There is strong evidence to show that the quality of parenting that a child receives during the earliest years of life can have a significant impact on the developing parent–child attachment relationship (Wolff & Ijzendoorn,
1997), and on the child’s social, emotional, and psychological outcomes (Moore et al.,
2017). With this in mind, various attachment-based parenting interventions have been developed with the aim of enhancing parenting quality and promoting parent–child attachment security in the early years (Steele & Steele,
2018). The current paper seeks to provide an overview of the attachment-based parenting interventions that are currently available for caregivers of toddlers aged 12–24 months, along with an overview of the empirical effectiveness of these interventions at improving attachment security in children of this age group.
Toddlerhood
The early toddler years, the period of life from around 12 to 24 months, represent a crucial developmental phase. During this time, children undergo significant and rapid growth in a range of areas including physical mobility, capacity for language and social relationships, play, independence and sense of self-identity, cognitive abilities, and capacities for self-regulation and emotional regulation (Crockenberg & Leerkes,
1993; Lieberman,
1993; Sroufe,
1995; Woody,
2003). With heightened levels of neuroplasticity and susceptibility to the influences of the environment, the quality of early parenting during this phase of life plays a key role in shaping the developmental and mental health trajectories (Lomanowska et al.,
2017; Moore et al.,
2017). Evidence suggests that children who experience adverse early caregiving (e.g., non-sensitive, harsh, hostile, or inconsistent parenting) in the toddler years are at elevated risk of a range of concurrent and subsequent social–emotional and behavioral issues (Mendez et al.,
2016; Samdan et al.,
2020; Van Aken et al.,
2007; Wiggins et al.,
2015), which in turn, place them on pathways to poor mental health throughout childhood, adolescence, and beyond (Campbell et al.,
2006; Kim-Cohen et al.,
2003).
Attachment Theory
Attachment theory is an ethological theory that seeks to account for the impact of the early parenting environment on a child’s social–emotional development and behavior (Bowlby,
1988). Originally proposed by Bowlby (
1969) and further developed in the work of Ainsworth (Ainsworth et al.,
1978), attachment theory argues that social, emotional, and cognitive capacities develop and flourish from infancy through the early toddler years in the context of early caregiving that is sensitive and contingently responsive (Lyons-Ruth,
1996), or in other words, caregiving that involves accurately perceiving and interpreting a child’s signals followed by prompt, appropriate responding (Ainsworth et al.,
1978). Specifically, attachment theory suggests that it is through repeated experiences of sensitive and responsive interactions with the caregiver that the infant or young toddler develops an internal working model of the primary caregiver as a “secure base” from which he or she can explore the environment, and feel assured that comfort and protection will be available when required. Conversely, insecure attachment patterns develop when the child experiences repeated interactions with a caregiver in which his or her bids for parental proximity/emotional support are rejected or met inconsistently. According to attachment theory, children who have experienced this type of caregiving typically develop internal working models of the parent as unavailable or unreliable, and thus they engage in compensatory strategies (attachment avoidance or attachment ambivalence/resistance) to deal with the resulting relational stress. In addition, infants and toddlers who experience abusive, frightening or frightened parenting may fail to develop a coherent or organized attachment strategy. These children typically show odd, disorganized behaviors in the presence of key attachment figures (Main & Solomon,
1986,
1990).
