Attachment security in children with disability or developmental delay: Systematic review of quality and interventions

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Evidence table – selected articles.

Author/Year	Level of evidence/Study design/Participants/Inclusion Criteria	Intervention and Control	Outcome Measures	Results
RQ1 – Part A – Systematic Review
Capps, Sigman, and Mundy (1994)	Level 3 19 dyads, ASD, chronological age three to five, mean developmental age 23 months, mean language age 18.5 months	No comparison group	A, B, C, D and unclassified	4 unclassified Of those classified: 6 (40%) B, 9 (60%) D
Clements and Barnett (2002)	Level 3 72 dyads of which 33 children had non-neurological defects, whereas 39 had a neurological defect, chronological age 12 to 36 months, developmental age 12 months	Children with neurological defects (n = 39 were compared to children with non-neurological defects (n = 33)	A, B, C, D Parent quality coded with rating scales by Ainsworth, Bell, and Stayton (1974) and Farran, Kasari, Comfort, and Jay (1986)	Participants with neurological defects: 8 (20.5%) A, 17 (43.6%) B, 8 (20.5%) C, 6 (15.4%) D Control group: 4 (12.1%) A, 22 (66.7%) B, 2 (6.1%) C, 5 (15.2%) D Parenting quality and functional severity of disability were associated with security.
Feniger-Schaal and Joels (2018)	Level 3 40 dyads, children with nonspecific intellectual disability, aged 26 to 75 months with developmental average of 25.9 months	No comparison group	A, B, C, D Emotional Availability Scales	5 (12.5%) A, 16 (40%) B, 6 (15%) C, 13 (32.5%) D Maternal sensitivity and structuring were associated with security but cognitive functioning was not.
Ganiban, Barnett, and Cicchetti (2000)	Level 3 30 dyads, children with Down syndrome, aged 19 to 27 months with average Bayley’s score of 62	No comparison group	A, B, C, D	3 (10%) A, 16 (53%) B, 4 (13%) C, 7 (23%) D
Koren-Karie, Oppenheim, Dolev, and Yirmiya (2009)	Level 3 45 dyads, ASD, 2.5 to 5.6 years old, mental age above 13 months	No comparison group	A, B, C, D Emotional Availability Scales	9 (20%) A, 19 (42.2%) B, 7 (15.6%) C, 10 (22.2%) D Maternal sensitivity was positively associated with security but no association found between severity of ASD and security
Naber, et al., 2007	Level 3 80 dyads, toddlers with Autism Spectrum Disorder (ASD)(n = 20), Pervasive Developmental Disorder (PDD)(n = 14), Mental Retardation (MR)(n = 12). Average age of 27 months	Language Development Disorder (LD)(n = 16) Non-clinical group (NC)(n = 18)	A, B, C, D Heart rate	ASD group: 3 (15%) A, 7 (35%) B, 0 (0%) C, 10 (50%) D PDD group 3 (21.4%) A, 6 (42%) B, 2 (14.4%) C, 3 (21.4%) D MR group: 2 (16.7%), 4 (33.3%), 2 (16.7%), 4 (33.3%) D LD group: 1 (6.25%) A, 11 (68.8%) B, 1 (6.25%) C, 3 (18.8%) D NC group: 0 (0%) A, 15 (83%) B, 3 (16.7%) C, 0 (0%) D Greater severity of ASD and severity of intellectual disability were negatively associated with security. D classification was associated with increased heartrate in SSP.
RQI – Part B – Narrative synthesis – Attachment quality
Lederberg and Mobley (1990)	Level 3 41 hearing impaired toddlers and their hearing mothers. Toddlers aged from 18 to 25 months (average 22 months)	Comparison group included 41 hearing toddlers and their mothers	Forced A, B, C D	Hearing impaired: D = 10 (24%) Hearing D = 4 (10%) Mothers of hearing impaired toddlers initiated more, however overall there was less interaction and toddlers with hearing impairment were more likely to end an interaction.
Rozga et al. (2017)	Level 3 30 pre-school-aged children with autism. Average chronological age was 47 months, non-verbal mental age 31 months, and overall language age of 21 months.	No comparison group	A, B, C, D – attachment D – autism	B − 45% D – attachment − 17% D – autism − 38% Language skills of the secure children were greater than for the insecure children. Security correlated with caregiver sensitivity. Secure children were more empathic
Willemsen-Swinkels, Bakermans-Kranenburg, Buitelaar, van Ijzendoorn, and van Engeland (2000)	Level 3 32 children with Pervasive Developmental Disorder (PDD)	22 children with Developmental Language Disorder (LD) and 28 typically developing (TD)children	Forced A, B, and C and Unclassifiable D and non-D Heart rate	Rates of D were 10.5% in the TD group, 15.8% in the LD group, 16.7% in the PDD group and 53.8% in the PD with intellectual disability group. The TD children were also compared on D with the clinical children − 14% to 35.5% D. The PDD children were found to initiate less, be less responsive, and face the parent less often than the children without PDD. Intellectual disability was associated with D, whereas severity of PDD was not. There was an association between heart rate and D classification.
RQ2 – Narrative Synthesis – Attachment interventions
Acquarone (1995)	Level 4 Single case study of a nine month old infant with cerebral palsy and her mother	Parent-infant psychotherapy 33 sessions over twelve months	Aim is to improve child security. Study is qualitative with no formal measures used.	Mother-child relationship improves. Mother becomes much more positive about child, appears resolved regarding the disability. Mother and child appear happier. Child is healthier. Relationship appears secure.
