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

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 resultsThis 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.