The two most established methods for assessing attachment in young children are the strange situation procedure (SSP) (Ainsworth et al.,
1978) and the Attachment Q-Set (AQS) (Waters,
1995). The SSP is a standardized, lab-based procedure that comprises a series of 8, 3-min episodes involving separations and reunions between a child (aged 12–18 months), his or her parent, and a ‘friendly’ stranger. Child behaviors in response to separations and reunions with the parent are observed and used to inform the allocation of 3-way and 4-way attachment classifications (Ainsworth et al.,
1978). For the 3-way classification system, a primary classification of ‘secure,’ ‘insecure-avoidant,’ or ‘insecure-ambivalent/resistant’ is given (with disorganized attachment forced into one of the three organized categories). For the 4-way classification, a primary classification of ‘secure,’ ‘insecure-avoidant,’ ‘insecure-ambivalent/resistant,’ or ‘disorganized’ is given, with the disorganization classification allocated for children who are observed to lack a coherent strategy of responding to distress associated with the caregiver, e.g., odd, disoriented behaviors; (Main & Solomon,
1986,
1990). As an alternative to the SSP, the AQS (Waters,
1995) was developed as a 90-item observer Q-sort procedure for use in naturalistic settings. The AQS was designed for use with children aged 12–48 months and is typically scored from a 60–90-min parent–child observation in the family home. It yields a continuous attachment security score ranging from − 1.00 (least like a securely attached child) to + 1.00 (most like a securely attached child).
The empirical evidence to support attachment theory is strong. Meta-analytic studies have identified maternal sensitivity as a significant predictor of infant attachment security (Wolff & Ijzendoorn,
1997). Numerous studies have documented links between insecure or disorganized attachment measured in infancy and a range of compromised outcomes later in life including externalizing and internalizing behaviors and self-regulation difficulties in middle childhood (Boldt et al.,
2020; Fearon et al.,
2010; Madigan et al.,
2013), and social, emotional, and mental health difficulties in adolescence and adulthood (Carlson,
1998; Girme et al.,
2020). Importantly, attachment security has been shown to be protective for children impacted by known risk factors such as poverty (Delker et al.,
2018) and parental substance abuse (Edwards et al.,
2006).
Attachment-Based Parenting Interventions
In response to the identified links between early parenting quality and infant/toddler attachment security, and between infant/toddler attachment security and subsequent positive social, emotional, and psychological outcomes, attachment-based parenting interventions have been developed and recommended (Moore et al.,
2017; Steele & Steele,
2018). Attachment-based interventions aim to improve parental capacity to provide sensitive and responsive caregiving, with the ultimate goal of improving child attachment patterns. While these interventions have a common goal, the methods and foci of individual interventions vary, with some programs intervening at a behavioral level (e.g., using live coaching, using video feedback with parents to target specific parental behaviors), and others focus on changing caregiver representations (e.g., parental reflective functioning; Wolff & Ijzendoorn,
1997).
Aims of the Current Paper
Given the growing empirical evidence base for the importance of the toddler years and the key role of early parenting and the parent–child attachment relationship in shaping child outcomes, many countries have started to develop health strategies and policies focusing on supporting early parenting, in the hope that the significant social and economic burdens presented by adult mental illness will be reduced (Australian Government National Mental Health Commission,
2021; Australian Government Productivity Commission,
2021). In this context, it is vital that clinicians who are working with young toddlers and families maintain a clear understanding of both the available attachment-based interventions, and also the research evidence to support these interventions. In particular, it is important that clinicians are aware of the ability for these interventions to bring changes in parent–child attachment relationships. To this end, the current paper aims to provide a narrative summary of (1) the attachment-based interventions currently available for caregivers of toddlers aged 12–24 months, and (2) the empirical effectiveness at improving attachment security.
Method
A literature search was conducted using PsycINFO and PsychARTICLES through June of 2020 to identify relevant articles. Search terms included attachment, attachment intervention, treatment, pre-, post-, measures, SSP, 12–24 months, toddlers, Circle of Security, COS, Attachment and Biobehavioral Catch-Up, ABC, Child-Parent Psychotherapy, and CPP. Reference lists of meta-analyses on this topic were also searched manually. Attachment studies in which no intervention occurred, interventions occurred only outside of our 12–24-month age range, or no attachment outcomes were measured, were excluded. Theoretical articles, commentaries, dissertations, theses, poster presentations, case studies, and publications not available in English were also excluded.
Discussion
This review paper provides a narrative summary of available attachment-informed interventions for caregivers and toddlers (aged 12–24 months), an overview of evidence showing the ability of these interventions to bring changes in child attachment patterns, and a description of the available meta-analysis examining the ability of parenting interventions to change infant attachment patterns.