Brisch, Bechinger, Betzler, and Heinemann (2003)	Level 1 RCT involving 87 very low birthweight infants weighing less than 1500 g. They were randomly assigned to intervention and control groups after birth.	43 participants in treatment group and 44 in control. Intervention involved supportive group psychotherapy, attachment-oriented focal individual psychotherapy, a home visit, and video-based sensitivity training	Strange Situation Procedure (ABC), neurological examination (Hagberg classification system)	In the intervention group 71.4% of the infants turned out to have a neurological impairment compared to 51.1% in the control group. In the control group 64.3% of the secure infants were neurologically healthy, whereas 75% of those with insecure attachment were neurologically impaired. In the intervention group there was no correlation between neurological impairment and security.
Charpak et al. (2017)	Level 1 RCT involving 264 premature, low birth weight infants weighing less than 1800 g at birth. Follow-up at age 20 years.	Infants were randomly assigned to Kangaroo Mother Care or control group. There were children with disabilities in both groups.	Survival, neurodevelopment, and mother-infant bonding (assessed through index of parent and peer attachment).	More control infants died during first year of follow-up. At 20 years mortality rate was 3.5% in the intervention group and 7.7% in the control group. Aggressiveness and hyperactivity were lower in the KMC group. KMC families were found to be more dedicated than control group families.
Chiarello and Palisano (1998)	Level 1 RCT involving 38 infants with motor delay aged from six to 34 months	Physical therapy aiming to improve mother-child interactions were provided weekly for five weeks to 19 infants along with care as usual – center-based ECI. The control group received center-based ECI only.	Maternal positive interactions with child and a range of physical measures.	Mothers in the experimental group became more directive, showed an increase in therapeutic holding, whereas the mothers in the control group showed a decrease. No differences were noted in positivity of parent-child interactions.
Cullen-Powell, Barlow, and Cushway (2005)	Level 3 Qualitative study involving 15 children aged two to 13 years with ASD. Interpretative phenomenological analysis of data from interviews with parents.	Massage intervention comparing pre-intervention (baseline), immediately post-intervention and 16 weeks from baseline.	Parent-reported outcomes on parent-child relationship	There was a high drop-out rate in this study with only eight parents available for the final interview. Parents overall reported that they felt physically and emotionally closer to their child.
Fardylous, C. & Coyne, J. (2016)	Level 4 Case study of two children under the age of five years with ASD and their mothers	Circle of Security intensive intervention – ten weekly sessions of 90 min	Pre-intervention the Circle of Security Interview (COSI) was administered and following intervention the McArthur Strange Situation Procedure was administered.	One dyad was reported to shift from avoidant to secure, whereas the other dyad maintained security. One of the parents displayed more controlling behaviors post-intervention. Both parents reported an increase in parenting competence.
Hansen and Ulrey (1988)	Level 1 RCT involving 19 infants aged three to 19 months with motor impairments and their mothers	Participants were randomly assigned to a control group receiving center-based ECI or an intervention group receiving center-based ECI and the parent being taught infant massage techniques	Adapted ASI observation protocol – Parent responses to infant’s cues, infant response to contact with people and parent reciprocity, child behavior regarding eating, sleeping, exploration and separation from parent.	Caregiver-infant discrepancy score improved in intervention group – increased reciprocity in attachment-separation behaviors observed.
Kim, J. & Mahoney, G. (2004)	Level 3 Comparative group study involving 18 mothers of children aged three to eight years old with disability or developmental delay	Ten mothers were assigned to Relationship-Focussed Intervention involving1.5–2 hr of instruction weekly for three months. The instruction included classroom and home-based instruction and feedback and evaluation. The intervention and control group attended center-based ECI.	Measures included Maternal Behaviour Rating Scale, Child Behavior Rating Scale, Parenting Stress Inventory.	Mothers in the treatment group improved in Responsiveness, Affect and Achievement Orientation and had a small but significant reduction in parent stress.
