Fase III: Comunicación de Resultados

Interventions to enhance parental sensitivity and/or infant attachment security

The meta-analytic study by Bakermans-Kranenburg et al (2003) focused on improving the sensitivity or parents (primarily mothers) or improving the attachment security of infants. This involved parents who appeared to be at high risk of, or actually engaging in, neglectful or intrusive parenting. The most effective interventions were found to be brief, with a clear cut behavioural focus on enhancing parental sensitivity. Interventions that involve videofeedback (see interaction guidance, below) were found to be more effective in enhancing sensitivity than those that did not. Although only a small number of interventions (3 of 81) included fathers as well as mothers, the involvement of fathers was found to enhance sensitivity effects. Interventions that had a clear focus on enhancing parental sensitivity were also most effective in enhancing infant attachment security, which supports a the notion of a causal role of sensitivity in shaping attachment.

Interventions to enhance sensitivity of parents of infants with faltering growth

The emphasis of the interventions studied in this section was slightly different to the other groups due in part to the fact that all of the study samples involved parents of infants, and, interventions for parents of infants have on the whole been influenced by either a behavioural approach (i.e. mostly directly at changing problems with feeding and crying) or attachment and psychotherapeutic approaches (i.e. that focus more on the mother- child relationship). We did not identify any cognitive-behavioural interventions in this group.

Interaction Guidance

Interaction guidance is a behavioural strengths-based approach that focuses on changing the interactions taking place between a mother and baby. It involves videotaping mothers and infants at play, showing selected sections in order to highlight and review strengths, build competence and enhance motivation, and teach skills in detailed one-to-one coaching sessions. It is aimed at increasing maternal sensitivity and is a brief (6-7 week) intervention that can be used with families who have been hard to engage, or who have a limited capacity for introspection. There is a developing body of literature pointing to the effectiveness of interaction guidance with mother-infant dyads that are experiencing a

range of difficulties122 but we were keen to examine its effectiveness in helping parents with a baby that has faltering growth.

We identified only one study that had evaluated the effectiveness of interaction guidance with this group of parents. 69 This compared the effect of a play-focused intervention form of Interaction Guidance, combined with training on feeding, with a feeding training intervention alone. The study measured not only sensitivity, but also reduction in mothers‟ „atypical‟ (frightening and frightened) behaviours and in disrupted communications. Results showed that this modified version of Interaction Guidance was effective in decreasing atypical behaviours and disrupted communication. The authors conclude that their findings confirm those of other studies, which suggests that brief, focused interventions may be as effective as, or sometimes more effective than, longer- term programmes.

Home visiting by nurses or paraprofessional lay visitors

There is extensive evidence evaluating the effectiveness of different types of home visiting programmes. A recent review of reviews suggested that professionally delivered home visiting programmes can be effective in improving some outcomes in high risk parents and babies.123 Studies that have compared professionally-delivered programmes with lay-delivered programmes, have on the whole favoured the former124 particularly with high risk populations. We were once again keen to identify studies that had assessed their effectiveness with parents of infants with faltering growth but were only able to identify studies that had involved lay home visitors.54/55 70 One of these studies showed delayed developmental and emotional decline of children in the intervention group at the four-year follow-up54 and the second showed no evidence of effectiveness, particularly with mothers who have been defined at the outset as having severe negative affect (e.g. active hostility) in relation to their children.70

While the evidence on the effectiveness of home visiting programmes in reducing the incidence of abuse and neglect more generally is mixed,116 this is due in part to the diversity of home visiting programmes that have been evaluated. One better quality programme has in fact demonstrated a role for home visiting programmes in reducing the

incidence of abuse and neglect in vulnerable parents125, but did not include sufficient emotionally abusive parents to be included in the current review.

While the focus of this systematic review has been on secondary prevention and treatment, it should be noted that home visiting programmes have considerable potential in terms of the primary prevention of emotional abuse.

Parent-child psychotherapy

Fraiberg et al (1981) evaluated a child-parent psychotherapy (CPP) service provided in an outpatient psychiatric unit. The authors conclude that the intervention can bring about an improvement in a substantial proportion of extremely troubled parent-child relationships. The study, which provides information on each of the families treated and on the intervention, clearly involved families for whom this treatment was the last resort before children would be taken into care. However, this (rather early) trial did not include a control or comparison group, and did not include significance levels or the use of standardised instruments.

Fraiberg‟s pioneering study should, however, be set within the broader context of work on parent-infant/child psychotherapy, which suggests that it may be an effective means of improving parent-infant interaction.126 There is a range of different types of parent- infant/child psychotherapy available, some based on more standard representational models of psychotherapy (i.e. that focus on changing aspects of the mothers internal world) and some incorporating behavioural components (e.g. Watch, Wait and Wonder123). However, research suggests that parents with particular types of attachment disorder (e.g. such as avoidant) are better suited to more behavioural than representational models of psychotherapy as a result of their inability to introspect about the role of earlier experiences on current parenting.51 The attachment status of parents can be identified using the Adult Attachment Interview127 or Parenting Bonding Instrument128 and could be used to identify parents that would benefit from interventions, such as interaction guidance, that have a more behavioural orientation.

Behavioural casework

Iwaniec (1985a, 1985b),56/57 explored the potential of behavioural social work for infants with faltering growth. The intervention was tailored to the needs of individual families and was highly flexible as a result. These studies suggested potential improvements in terms of the child's feeding and overall development, although the long-term effects on mother- child interaction were less clear, and the author points to the possible need for booster sessions. However, neither of these studies used a rigorous methodology (i.e. one group design and one case study), and as such, the premise of this intervention (i.e. that the building of more adaptive interaction during feeding and improved infant intake will result in improved parent-child relationship) requires further research.

While case studies suggest that behavioural social work can help some troubled parents and families, further research is needed to establish evidence and to see which groups of parents respond best to this treatment.

Multi-component interventions

The Austrian intervention discussed by Dunitz et al. (1996)71differs from the others presented here in several significant ways. First, unlike most studies of faltering growth which tend to focus on maternal-infant relations, this treatment involved both fathers and mothers and, in some cases aimed to involve extended family members, based on the premise that the syndrome may be affected by the father's attachment status, and by the relationship between the couple. Others have also pointed to the beneficial effect of the extended family in cases of faltering growth, and that grandparents and other relatives should be included when necessary.129 Second, the psychological functioning of parents was evaluated by psychiatrists in the clinic where infants were being treated. This enabled clinicians to identify appropriate interventions and parents were also permitted to choose the treatment that they wanted. Different forms of psychotherapy, family therapy or counselling were available for the time they were needed and were paid for by the Austrian national health service. This study points to the value of diagnostic specificity - matching interventions to the needs of parents - and indeed, to the importance of taking the preferences of parents into account when planning treatment. No assessment of cost or cost-benefit was provided.