The Evidence Base for Psychoanalytic

and Psychodynamic Interventions

with Children Under 5 Years of Age
and Their Caregivers: A Systematic
Review and Meta-Analysis

Michelle Sleed, Elizabeth Li, Isabella Vainieri, Nick Midgley

Anna Freud National Centre for Children and Families

Funding
This review was commissioned by the Association of Child Psychotherapists (ACP), the
professional body and accredited register for Child and Adolescent Psychotherapists in the
UK.

Reference
Sleed, M., Li, E., Vainieri, I., Midgley, N. (2022). The Evidence Base for Psychoanalytic and
Psychodynamic Interventions with Children Under 5 Years of Age and their Caregivers: A
Systematic Review and Meta-Analysis. London: The Anna Freud Centre.

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Foreword

On behalf of the Association of Child Psychotherapists (ACP) we are very pleased to

welcome the publication of this systematic review and meta-analysis of the evidence-base
for psychoanalytic and psychodynamic interventions with children under five years of age
and their caregivers. It provides an important step forward in the development of our
knowledge in this field.

The context for this report

The scientific evidence for the crucial importance of the period from before conception
through to age five is well known. There is a powerful and well-established case - scientific,
moral, and economic - for providing effective services which draw upon best evidence,
alongside family voice and clinical experience. Our current understanding of the potentially
life-long impacts of early adversity, and of its intergenerational transmission, presents us
with real opportunities to improve the wellbeing of parents and babies. We know too that
change is possible, so that a challenging start in life does not inevitably result in poor
outcomes. Despite this, there continue to be major ‘baby blind spots’ in current policy and
provision1. We hope that, by increasing knowledge that effective interventions lead to real
change, improvements can be made to the provision of services for all families.

The review illuminates contemporary developments in parent-infant psychotherapy and

moves us towards better supporting and investing in parents in order that they can provide
the nurturing care needed for children to thrive. It also points to the deep psychoanalytic
roots of early intervention. Child and Adolescent Psychotherapists have an important role in
delivering and supporting these services, equipped as we are to hold the baby in mind and
to navigate the complex interrelationships between parental and infant mental health, and
between physical and mental states. As frontline clinicians, working in a wide range of
settings with families, we recognise the central importance of the early years of a child's life
as being vital to their ongoing physical, mental and emotional health and development. We
know the developmental benefits of often brief interventions at crucial times in families’
lives when the transition to parenthood brings opportunities and motivation to engage. We
also recognise the challenges inherent in services touching parents and babies’ lives,
sometimes fleetingly and sometimes at depth, where difficulties may be severe, complex
and intergenerational.

In the UK, we are at a cross-roads in relation to providing effective early intervention for
families with babies and young children. Initiatives such as Family Hubs have the potential

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to improve service integration and access. The recommendations of the independent review
of children’s social care could enable a step-change in the availability and quality of early
help. An increase in the provision of timely and effective interventions during early parent-
child relationships offers the opportunity to improve the quality of these foundational
relationships which are strongly associated with later psychosocial outcomes. As the
aftershocks of the Covid-19 pandemic continue to be felt, and as further adversities are
heralded by a cost-of-living crisis, this is a crucial time for shining a light on the importance
of nurturing care and the wellbeing of parents and their young children.

Key findings from the report

We are very grateful to Michelle Sleed and her colleagues at the Anna Freud National
Centre for Children and Families for their thorough and impressive work in completing this
clear and accessible review. The review is the first of its kind focussing on psychoanalytic
and psychodynamic interventions available to children under five and their caregivers and,
as such, little systematized information was previously available about the effectiveness of
such approaches. It was therefore important to ask questions about whether, and to what
extent, there is evidence for the effectiveness of these approaches. This is achieved in this
report which systematically reviews, synthesises, and critically appraises 77 studies, across
22 different intervention types/programmes, comprising 5,660 caregivers as participants.

The review shows that the majority of interventions have an impact on a range of validated
outcome domains, including parental reflective functioning, parental depression, infant
socio-emotional and behavioural wellbeing, infant attachment, and parent-infant
interactions and parenting stress. When outcomes were systematically compared to a
control intervention, psychoanalytic and psychodynamic interventions were significantly
more effective at helping caregivers and infants in most of these same outcome domains,
with the largest differential impact for infant attachment. Although effect sizes were
generally small, these findings have real-world significance as a positive shift in the
developmental trajectory of the infant or very young child which may have wide-reaching
and longstanding benefits to the child, the family and society.