Overall, the programs with the strongest evidence base for changes in parent–child attachment when delivered in the early toddler years were CPP and ABC. The CPP intervention is supported by four separate RCTs and one follow-up study, including studies conducted by research teams who were uninvolved in the original development of the intervention (Cicchetti et al.,
1999,
2006; Stronach et al.,
2013; Toth et al.,
2006). CPP was developed for high-risk parent–child dyads, so it is encouraging to see positive changes in attachment in high-risk samples. It must be noted, however, that of all the programs reviewed, CPP has one of the longest treatment durations and therefore is likely to be one of the most resource-intensive interventions. ABC was shown in two separate RCTs to be associated with positive child attachment outcomes (Bernard et al.,
2012; Dozier et al.,
2009), with 1 of these studies including a 9-year post-intervention follow-up (Zajac et al.,
2020). These gains are impressive and encouraging given that ABC is a relatively brief intervention (10 weeks).
There was also evidence suggesting that various other interventions are also associated with positive attachment outcomes in toddlers (COS-HV4, STEEP, EHS, WWW, UCLA Family Development Project, Moss’s Home-Visiting Intervention, Lyons-Ruth’s Home-Visiting Intervention, Minding the Baby). However, while evidence for the great majority of these interventions came from RCTs, in most cases, evidence came from just one study, conducted by the program developers. It must also be noted that with the exception of two RCT studies (Dozier et al.,
2009; Lieberman et al.,
1991), attachment outcomes for the intervention and control group were assessed post-treatment only, rather than at both pre- and post-intervention. This means that individual changes in attachment over time were not examined, making it difficult to know whether the groups differed at baseline. For some interventions (e.g., COS-I, COS perinatal), available evidence about the interventions’ effect on attachment was positive but limited by the fact that it came from open-trial studies rather than RCTs. Future studies utilizing RCT designs should be conducted to test outcomes of these intervention programs further.
Finally, there were a couple of interventions for which the evidence of changes in toddler attachment was inconclusive (i.e., PCIT-T, RFTS). While it is possible that these programs are ineffective in addressing attachment issues in young children, such a conclusion is likely to be premature given that there has been so little research conducted on these programs to date. The only study conducted to assess attachment outcomes following PCIT-T, for example, used an open-trial design and had a small sample size. While results were non-significant, the study was underpowered, increasing the likelihood of a type II error (Kohlhoff et al.,
2020).
Results from available meta-analyses suggest that targeting parenting sensitivity is the most effective way to change infant attachment security and organization. Other common features of effective interventions included being brief, having a behavioral focus, and being delivered after the child was 6 months old.
The current paper makes an important contribution to the literature because while previous reviews have examined the impact of attachment-based interventions on child attachment (Bakermans-Kranenburg et al.,
2003,
2005; Facompré et al.,
2018; Letourneau et al.,
2015; Van Ijzendoorn et al.,
1995; Wright & Edginton,
2016; Wright et al.,
2015,
2017), these have included children from a wide range of ages rather than focusing specifically on interventions delivered in the period of early toddlerhood. In addition, in most cases, the focus of previous reviews was on meta-analysis rather than narrative review of available programs. The strengths of this paper must be considered, however, alongside an acknowledgment of its limitations. The review was not systematic in nature, and while every effort to uncover relevant studies was taken, it is possible that some studies may have been missed. Furthermore, only English language studies were reviewed due to the costs associated with translation, reducing the generalizability of findings.
In sum, this paper describes the attachment-based parenting interventions that have been developed to improve the quality of caregiver–child attachment relationships, and that have been applied to the early toddler age group. There was evidence to suggest that a number of interventions were associated with changes in child attachment, with CPP and ABC emerging as the interventions with the strongest evidence bases. For most of the other interventions, however, evidence came from just a single research study, and in some cases the studies lacked control groups. In order for clinicians to make informed decisions about the interventions they use with parents and toddlers, it is vital that more studies be conducted to test each intervention, and that future studies should use RCT designs, in a range of settings and clinical and cultural groups, and with longitudinal follow-ups.
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