Parenting children with severe attachment problems

This blog is about a systematic review that aimed to evaluate the effectiveness and cost effectiveness of interventions for parents of children who display attachment problems.

The review was commissioned by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme.

Attachment problems describe children’s problems connecting with their primary caregivers and forming normal relationships.

Children with attachment problems have difficulty connecting to others and managing their own emotions.

Methods

To gather the material for this report, the authors searched for papers that:

Described the results of an RCT (randomised controlled trial: other study designs were not examined)
Reported on interventions given to parents or caregivers of children below the age of 13, who either already displayed severe attachment problems, or were thought to be at risk of doing so in the future (for example because they had been maltreated)
Included interventions aimed at parents or caregivers (as opposed to other people interacting with children, such as teachers)
Compared the intervention to either no intervention, an unspecific intervention, or care as usual
Included as their primary outcome the children’s attachment to their caregivers

The authors also undertook a quality assessment of the studies they identified, to assess any biases studies may contain. They did this using criteria developed by the Cochrane Handbook (Cochrane is an NGO dedicated to producing high-quality evidence on healthcare interventions).

In addition to their main review, this report also includes two supplemental reviews: one on the validity of methods used to identify attachment problems; and the other on the long-term outcomes of attachment problems in childhood. There isn’t space to cover either of those in this blog.

This systematic review of RCTs looked at interventions to help parents and caregivers improve their attachment to their children.

Results

The final number of papers that met the inclusion criteria was 39 (out of 10,167 initial hits). These 39 reports reflected 30 studies (some papers reported on different aspects of the same study).

What were the intervention programs like?

The content of the interventions varied quite a bit across the studies. Some were group-based, with parent training sessions aimed at increasing parents’ sensitivity; others were intensive one-to-one sessions with mothers, that sometimes included video feedback; some focused exclusively on the parent (most often the mother only) whereas many others also included sessions for children. In addition, the age of children varied, with some interventions targeted towards parents of babies and others towards toddlers and preschool-aged children.

What was the quality of the included studies?

When the authors evaluated the quality of the studies, they found several sources of biases that were consistent across many of them. Among these were high dropout, such that families did not participate in the intervention until its end. Another source of bias was unexplained missing data and insufficient reporting of secondary outcomes or other details of the study.

Did the interventions have any effect?

The authors then conducted a meta-analysis to examine whether children in families who received an intervention showed reduced attachment problems afterwards. The analysis showed an overall positive effect, that is, children in the intervention group fared better than those in the control group. In a second, supplementary meta-analyses they also analysed whether children whose families received an intervention were more likely to display secure attachment. This was also the case.

The authors then conducted some comparisons to see if different characteristics of the intervention made a difference. These results have to be interpreted with caution because the comparison groups often included only a small number of studies.

First, the effect in reducing attachment problems appeared somewhat larger if the intervention went on for longer than 12 months or had a greater number of sessions.
Second, the effects were only significant when children were older than 6 months at the time of intervention.
Third, whether a male caregiver was included in the intervention or not did not make a difference to the success of the intervention when reduced attachment problems was the outcome.
Fourth, whether video feedback was used or not did also not make a difference.

Interventions for reducing disorganised attachment showed good outcomes overall.

Are the interventions cost-effective?

Another aim of the study was to review the cost-effectiveness of attachment-improving interventions. However, only 2 studies were identified that examined cost-effectiveness, and neither of these found any significant effects for the intervention.

The authors then evaluated whether it was possible to conduct cost-effectiveness analyses based on the results of the reviews. Economists scanned the studies to gain an idea of the cost of the intervention (e.g. how many units of time it required, overhead costs, such as the type of venue, etc). They also examined whether attachment problems were associated with long-term psychosocial and health outcomes, to calculate whether a reduction in attachment problems would be cost-effective by reducing these problems. However, there was limited good-quality evidence researching this question, so the authors had to abandon this analysis. Because of these gaps in the literature, the authors had to make certain assumptions in light of the absence of enough evidence and, using these, came up with the following calculations:

The cost for identifying children with attachment problems in the population was calculated as between £968 (if all children in an average clinical commissioning group catchment area would be screened) vs. £77 per case (if only children born into poor families, who are at risk of developing attachment problems, are screened)
The average cost of intervention would be £2,265 per case
Taken together, these costs would add up to approximately £313,860 per year for a clinical commissioning group, to screen the child population and reduce attachment problems in cases
To justify this amount of spending, according to NICE rules of cost-effectiveness, the screening and intervention would need to lead to an improvement of approximately 0.20 to 0.30 QALYs over the lifetime of the child

A well-planned large birth cohort study with long-term follow-up and a range of assessments and outcome measures is needed.

Conclusions

This review is extremely thorough, including not only the main analysis on interventions to reduce attachment problems, but also two supplementary reviews and one supplementary meta-analysis. The authors also appeared to make every effort to give attachment interventions a “fair” assessment despite the relatively sparse high-quality literature that was available (for example on its long-term outcomes).

Another interesting aspect of this review is that it includes some patient and public involvement, through consultations with service users and therapists, i.e. the very people who are involved in the interventions.

This review shines a spotlight on several problems within the attachment literature that may need attention from attachment researchers hoping to translate their findings into benefit for children:

First, it is concerning that some of the study biases that this review identified stem from something as avoidable as insufficient reporting on crucial details of the study.
Second, it highlighted the confusion and inconsistency about definitions of attachment. As the authors themselves say “This makes the literature very confusing for all but the most avid attachment researcher”.
Third, because we know that attachment problems are often comorbid with other issues, the question is: do we need to develop interventions that specifically address attachment problems, or are the established interventions enough? After all, we know they do a reasonably good job at modifying the correlates of attachment problems (such as externalising problems or depression).
Finally, this review identified very few studies examining the long-term consequences of attachment problems. It is important to know whether attachment problems are indeed associated with long-term negative outcomes, particularly over and above other concurrent problems that children with attachment issues are likely to experience (such as externalising problems or depression).

Thus, the review shows us that attachment problems can be reduced, but the long-term benefits of doing so are unclear. Long-term follow-up studies are needed to examine this question. There’s a road ahead for research on attachment problems.