There are other welcome aspects of the findings, in particular that families who participated
in the interventions were ethnically and socially diverse. Many studies had higher numbers
of parents and children from minoritized ethnic backgrounds than is representative of those
country populations. As many of the interventions specifically targeted socially
disadvantaged groups, these families were also well represented in the research. There is a
trend for more recent studies to have greater diversity and targeted interventions for
socially disadvantaged groups than earlier ones, suggesting an increased focus and
relevance of these approaches to all parts of the community. It is encouraging that many
psychodynamic or psychoanalytic interventions are seeking to address persistent

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inequalities in outcomes for children from disadvantaged backgrounds, but more work
needs to be done to ensure services are reaching different communities.

A continuum of early years support, from universal provisions to specialist services, is

necessary to meet the needs of all families with young children, identifying issues as they
arise and intervening in a timely way. This support must be sufficiently intensive when
families are experiencing significant and ongoing challenges. A further positive finding in
this review therefore was that studies mostly showed better outcomes for those with more
severe parental or parent-infant relational difficulties at the outset. This is helpful in making
the case for ensuring access to appropriately resourced specialist services for all families
experiencing severe and complex difficulties, and for psychoanalytic and psychodynamic
interventions to be a central component of this response. These interventions have been
implemented in a broad variety of settings and for a broad range of problems and as such
have real-world applications. They clearly demonstrate the ways in which young children
and their caregivers can be supported to build resilience and develop core skills enabling a
more positive developmental trajectory.

The need for further research

It is important to recognize the limitations of the studies presented here. One of the most
significant limitations is that there are, as yet, very few high-quality studies in the field.
Given the limited investment in research in this area this is not entirely surprising. Further
randomized controlled trials that adhere to good practice reporting guidelines are needed.
As the review only included studies where an empirical evaluation had been published it
does not cover the full range of psychodynamic and psychoanalytic interventions that have
been developed for use with children under five. We know of promising interventions
within the psychoanalytic field that would not have been identified in the literature search
and which could be the subject of future high quality empirical research.

We hope that this report contributes to an increased confidence that interventions for
children under five years of age and their caregivers, from a wide range of social and ethnic
backgrounds, with often severe and complex difficulties, are not only essential but can be
effective in improving outcomes. Child and Adolescent Psychotherapists must have an
increasing role in providing psychoanalytic and psychodynamic interventions for parents
and infants, in the provision of training and in supervising others, as well as in evaluating the
outcomes of these interventions.

Becky Saunders and Silvina Diaz-Bonino

Leads of the ACP 0-3 and Perinatal Clinical Network

On behalf of the Association of Child Psychotherapists, childpsychotherapy.org.uk

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Table of Contents
Foreword ......................................................................................................................... 3
The context for this report ..................................................................................................... 3
Key findings from the report .................................................................................................. 4
The need for further research ................................................................................................ 5
Introduction ..................................................................................................................... 7
The current study ................................................................................................................... 8
Methods .......................................................................................................................... 9
Search strategy ....................................................................................................................... 9
Database searches.................................................................................................................. 9
Inclusion/exclusion criteria .................................................................................................. 10
Data extraction ..................................................................................................................... 10
Quality Assessment .............................................................................................................. 11
Measures of effect ............................................................................................................... 11
Results ........................................................................................................................... 12
Included Studies ................................................................................................................... 12
Table 1. Final included papers grouped by intervention model. ......................................... 13
Characteristics of families .................................................................................................... 30
Description of interventions ................................................................................................ 31
Contemporary psychodynamic, mentalization-based interventions ................................31
Psychodynamically-informed attachment-based interventions .......................................33
Dyadic (or triadic) Psychoanalytic Psychotherapies .........................................................35
Outcomes of interventions .................................................................................................. 37
Table 2. Summary of the outcomes by grouped by intervention model description.......... 39
Comparison with control interventions - meta-analysis results ......................................47
Study Quality ........................................................................................................................ 51
Discussion ...................................................................................................................... 51
References ..................................................................................................................... 56
Supplementary material ................................................................................................. 68
Table S3. Quality Assessment of Controlled Intervention Studies ...................................... 68
Table S4. Quality Assessment for Pre-Post Studies with No Control Group........................ 73

