Video feedback for parental sensitivity and attachment security in children under five years

Leeanne O'Hara, Emily R Smith, Jane Barlow, Nuala Livingstone, Nadeeja Ins Herath, Yinghui Wei, Thees Frerich Spreckelsen, Geraldine Macdonald, Leeanne O'Hara, Emily R Smith, Jane Barlow, Nuala Livingstone, Nadeeja Ins Herath, Yinghui Wei, Thees Frerich Spreckelsen, Geraldine Macdonald

Abstract

Background: Children who are securely attached to at least one parent are able to be comforted by that parent when they are distressed and explore the world confidently by using that parent as a 'secure base'. Research suggests that a secure attachment enables children to function better across all aspects of their development. Promoting secure attachment, therefore, is a goal of many early interventions. Attachment is mediated through parental sensitivity to signals of distress from the child. One means of improving parental sensitivity is through video feedback, which involves showing a parent brief moments of their interaction with their child, to strengthen their sensitivity and responsiveness to their child's signals.

Objectives: To assess the effects of video feedback on parental sensitivity and attachment security in children aged under five years who are at risk for poor attachment outcomes.

Search methods: In November 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, nine other databases and two trials registers. We also handsearched the reference lists of included studies, relevant systematic reviews, and several relevant websites SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs that assessed the effects of video feedback versus no treatment, inactive alternative intervention, or treatment as usual for parental sensitivity, parental reflective functioning, attachment security and adverse effects in children aged from birth to four years 11 months.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: This review includes 22 studies from seven countries in Europe and two countries in North America, with a total of 1889 randomised parent-child dyads or family units. Interventions targeted parents of children aged under five years, experiencing a wide range of difficulties (such as deafness or prematurity), or facing challenges that put them at risk of attachment issues (for example, parental depression). Nearly all studies reported some form of external funding, from a charitable organisation (n = 7) or public body, or both (n = 18). We considered most studies as being at low or unclear risk of bias across the majority of domains, with the exception of blinding of participants and personnel, where we assessed all studies as being at high risk of performance bias. For outcomes where self-report measures were used, such as parental stress and anxiety, we rated all studies at high risk of bias for blinding of outcome assessors. Parental sensitivity. A meta-analysis of 20 studies (1757 parent-child dyads) reported evidence of that video feedback improved parental sensitivity compared with a control or no intervention from postintervention to six months' follow-up (standardised mean difference (SMD) 0.34, 95% confidence interval (CI) 0.20 to 0.49, moderate-certainty evidence). The size of the observed impact compares favourably to other, similar interventions. Parental reflective functioning. No studies reported this outcome. Attachment security. A meta-analysis of two studies (166 parent-child dyads) indicated that video feedback increased the odds of being securely attached, measured using the Strange Situation Procedure, at postintervention (odds ratio 3.04, 95% CI 1.39 to 6.67, very low-certainty evidence). A second meta-analysis of two studies (131 parent-child dyads) that assessed attachment security using a different measure (Attachment Q-sort) found no effect of video feedback compared with the comparator groups (SMD 0.02, 95% CI -0.33 to 0.38, very low-certainty evidence). Adverse events. Eight studies (537 parent-child dyads) contributed data at postintervention or short-term follow-up to a meta-analysis of parental stress, and two studies (311 parent-child dyads) contributed short-term follow-up data to a meta-analysis of parental anxiety. There was no difference between intervention and comparator groups for either outcome. For parental stress the SMD between video feedback and control was -0.09 (95% CI -0.26 to 0.09, low-certainty evidence), while for parental anxiety the SMD was -0.28 (95% CI -0.87 to 0.31, very low-certainty evidence). Child behaviour. A meta-analysis of two studies (119 parent-child dyads) at long-term follow-up found no evidence of the effectiveness of video feedback on child behaviour (SMD 0.04, 95% CI -0.33 to 0.42, very low-certainty evidence). A moderator analysis found no evidence of an effect for the three prespecified variables (intervention type, number of feedback sessions and participating carer) when jointly tested. However, parent gender (both parents versus only mothers or only fathers) potentially has a statistically significant negative moderation effect, though only at α (alpha) = 0.1 AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that video feedback may improve sensitivity in parents of children who are at risk for poor attachment outcomes due to a range of difficulties. There is currently only little, very low-certainty evidence regarding the impact of video feedback on attachment security, compared with control: results differed based on the type of measure used, and follow-up was limited in duration. There is no evidence that video feedback has an impact on parental stress or anxiety (low- and very low-certainty evidence, respectively). Further evidence is needed regarding the longer-term impact of video feedback on attachment and more distal outcomes such as children's behaviour (very low-certainty evidence). Further research is needed on the impact of video-feedback on paternal sensitivity and parental reflective functioning, as no study measured these outcomes. This review is limited by the fact that the majority of included parents were mothers.

Conflict of interest statement

Leeanne O'Hara received a Cochrane Fellowship Award from the Health and Social Care Research and Development Division of the Public Health Agency, Belfast, to cover salary expenses, travel, training and research expenses.

Jane Barlow (JB) is the lead author of one of the included studies (Barlow 2016), which was funded by the Grace Fund to evaluate VIG with mothers of preterm infants; she is also in the process of resubmitting an application to NIHR to evaluate the effectiveness of VIG with women experiencing perinatal mental health problems. JB did not extract data from this study, nor did she assess the study for eligibility, assess its potential risk of bias or grade the certainty of its evidence. JB is a coapplicant on a recently funded National Institute for Health Research (NIHR), Health Technology Assessment (HTA) feasibility study of the use of Video‐feedback Intervention to promote Positive Parenting (VIPP) with young children with reactive attachment disorder living in foster care. JB began a training programme to learn how to deliver Video Interaction Guidance but discontinued this and therefore did not receive any accreditation. JB is an Editor with Cochrane Developmental, Psychosocial and Learning Problems (CDPLP).

Nuala Livingstone is an Editor with CDPLP and the Cochrane Editorial and Methods Department.

Geraldine Macdonald is the Co‐ordinating Editor of CDPLP.

Emily Smith (ES) held an NIHR‐funded Academic Clinical Fellowship at the University of Warwick and undertook work for this review whilst on placement. This funding covered her salary, training and travel expenses for the purpose of this review. ES was previously employed by Walsall Healthcare NHS Trust, who granted her study leave to undertake training to carry out this review, and is currently employed by St Helens and Knowsley Teaching Hospitals NHS Trust.

Nadeeja Herath ‐ none known.

Yinghui Wei is a Statistical Editor with CDPLP.

Thees F Spreckelsen (TS) is an Associate Editor (quantitative methods) for the journal Child and Adolescent Mental Health for which he receives an honorarium. TS has worked previously as a quantitative analyst on two industry‐funded (DSM (Dutch State Mines ‐ 'De Nederlandse Staatsmijnen')) randomised controlled trials on omega‐3 DHA (docosahexaenoic acid) supplementation as an intervention for child learning and behaviour (DOLAB study (DHA Oxford Learning and Behaviour) I and II). TS has undertaken paid analyses of clinical records of children and adolescents living with HIV in Nigeria for the International Catholic Relief Services and received an honorarium for teaching introductions to R at the Department of Education's Advanced Quantitative Methods Summer School at the University of Oxford. TS declares that these activities do not relate directly to the content of this review.

Disclaimer: The views expressed in this article are those of the authors, and not of NIHR, the NHS or the Department of Health.