abuse-reared pups, the behavioral and PFC effects were attenuated after maltreatment. Our data suggest that pups transition to the adult-like PFC social support circuit after independence from the mother (PN28), and this circuit remains functional after early-life trauma, although its effectiveness appears reduced. This is in sharp contrast to the effects of early life trauma during infancy, where social buffering of the infant is more robustly impacted. We suggest that the infant social buffering circuit is disengaged by early-life trauma, while the adolescent PFC-dependent social buffering circuit may use a safety signal with unreliable safety value.

Effects of an attachment-based intervention in infancy on children's autonomic regulation during middle childhood

The present study used a longitudinal randomized clinical trial to test whether an early intervention has causal effects on children's autonomic nervous system regulation. When children were infants, parents involved with Child Protective Services received Attachment and Biobehavioral Catch-up (ABC; N = 43), an intervention that promotes sensitive parenting, or a control intervention (N = 53). When children were 9 years old, children whose parents had received ABC exhibited higher respiratory sinus arrhythmia and lower heart rate at rest and during a parent-child interaction than children in the control group. Intervention effects were not detected for children's average skin conductance levels or for indices of autonomic reactivity. Results suggest that a parenting-focused early intervention impacted the development of children's autonomic regulation.