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Introduction
The first five years of a life play a critical role in psychological and social development. The
human brain develops most rapidly during the perinatal period and first years of life, and
the social environment is essential for shaping the areas of the brain involved in self-
regulation and psychological resilience (Parsons et al., 2010; Schore, 2002). The
psychoanalyst Donald Winnicott (1964) once famously stated: “There’s no such thing as a
baby” (1977, p.99), implying that the infant is entirely reliant on someone to take care of
their fundamental survival needs and only exists within the relational environment with
their caregivers. Thus, these early parent-child relationships provide the context in which
this important phase of development occurs, and the quality of these relationships is
strongly associated with later psychosocial outcomes (Shonkoff et al., 2009).

Impingements on this phase of development can have broad and longstanding

consequences for subsequent development. The deleterious outcomes from adverse
childhood experiences -in terms of later mental health, employment and educational
attainment, and susceptibility to physical illness - are well documented (Felliti, 2009; Hughes
et al., 2017; Kalmakis & Chandler, 2015). Risk factors for suboptimal infant mental health
development include social disadvantage and poverty (Sameroff & Seifer, 1995), parental
psychopathology including depression and trauma (Goodman et al., 2011; Roubinov et al.,
2022), and intergenerational parenting difficulties and maltreatment (Assink et al., 2018).
These risk factors are often associated with each other, and the cumulative effect of
multiple risk factors is most predictive of later difficulties for the child (Gach et al. 2018;
Sameroff & Rosenblum, 2006).

Effective perinatal and early years interventions have the potential to significantly change
the child’s developmental trajectory and long-term outcomes. There is widespread
recognition that preventative early interventions in the perinatal, postnatal and preschool
years can be powerful and cost-effective for improving the wellbeing and development of
the child, and there are many interventions available (Lyons-Ruth et al., 2017).

Early intervention has deep historical roots in psychoanalytic and psychodynamic

psychotherapies. From the beginning, psychoanalysis saw the roots of psychological well-
being in early infantile experiences, and from the 1920s there was already a growing
interest in the application of psychoanalytic ideas to the treatment of children (Geissmann
& Geissmann, 1997; Salomonsson, 2014). However, it was only in the years after the Second
World War that the development of parent-infant psychotherapy took off, inspired by the
work of Selma Fraiberg, John Bowlby, Esther Bick, D.W. Winnicott and others (Salomonsson,
2014). Therapists showed an interest from the start in integrating understanding from
attachment theory and developmental psychology (e.g. A. Freud, 1965), and in more recent

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years from developmental neuroscience (e.g. Jurist, Slade & Bergner, 2008; Music, 2016;
Schore, 1994). However, as with psychoanalysis more generally, the links with empirical
researchers were limited, and it was only since the 1990s, with the increased focus on
evidence-based practice, that there has been any systematic evaluation of these ways of
working.

A recently updated systematic review of psychodynamic and psychoanalytic interventions

for children and adolescents evaluated the evidence of these interventions for a broad
range of mental health difficulties (Midgley et al., 2021). This review showed that both the
quantity and quality of research in this field has increased substantially in recent years.
However, it did not include studies of interventions for children under three years of age.
Several systematic reviews have evaluated the evidence of early interventions for infants
and their caregivers, but these have either focused on particular modalities such as parent-
infant psychotherapy (Barlow et al. 2016), or on particular difficulties such as depression
(Letourneau et al., 2017) or maltreatment (Mikton et al., 2019). No review has
systematically described the broad range of psychodynamic or psychoanalytici interventions
available to children under five and their caregivers, and the evidence of the effectiveness
of such approaches has not been systematically evaluated and synthesised.

