Routinely used interventions to improve attachment in infants and young children: a national survey and two systematic reviews.

BACKGROUND: Attachment refers to an infant's innate tendency to seek comfort from their caregiver. Research shows that attachment is important in promoting healthy social and emotional development. Many parenting interventions have been developed to improve attachment outcomes for children. However, numerous interventions used in routine practice have a limited evidence base, meaning that we cannot be sure if they are helpful or harmful. OBJECTIVES: This research aimed to conduct a large-scale survey to identify what interventions are being used in UK services to improve child attachment; conduct a systematic review to evaluate the evidence for parenting attachment interventions; and develop recommendations for future research and practice. DESIGN AND METHODS: We worked closely with our Expert Reference Group to plan a large-scale survey focused on relevant UK services. We then conducted two systematic reviews. One searched for all randomised controlled trial evidence for any attachment parenting intervention. The second searched for all research for the top 10 routinely used interventions identified from the survey. RESULTS: The survey collected 625 responses covering 734 UK services. The results identified the 10 most commonly used interventions. The responses showed a limited use of validated measures and a wide variety of definitions of attachment. For the first review, seven studies were included from 2516 identified records. These were combined with results from previous reviews conducted by the team. Meta-analyses showed that, overall, parenting interventions are effective in reducing disorganised attachment (pooled odds ratio 0.54, 95% confidence interval 0.39 to 0.77) and increasing secure attachment (pooled odds ratio 1.85, 95% confidence interval 1.36 to 2.52). The second review searched the literature for the top 10 routinely used interventions identified by the survey; 61 studies were included from 1198 identified records. The results showed that many of the most commonly used interventions in UK services have a weak evidence base and those with the strongest evidence base are not as widely used. CONCLUSIONS: There is a need for better links between research and practice to ensure that interventions offered to families are safe and effective. Possible reasons for the disparity include the cost and accessibility of training. There is also a need for improved understanding by professionals regarding the meaning of attachment. LIMITATIONS: Although the survey had good geographical spread, most respondents were based in England. For review 2 we were unable to access a large number of papers; however, we conducted extensive reference checking to account for this. FUTURE WORK: There is a need for robust research to test the efficacy of routinely used attachment interventions. Research could also explore why routinely used interventions are not consistently subject to thorough evaluation; how to embed dissemination, cost-effectiveness, fidelity and sustainability into research; and how to keep clinical practice up to date with research developments. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019137362. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 2. See the NIHR Journals Library website for further project information.

Attachment refers to an infant's natural instinct to seek comfort from their main carers. There are four ways in which infants show attachment ('attachment patterns'). These are known as secure, insecure-avoidant, insecure-resistant and disorganised. Secure attachment usually occurs with consistent and responsive parenting/caregiving and is linked with positive social and emotional child development. Inconsistent, neglectful or abusive parenting/caregiving can lead to problems with attachment, including disorganised attachment, and is linked to poorer outcomes. Parenting support, education and therapies help parents improve infant attachment and their child's outcomes. We surveyed UK services to see what they offered families with attachment problems. A total of 734 UK services responded. This identified 10 therapies or support packages most commonly offered to parents. We checked what research had been done on these. We found very little. We found 61 studies of support packages with quite good evidence, but these were generally not ones offered by UK services. We also looked in detail at research for all types of support/therapies to improve attachment. We looked for the best research (called 'randomised controlled trials'); 26 studies had tested therapies to see if they improved secure attachment and 20 had tested whether or not they improved (i.e. reduced) disorganised attachment. We found that these therapies or support packages are good at increasing secure attachment and improving disorganised attachment. Mostly they did this by helping parents/caregivers improve caregiving and particularly how sensitive and responsive they are to their child and their needs. Currently, practice is not following research, and research is not being done to properly evaluate current practice. We need to improve the evidence and the way it links to practice, including how those organising and paying for services are made aware of up-to-date research to make sure that the best treatments are available. High-quality training for staff is also important.

Co-production of a nature-based intervention for children with ADHD study (CONIFAS): Protocol for co-production phases.

Children with Attention Deficit Hyperactivity Disorder can face difficulties with inattention, hyperactivity, and impulsivity, which can impact many areas of their lives, including their educational attainment and social and emotional wellbeing. Involvement in nature-based activities can reduce these difficulties and improve wellbeing, but there are limited resources for supporting children with this diagnosis to access these approaches and no nature-based interventions designed with and for this group. This protocol describes a co-production study in which children diagnosed with Attention Deficit Hyperactivity Disorder aged 5-11 years old, their parents/guardians, and professionals will attend a series of workshops to share their knowledge to co-produce a new nature-based intervention for this population of children. We aim to understand how the children's' experiences of Attention Deficit Hyperactivity Disorder may affect their interactions with nature, identify how activity in and with nature may help with symptom reduction and general wellbeing, and co-produce an intervention for families which applies our learning. The result of this study will be the designed intervention and insights into how children and young people with Attention Deficit Hyperactivity Disorder interact with nature. The prototype intervention will then undergo feasibility testing in a future study. Trail registration: NIHR203043; ISRCTN11763460.

