A randomized controlled trial comparing Circle of Security Intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill mothers: Study Protocol.

BACKGROUND: Psychopathology in women after childbirth represents a significant risk factor for parenting and infant mental health. Regarding child development, these infants are at increased risk for developing unfavorable attachment strategies to their mothers and for subsequent behavioral, emotional and cognitive impairments throughout childhood. To date, the specific efficacy of an early attachment-based parenting group intervention under standard clinical outpatient conditions, and the moderators and mediators that promote attachment security in infants of mentally ill mothers, have been poorly evaluated. METHODS/DESIGN: This randomized controlled clinical trial tests whether promoting attachment security in infancy with the Circle of Security (COS) Intervention will result in a higher rate of securely attached children compared to treatment as usual (TAU). Furthermore, we will determine whether the distributions of securely attached children are moderated or mediated by variations in maternal sensitivity, mentalizing, attachment representations, and psychopathology obtained at baseline and at follow-up. We plan to recruit 80 mother-infant dyads when infants are aged 4-9 months with 40 dyads being randomized to each treatment arm. Infants and mothers will be reassessed when the children are 16-18 months of age. Methodological aspects of the study are systematic recruitment and randomization, explicit inclusion and exclusion criteria, research assessors and coders blinded to treatment allocation, advanced statistical analysis, manualized treatment protocols and assessments of treatment adherence and integrity. DISCUSSION: The aim of this clinical trial is to determine whether there are specific effects of an attachment-based intervention that promotes attachment security in infants. Additionally, we anticipate being able to utilize data on maternal and child outcome measures to obtain preliminary indications about potential moderators of the intervention and inform hypotheses about which intervention may be most suitable when offered in a clinical psychiatric outpatient context. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88988596.

[Attachment and attachment-based intervention: the Circle of Security intervention project in Hamburg]. / Bindung und Bindungstherapie Die Hamburger Interventionsstudie "Kreis der Sicherheit".

Since the early sixties empirical research into early childhood and the parent-infant relationship has increased, commonly informed by attachment theory. The mutually regulated interaction within the attachment and care giving relationship of mother and infant gives this relationship its exceptional emotional quality. Early attachment experiences organize socio-emotional and cognitive development beyond childhood. Attachment theory and research define observable behaviors and the level of internal representations as an intervening variable of the transmission of attachment patterns between mother and child. Basic attachment derived concepts are the starting points of the Circle of Security approach. The Circle of Security Intervention Project in Hamburg for mothers with postpartum mental illness and their infants is described in more detail. Specific aspects are discussed with reference to a diagnostic case study.

Enhancing attachment security in the infants of women in a jail-diversion program.

Pregnant female offenders face multiple adversities that make successful parenting difficult. As a result, their children are at risk of developing insecure attachment and attachment disorganization, both of which are associated with an increased likelihood of poor developmental outcomes. We evaluated the outcomes of participants in Tamar's Children, a 15-month jail-diversion intervention for pregnant, nonviolent offenders with a history of substance abuse. All women received extensive wrap-around social services as well as the Circle of Security Perinatal Protocol (Cooper, Hoffman, & Powell, 2003). We present data on 20 women and their infants who completed the full dosage of treatment (a residential-living phase from pregnancy until infant age six months and community-living phase until 12 months). Results indicated that (1) program infants had rates of attachment security and attachment disorganization comparable to rates typically found in low-risk samples (and more favorable than those typically found in high-risk samples); (2) program mothers had levels of maternal sensitivity comparable to mothers in an existing community comparison group; and (3) improvement over time emerged for maternal depressive symptomatology, but not other aspects of maternal functioning. Given the lack of a randomized control group, results are discussed in terms of the exploratory, program-development nature of the study.

Changing toddlers' and preschoolers' attachment classifications: the Circle of Security intervention.

The Circle of Security intervention uses a group treatment modality to provide parent education and psychotherapy that is based on attachment theory. The purpose of this study was to track changes in children's attachment classifications pre- and immediately postintervention. Participants were 65 toddler- or preschooler- caregiver dyads recruited from Head Start and Early Head Start programs. As predicted, there were significant within-subject changes from disorganized to organized attachment classifications, with a majority changing to the secure classification. In addition, only 1 of the 13 preintervention securely attached children shifted to an insecure classification. Results suggest that the Circle of Security protocol is a promising intervention for the reduction of disorganized and insecure attachment in high-risk toddlers and preschoolers.

The circle of security parenting and parental conflict: a single case study.

The Circle of Security Parenting (COS-P) is an early attachment based intervention that can be used with groups, dyads, and individuals. Created in the USA and now used in many countries, COS-P is a visually based approach that demonstrates its central principles through videos of parent/child interactions. The core purpose of the COS-P is to provide an opportunity for caregivers to reflect on their child's needs and on the challenges each parent faces in meeting those needs. Even though there is a wide range of clinical settings in which child/parent attachment is an important component of assessment there is limited empirical data on when and how attachment based interventions are appropriate for specific clinical profiles and contexts. The aim of this paper is to present a clinical application of COS-P in order to explore and reflect on some specific therapeutic tasks where it works and on some clinical indicators and contexts appropriate for its application. A single case study of a father, "M." (43 years old) in conflict for the custody of his 5 years old daughter is reported. The Adult Attachment Projective Picture System (AAP), the Parenting Stress Index, the Strengths and Difficulties Questionnaire, and the Parental Alliance Measure, were administered pre- and post-intervention. The clinical significance analysis method revealed that numerous changes occurred in the father. The AAP showed improvements in the level of agency of self. M. made gains in his capacity to use internal resources and to increase his agency of self. M. was classified as recovered in his perception of the child's functioning and as improved in his parenting stress and parenting alliance with the mother. Considerations on specific contexts and clinical indicators for the application of COS-P are proposed.

The Circle of Security project: attachment-based intervention with caregiver-pre-school child dyads.

The Circle of Security intervention protocol is a 20-week, group-based, parent education and psychotherapy intervention designed to shift patterns of attachment-caregiving interactions in high-risk caregiver-child dyads to a more appropriate developmental pathway. All phases of the protocol, including the pre- and post-intervention assessments, and the intervention itself, are based on attachment theory and procedures, current research on early relationships, and object relations theory. Using edited videotapes of their interactions with their children, caregivers are encouraged: 1. to increase their sensitivity and appropriate responsiveness to the child's signals relevant to its moving away from to explore, and its moving back for comfort and soothing; 2. to increase their ability to reflect on their own and the child's behavior, thoughts and feelings regarding their attachment-caregiving interactions; and 3. to reflect on experiences in their own histories that affect their current caregiving patterns. In this paper we describe the conceptual background of the protocol, and the protocol itself. We then present a case study from our current data set of 75 dyads who have completed the protocol.