The current study

The aim of this work is to systematically review, synthesise, and critically appraise evidence
for the efficacy (i.e., the performance of an intervention under ideal and controlled
circumstances) and/or effectiveness (i.e., the performance of an intervention under 'real-
world' conditions) of psychoanalytic and psychodynamic interventions for children under
five years of age and their caregivers. Our primary review question is: To what extent are
psychoanalytic and psychodynamic interventions effective/efficacious in the prevention and
treatment of mental health difficulties in children under 5 years of age and their caregivers?
Our secondary review questions are: What models of psychoanalytic or psychodynamic
oriented intervention or specific programmes are available for children under 5 years of age
and their caregivers? What are the populations and presenting difficulties that these
interventions target? What is the quality of research done in this area?

ii
https://www.apa.org/monitor/2017/12/psychoanalysis-psychodynamic

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Methods
Search strategy
This systematic review and meta-analysis protocol was registered with the PROSPERO
systematic review database (2021 - CRD42021285407) and carried out in line with PRISMA
guidance (see Appendix 1 for PRISMA Checklist). The database search was conducted based
on the Population Intervention Comparison Outcome Model (PICO: Schardt, Adams, Owens,
Keitz & Fontelo, 2007) for health-related research. The target population for this search
were children under 5 years of age and their caregivers as well as those in the prenatal
period. However, no limit was placed on age for the initial search in order to maximize the
chance of identifying relevant studies. The interventions searched for were those based on
psychodynamic or psychoanalytic psychotherapy including those based on attachment
theory and contemporary psychodynamic approaches such as mentalization-based
treatments, where aims might include promoting reflective-functioning or maternal mind-
mindedness. No limits were placed on what outcome data were reported. In order to
increase the sensitivity of the search, key researchers in the field were contacted to ask for
recommendations and several pilot database searches were undertaken. Based on above
criteria, the following Boolean operators were used in the search strategy:

("early years" OR infan* OR baby OR babies OR toddler* OR child* OR mother* OR

father* OR parent* OR maternal* OR paternal* OR caregiver* OR pregnan* OR
prenatal OR famil* OR carer* OR dyad*) AND (psychoanaly* OR psychodynamic*
OR mentaliz* or mentalis* OR "reflective function*" OR "parent-infant
psychotherapy" OR "parent-toddler psychotherapy" OR "parent-child
psychotherapy" OR "infant-parent psychotherapy" OR "toddler-parent
psychotherapy" OR "child-parent psychotherapy") AND (psychotherap* OR therap*
OR intervention OR treatment OR prevention) AND (evidence OR efficacy* OR
effective* OR trial* OR experiment* OR empirical* OR investigate* OR outcome*
OR measur* OR evaluat*)

Database searches
Ten databases were searched: CINAHL, EMBASE, PsychInfo, Scopus, Web of Science,
MEDLINE, PubMed, Science Citation Index, Sociological Abstracts, and The Cochrane Library.
The range of databases was mostly informed by previous reviews of psychodynamic or
psychoanalytic oriented interventions for children and caregivers (e.g., Barlow et al., 2016;
2021; Midgley et al., 2021; Midgley & Kennedy, 2011). The specified terms were searched

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for in titles, abstracts and keywords of database items published between 1990 and 30
September 2021.

Inclusion/exclusion criteria
The inclusion criteria for items were a) the study was peer-reviewed and published in
English Language; b) the study was published from 1990 onward; c) the study included the
description of intervention explicitly stating that the approach is informed by psychoanalytic
or psychodynamic theories, or the approach was defined as psychoanalytically or
psychodynamically informed by the first authors who were contacted by the research team
when review of the paper left it unclear; d) the study’s primary target of intervention was
children under 5 years of age and their caregivers as well as those in the prenatal period, or
the majority of children in the study sample fell within the 0-5 age group; e) the study was
primarily concerned with evaluating treatment outcomes, using any form of treatment (e.g.,
individual, dyadic, family, group etc.) and any design involving quantitative measurement of
outcomes (e.g., Randomised Control Trial, quasi-randomised controlled trials, cohort study,
observational study etc.).

No restrictions were placed on gender or ethnicity or on the child or caregiver’s presenting

condition. Studies that did not designate the model of intervention as psychodynamic or
psychoanalytic or did not use descriptive terms derived from these theoretical models were
excluded even if in practice the model or parts of the intervention resembles that of
psychodynamic psychotherapy (e.g., the Brazelton Neonatal Behavioral Assessment;
Brazelton, 1978). As this review aimed to capture the full range of studies evaluating this
type of therapy, we included studies with or without a comparator or control group,
including studies with a waiting list or treatment as usual control group, as well as studies
with any type of active comparator or control intervention.

