Parenting interventions to support parent/child attachment and psychosocial adjustment in foster and adoptive parents and children: A systematic review

Background Adopted children and children placed in foster care are at increased risk of developing a range of mental health, behavioural, and psychosocial adjustment problems. Previous studies suggest that due to early experiences of separation and loss some children may have difficulties forming a secure attachment relationship with the adoptive/foster parents. Objectives The objectives of the present review were: (1) to assess the efficacy of attachment‐based interventions on measures of favourable parent/child outcomes (attachment security, dyadic interaction, parent/child psychosocial adjustment, behavioural and mental health problems, and placement breakdown) within foster and adoptive families with children aged between 0 and 17 years. (2) to identify factors that appear to be associated with more effective outcomes and factors that modify intervention effectiveness (e.g., age of the child at placement and at intervention start, programme duration, programme focus). Search Methods Relevant studies were identified through electronic searches of bibliographic databases, governmental and grey literature repositories, hand search in specific targeted journals, citation tracking, contact to international experts and Internet search engines. The database searches were carried out to October 2020. Selection Criteria The interventions of interest were parenting interventions aimed at helping the foster/adopted children and their parents to form or sustain a secure attachment relationship. The interventions had to be at least partly informed by attachment theory. Data Collection and Analysis The total number of potentially relevant studies constituted 17.822 hits after duplicates were removed. A total of 44 studies (27 different populations) met the inclusion criteria and were critically appraised by the review authors. Due to critical study quality, missing numeric data and re‐use of the same data, only 24 studies analysing 16 different populations could be used in the data synthesis (children, N = 1302; parents, N = 1344). Meta‐analysis using both child and parent outcomes were conducted on each metric separately. All analyses were inverse variance weighted using random effects statistical models. Random effects weighted mean effect sizes were calculated using 95% confidence intervals (CIs). When possible, we conducted moderator analysis using meta‐regression and single factor sub group moderator analysis. Sensitivity analysis were conducted across study design and domains of the risk of bias assessment. Main Results Ten studies analysed the effect of attachment‐based interventions on the overall psychosocial adjustment of foster or adopted children as reported by their caregivers post intervention. Measures used include the Child Behaviour Checklist, The Strengths and Difficulties Questionnaire, Brief Infant–Toddler Social and Emotional Assessment (BITSEA) and Eyberg Child Behaviour Inventory. The random effects weighted standardised mean difference (SMD) favouring the intervention group was 0.37 (95% CI, 0.10–0.65) and statistically significant. Three studies analysed the effects of attachment‐based interventions on the observed attachment security of foster and adopted children as measured by independent observation. Measures include the Strange Situation Procedure, Attachment Q‐Set, and The Emotional Availability Clinical Screener. The random effects weighted SMD was 0.59 (95% CI, −0.40–1.57) and not statistically significant. Four studies analysed the effect of attachment‐based interventions on positive child behaviour post intervention as measured by independent observation of video‐taped interaction between the child and caregivers. Measures include Disruptive Behaviour Diagnostic Observation Schedule (DB‐DOS) and Emotional Availability Scales). The random effects weighted SMD was 0.39 (95% CI, 0.14–0.64) and statistically significant. Ten studies analysed the effect of attachment‐based interventions on positive parenting behaviour post intervention as measured by independent observation of video‐taped interaction between the child and caregivers or coding of audio‐taped recordings of parental speech. Measures include Adapted Ainsworth Scales for sensitivity and noninterference, Measurement of Empathy in Adult–Child Interaction, The Dyadic Parent–Child Interaction Coding System, Reflective functioning scale, and Emotional Availability Scales. The random effects weighted SMD was 1.56 (95% CI, 0.81–2.31) and statistically significant. Nine studies analysed the effect of attachment‐based interventions on self‐reported post intervention parenting stress (Parenting Stress Index). The random effects weighted SMD was 0.24 (95% CI, 0.03–0.46.) and statistically significant. Three studies analysed the effect of attachment‐based interventions on parental post intervention self‐reported depressive symptoms (Beck Depression Inventory). The random effects weighted SMD was 0.59 (95% CI, −0.08–1.25.) and not statistically significant. Follow‐up analyses were carried out for the outcomes externalising behaviour, positive parenting, and parenting stress, but due to the low number of studies, results should be viewed with caution. Results of the single factor sub group moderator analysis suggest that it cannot be ruled out the effects differ depending on whether the interventions take place in the family home or in a clinical setting. However, it is unclear which location is associated with more positive effects as our findings differ between child and parent outcomes. Results of the sensitivity analysis showed no appreciable changes in the results following the removal of any of the studies in any of the analyses. Authors' Conclusions Parenting interventions based on attachment theory increase positive parent/child interactional behaviours, decrease parenting stress, and increase the overall psychosocial adjustment of children in foster and adoptive families postintervention. Due to the low number of studies evidence regarding the effects of attachment‐based parenting interventions on attachment security and disorganised attachment in foster and adopted children was inconclusive. Theoretically, it is possible that child attachment security and/or attachment disorganisation cannot change within the relatively short period of time that parenting interventions typically last. It is possible that if postintervention improvements in parenting behaviours are sustained over time, it may lead to possible improvement in child attachment security and a decrease in child disorganised attachment. Thus, more longitudinal research is needed. Furthermore, evidence regarding the long‐term effects of attachment‐based parenting interventions on any outcomes was inconclusive due to too few studies, but findings suggest that attachment‐based interventions increase positive parenting behaviour at follow‐up points 3–6 months after the intervention. No study included in the present review provided a measure of placement stability or breakdown as an outcome, which could be used in the meta‐analysis. This further emphasises the need for future longitudinal research in prevention of placement breakdown.