Attachment & Child Health (ATTACH) pilot trials: Effect of parental reflective function intervention for families affected by toxic stress

Abstract

Toxic stressors (e.g., parental violence, depression, low income) place children at risk for insecure attachment. Parental reflective function—parents’ capacity to understand their own and their child's mental states and thus regulate their own feelings and behavior toward their child—may buffer the negative effects of toxic stress on attachment. Our objective was to test the effectiveness of the Attachment and Child Health (ATTACH) intervention, focusing on improving reflective function and children's attachment security, for at‐risk mothers and children <36 months of age. Three pilot studies were conducted with women and children from an inner city agency serving vulnerable, low‐income families and a family violence shelter. Randomized control trial (n = 20, n = 10 at enrollment) and quasi‐experimental (n = 10 at enrollment) methods tested the effect of the ATTACH intervention on the primary outcome of reflective function scores, from transcribed Parent Development Interviews. Our secondary outcome was children's attachment patterns from Ainsworth's Strange Situation Procedure. Despite some attrition, mixed methods analysis of covariance and t tests revealed significant differences in maternal, child, and overall reflective function, with moderate effect sizes. While more children whose mothers received the ATTACH program were securely attached posttreatment, as compared with controls, significant differences were not observed, which may be due to missing observations (n = 5 cases). Understanding the effectiveness of programs like the ATTACH intervention contributes to improved programs and services to promote healthy development of children affected by toxic stress.

Fidelity Assessment Checklist Development for Community Nursing Research in Early Childhood

“…Details of the ATTACH TM program and the guiding theory are published elsewhere (16,17). Briefly, ATTACH TM is a 1-h, 10-12 session, face-to-face intervention with dyadic (mother and infant) and triadic (mother, infant, and co-parent) elements.…”

“…Briefly, ATTACH TM is a 1-h, 10-12 session, face-to-face intervention with dyadic (mother and infant) and triadic (mother, infant, and co-parent) elements. ATTACH TM is designed to help parents bolster a skill called parental Reflective Function (RF), the capacity of parents to think about mental states (thoughts, feelings, and intentions) in themselves and their children, and to consider how their mental states might affect their children to regulate behavior (16,17). Parental RF is distinguishable from many related terms including mindful parenting (48)(49)(50), mindblindedness (51), empathy (52), insightfulness (53), and mind mindedness (54).…”

“…For ATTACH TM to be paced adequately, the facilitator was expected to deliver each of the five steps in dyadic sessions, and four steps in triadic sessions in 45-60 min. We analyzed videorecorded sessions from pilot studies to determine recommended durations for the steps (17). For example, the duration of…”

“…This paper describes how to develop and conduct an evaluation of a program fidelity checklist, including the step-by-step developmental process our research team used for the Attachment and Child Health (ATTACH TM ) parenting program. ATTACH TM is a psycho-educational parenting program that fosters parental reflective function (RF), the ability of parents to envision mental states in themselves and their children to promote healthy child development (16,17). Compared to routine care, ATTACH TM has been shown to be effective in randomized controlled trials and quasi-experimental studies (16,17); however, program fidelity assessment was needed to contextualize results and assure ongoing internal validity in support of wider implementation.…”

“…ATTACH TM is a psycho-educational parenting program that fosters parental reflective function (RF), the ability of parents to envision mental states in themselves and their children to promote healthy child development (16,17). Compared to routine care, ATTACH TM has been shown to be effective in randomized controlled trials and quasi-experimental studies (16,17); however, program fidelity assessment was needed to contextualize results and assure ongoing internal validity in support of wider implementation. Thus, the purpose of our paper is to demonstrate the step-by-step process for development of a fidelity checklist, specifically for ATTACH TM , and to provide preliminary data on its utility.…”