While inclusion criteria remained relatively broad to include the full spectrum of mental
health difficulties and types of evaluation design, the following items were excluded: a)
theoretical, clinical, qualitative, measurement, review, or single-case papers; b)
interventions not centrally informed by psychoanalytic or psychodynamic theories; c)
studies focusing on the process rather than outcome of psychotherapy; and d) grey
literature, including dissertations, conference abstracts, pre-registered clinical trials.

Data extraction
Using the CADIMA systematic review software, the titles and abstracts of studies identified
by the searches were screened by two review authors to assess whether they met the
inclusion criteria. Full text of papers that appeared to meet the inclusion criteria were

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double screened by the same authors. Data extraction was then carried out for all eligible
studies, including the following: 1) Authors, 2) Number of participants, 3) Participant
demographics (age, gender, and ethnicity), 4) Location (country/area), 5) Type of problem,
6) Study design, 7) Control group (where applicable), 8) Description of therapy (including
type and format of psychoanalytic/psychodynamic therapy, length, frequency and
intensity), 9) Treatment delivery setting, 10) Primary outcome measures, 11) Secondary
outcome measures, 12) Key findings, 13) Effect sizes (where reported), and 14) Mediators or
moderators of outcomes (where applicable). For all studies that meet the inclusion criteria,
a descriptive data synthesis was undertaken, and key study characteristics were
summarised, appraised and presented in tables. Where multiple papers described
secondary analysis from the same study, papers were grouped together. Disagreements and
uncertainties were resolved by consultation with a third review author.

Quality Assessment
In all cases a critical appraisal of each included study was undertaken, focusing on potential
sources of bias in the design and conduct of the study, and in this way the ‘quality of
evidence’ was taken into consideration when reporting overall findings. The quality of the
studies was assessed using the NIH’s Quality Assessment Tools, available from
https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Two separate
quality assessment tools were used, one for controlled intervention studies and one for
naturalistic pre-post studies without a control group. Independent ratings were carried out
by two of the authors. Consensus were reached on how to apply the criteria before
separately rating the remaining papers. Differences and uncertainties in ratings were
resolved by consultation with a third review author.

Measures of effect
We combined the effect sizes from the studies to assess post-intervention effects on
different intervention outcomes in meta-analyses using a random effects model (rma.uni
function of the metafor package in R with the method set to ‘REML’). Only case-control
studies using similar populations as cases and controls (e.g. not healthy controls), with
information on mean and standard deviations for the relevant outcomes were included in
the meta-analyses. Studies without a control group, and those that reported pre- and post-
intervention data only were excluded from the meta-analysis to avoid biased outcomes
(Cuijpers et al., 2017). Outcomes included parental reflective functioning (PRF), maternal
depression, infant behaviour, attachment, parent-infant interaction and parental stress.
There were only two controlled studies that reported infant development outcomes, so this
domain was excluded from the meta-analyses. Between-group standardised mean
differences (SMDs) with 95% confidence intervals for post-intervention effects are

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presented for continuous data, risk ratios with 95% confidence intervals for post-
intervention effects were used for dichotomous data. To quantify the heterogeneity in
effect sizes across studies, we used I2, which represents the percentage of variation across
studies that is due to heterogeneity.

Results
Included Studies
The PRISMA flow chart (see Figure 1) shows that a total of 9587 records were identified
following removal of duplicates. After screening of titles and abstracts, 776 studies
proceeded to full-text assessment, which led to a final number of 77 studies to be included
in the current review. Studies that met inclusion criteria for the review are presented in
Table 1. Where multiple papers described results from the same study, these were grouped
together, resulting in 68 discrete studies of 22 different intervention types/programmes.

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Table 1. Final included papers grouped by intervention model.