Platje, Sterkenburg, Overbeek, Kef, and Schuengel (2018)	Level 1 RCT involving 77 children aged one to five years with visual or visual and intellectual disabilities and their parent (85% mothers).	40 parents were randomly assigned to Video-feedback Intervention to Promote Positive Parenting – Visual (VIPP-V) involving seven 1.5-hr sessions at home and also received care-as-usual (CAU), whereas 37 parents were randomly assigned to CAU.	Parent sensitivity, parent-child interaction, parenting stress, parenting self-efficacy assessed at pretest, posttest and follow-up. Parental sensitivity and quality of parent-child interactions was assessed using the Three Boxes-procedure (Applebaum et al, 1999;Vandell 1979). National Institute of Child Health and Human Development Scales. Nurturing Role questionnaire in Dutch translation	While parenting self-efficacy improved in the VIPP-V group, parental sensitivity and parent-child interaction did not. There was trend toward decreased parental stress.
Poslawsky et al. (2015)	Level 1 RCT involving 78 children aged 16 to 61 months with ASD and their primary caregiver	40 parents were randomly assigned to the treatment group and received VIPP-AUTI – five home visits of 60 to 90 min at two week frequency over three months.	Primary focus of the study was parent-child interactions. Measures included ADOS-G; Mullen Scales of early learning (MSEL); Reynell test for Dutch language; Symptom checklist (SCL-90); Emotional Availability Scales (EAS); Parental Efficacy Questionnaire (PEQ); PDH; Client satisfaction questionnaire (CSQ-8); Early Social and Communication Scales (ESCS)	Parents in the VIPP-AUTI group showed decreased parental intrusiveness; increased parental efficacy; and children’s joint attention also improved.
Sealy and Glovinsky (2016)	Level 1 RCT involving 40 parent-child dyads. Children were aged two years to six years, 11 months and had a neurodevelopmental disorder.	Half of the dyads were randomly assigned to the intervention group receiving DIR-Floortime (DIR/FT) weekly for 12 weeks in a clinic, whereas the other 20 were allocated to a wait-list group.	Parental Reflective Functioning was measured using the PDI.	DIR/FT was found to have a large and significant effect on parental reflective functioning.
Seifer, R., Clark, G., & Sameroff, A. (1991)	Level 2 Quasi RCT involving 40 infants with an average age of 8.5 months and a moderate to severe developmental disability.	There were 23 families in the treatment group and 17 in the control group. The allocation was determined by whether the families attended on the same days that the part-time interaction coach attended the center. Both groups received centered-based ECI weekly for ten months. The treatment group also received six sessions of interaction coaching toward the end of the ten months.	Focus was on maternal responsivity and reducing over stimulation. Measures included. Mental Development scale and Psychomotor Development scale from the Bayley (1969) and the Uzgiris and Hunt (1975) Ordinal Scales of Development	Maternal responsivity increased, incidents of overstimulation decreased, and child “fussiness” decreased.
Siller, Swanson, Gerber, Hutman, and Sigman (2014)	Level 1 RCT involving 70 children with aged two to six years with ASD and their mother.	36 dyads were randomly allocated to Focussed Playtime Intervention (FPI) and 34 allocated to a control group. FPI involved weekly 90-min sessions at home for 12 weeks.	Parental reflective functioning and child attachment behaviors. Measures included Autism Diagnostic Observation Schedule (ADOS); Autism Diagnostic Interview-Revised (ADI-R); Mullens Scales of Early Learning; Early Social Communication Scale; Maternal Perception of Child Attachment (MPCA)	The children allocated to the FPI group showed greater increases in attachment-related behaviors. Attachment behaviors worsened in the control group over time indicating that parents may get increasingly strained as children get older without intervention.
Solomon, Van Egeren, Mahoney, Quon Huber, and Zimmerman (2014)	Level 1 RCT involving 125 children aged two years eight months to five years 11 months with autism and their caregiver	61 dyads were randomly allocated to the treatment group and 64 to the control group.	Parent-child interaction. Measures included ADOS, Mullen Scales of Early Learning, Maternal Behaviour Rating Scale (MBRS) and Child Behavior Rating Scale (CBRS), Parenting Stress Index (PSI), Functional Emotional Assessment Scale (FEAS)	Improved maternal responsiveness, child orientation and affect/animation, improved child attention and initiation.

Table 2. Attachment-type proportion estimates from Table 1 data using a random effect meta-analysis.

Attachment type	Proportion	SE	95% CI	I^2 (%)	τ^2
A	0.1413	0.0721	(0.0916, 0.1983)	10.22, p = 0.35	0.004
B	0.4223	0.0676	(0.3547, 0.4913)	0.00, p = 0.94	0.000
C	0.1099	0.0923	0.0544, 0.1785)	42.73, p = 0.09	0.028
D	0.2983	0.1045	(0.2044, 0.4006)	55.12, p = 0.03	0.046

SE – Standard Error.

I2 - Estimated variation in estimates attributable to heterogeneity between studies.

τ2 - Between study variance.

Figure 2. Forest plot for meta-analysis of attachment type A.

Figure 3. Forest plot for meta-analysis of attachment type B.

Figure 4. Forest plot for meta-analysis of attachment type C.

Figure 5. Forest plot for meta-analysis of attachment type D.

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