Mental Health Provision in UK Secondary Schools.

Research reports high levels of mental health problems faced by young people in the UK. Schools provide a range of mental health support services, although these are often not robustly evaluated. This paper aims to explore the mental health provision of secondary schools across two large regions in the North of England and provide comparisons to the mental health questionnaire scores of their pupils. Results are part of a wider study providing an overview of the mental health of secondary school pupils. Measures include the Strengths and Difficulties Questionnaire, distributed to year 8, 9, and 11 pupils attending secondary schools and a bespoke mental health service provision questionnaire for school staff at the same schools. A total of 6328 pupil questionnaires and 36 staff questionnaires were returned from 21 schools. Results showed a non-significant correlation between provision and young people's mental health scores and highlight a range of factors to take into consideration. There is a need to improve the evaluation and recording of school-based mental health provision. Mental health difficulties in young people are prevalent in schools. Future research is needed to elucidate which types of services are most helpful in preventing, supporting, and signposting those with mental health problems.

A large population-based study of the mental health and wellbeing of children and young people in the North of England.

BACKGROUND: There has been a recent reported rise in prevalence of mental health problems among children in the United Kingdom, alongside increased referrals into specialist services. There is a need for up-to-date information regarding changing trends of young people's mental health to allow for improved understanding and service planning. OBJECTIVES: This article aims to provide an overview of the current mental health and well-being of years 8, 9 and 11 secondary school-aged pupils from two large regions in the North of England. METHOD: This was a cohort cross-sectional study. Measures including the Strengths and Difficulties questionnaire, the EQ-5D-Y, social media use questions, and a mental health service use questionnaire were completed by participants. RESULTS: In total, 6328 questionnaires were returned from 21 secondary schools. One in 10 participating pupils scored 'very high' for total mental health difficulties. Significant differences on well-being scores were found between both gender and year groups. CONCLUSION: In recent years, the proportion of children facing mental health problems has increased. In particular, high levels of female pupils and year 11 pupils report facing difficulties. It is important to develop targeted, accessible interventions, and to continue to collect up-to-date measures for this population.

Decreasing rates of disorganised attachment in infants and young children, who are at risk of developing, or who already have disorganised attachment. A systematic review and meta-analysis of early parenting interventions.

BACKGROUND: Disorganised attachment patterns in infants have been linked to later psychopathology. Services have variable practices for identifying and providing interventions for families of children with disorganised attachment patterns, which is the attachment pattern leading to most future psychopathology. Several recent government reports have highlighted the need for better parenting interventions in at risk groups. OBJECTIVES: The objective of this review and meta-analysis was to evaluate the clinical effectiveness of available parenting interventions for families of children at high risk of developing, or already showing, a disorganised pattern of attachment. METHODS: Population: Studies were included if they involved parents or caregivers of young children with a mean age under 13 years who had a disorganised classification of attachment or were identified as at high risk of developing such problems. Included interventions were aimed at parents or caregivers (e.g. foster carers) seeking to improve attachment. Comparators included an alternative intervention, an attention control, treatment as usual or no intervention. The primary outcome was a disorganised pattern in childhood measured using a validated attachment instrument. Studies that did not use a true Randomised Controlled Trial (RCT) design were excluded from the review. Both published and unpublished papers were included, there were no restrictions on years since publication and foreign language papers were included where translation services could be accessed within necessary timescales. RESULTS: A comprehensive search of relevant databases yielded 15,298 papers. This paper reports a systematic review as part of an NIHR HTA study identifying studies pre-2012, updated to include all papers to October 2016. Two independent reviewers undertook two stage screening and data extraction of the included studies at all stages. A Cochrane quality assessment was carried out to assess the risk of bias. In total, fourteen studies were included in the review. In a meta-analysis of these fourteen studies the interventions saw less disorganised attachment at outcome compared to the control (OR = 0.50, (0.32, 0.77), p = 0.008). The majority of the interventions targeted maternal sensitivity. We carried out exploratory analyses to examine factors that may influence treatment outcome but these should be treated with caution given that we were limited by small numbers of studies. CONCLUSIONS: Parenting interventions that target parental sensitivity show promise in reducing disorganised attachment. This is limited by few high quality studies and the fact that most studies are with mothers. More high quality randomised controlled trials are required to elucidate this further.