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Mentalization based interventions
Attachment & Child Health (Attach)
Anis et al. Mothers (N=30) 57% Caucasian; low SES <36 months Controlled Socially ATTACH Home-based
(2020) & (N=10); disadvantaged/
Letourneau et RCT (N=20) high risk
al. (2020), families 10 sessions with mother and
Canada therapist. Coparenting
support person joining 2-3
sessions

Mothering from the inside out (MIO)/ Mothers and toddlers program (MTP)
Suchman et al. Mothers (N=14) 72% Caucasian, 14% Hispanic, M=26.4 months Cohort Parental Mothers and Toddlers Outpatient
(2008), USA 14% African American; 71% (SD=8.02) substance abuse Programme
unemployed; 64% either
married or cohabiting with a
partner, 21% were separated 12 session individual therapy
or divorced, and the with parent
remaining 15% had never
been married
Suchman et al. Mothers 70.8% Caucasian, 20.8% M=18.54 RCT Parental Mothers and Toddlers Outpatient
(2010, 2011, receiving MTP African American, 38.3% months substance abuse Programme
2012), USA (N=23) or Hispanic or Latino; 87% (SD=12.27)
parent unemployed
education As above
(N=24)
Suchman et al. Mothers (N=17) 44.4% Caucasian, 33.3% M=38 months Cohort Parental mental Mothering from the Inside Outpatient
(2016), USA Hispanic or Latina, 22.2% (SD=23.51) health Out (MIO)
African American; 55.6% had
never been married; 94.1%
living independently 12 session individual therapy
with parent
Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Suchman et al. Mothers 77% Caucasian, 13.8% African M=27.62 RCT Parental Mothering from the Inside Outpatient
(2017), USA receiving MIO American, 3.4% Hispanic or months substance abuse Out (MIO)
(N=40) or Latino, 5.7% mixed race; (SD=14.73)
parent 42.5% had never been
education married; 69.8% living As above
(N=47) independently

Minding the baby

Condon et al. Mothers (N=97) 33% Black, 62% Hispanic, 5% M=6 years RCT Socially MTB Home-based
(2021), USA other disadvantaged/
high risk
families Weekly-biweekly home visits
from pregnancy – 2 years,
delivered by paediatric
nurses and social workers
Ordway et al. Mothers (N=50) 22% Hispanic, 15% White, 5% M=51.8 months; Cohort Socially MTB Home-based
(2014), USA Black, 1% Native age ranges from disadvantaged/
Hawaiian/Pacific Islander, 3% 3 to 5 years high risk
Other families As above
Ordway et al. Mothers 77.2% Hispanic, 5.4% White, M=38.5 weeks RCT Socially MTB Home-based
(2018), USA receiving MTB 14.1% African American, 1.1% (SD=2.9) disadvantaged/
(N=106) or in Native Hawaiian and/or Pacific high risk
the control Islander families As above
group (N=95)
Sadler et al., Mothers 28% Black, 62% Latina, 10% M=39 weeks RCT Socially MTB Home-based
(2013), USA receiving MTB Other; 83.8% never married or (SD=2.4) disadvantaged/
(N=60) or TAU single high risk
(N=45) families As above

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Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Slade et al. Mothers 67% Hispanic or Latino, 24% MTB: M=38.8 RCT Socially MTB Home-based
(2020), USA receiving MTB African American, 5% White, weeks (SD=2.6) disadvantaged/
(N=77) or in the and 4% Other; 84% single or Control group: high risk
control group never married, 16% ever M=39.2 weeks families As above
(N=79) married or engaged (SD=1.4)

Infant mental health home visiting (IMH-HV) – “the Michigan Model”

Rosenblum et Mothers (N=78) 55% White, 45% Black or M = 9.8 months Cohort Socially IMH-HV Home-based
al. (2020), USA African American, 4% (SD = 8.4); age disadvantaged/
American Indian or Alaskan ranges from high risk
Native, 5% Hispanic or Latina, prebirth to 24 families 1-2 hours of home visiting/
and 1% as Native Hawaiian or months week by trained home
Pacific Islander; low SES visitor; from pregnancy to 3
years, intensity dependent
on needs of family
Stacks et al. Parents (N=16) 75% Black; 68.8% female; 50% M=18.57 Cohort Socially IMH-HV Home-based
(2019), USA were in foster care as months disadvantaged/
children; 43.8% had not (SD=7.10); age high risk
completed high school; 81.3% ranges from 7 to families Weekly sessions with
single parents; low SES 32 months parent(s) and child(ren) and
court IMH-HV therapist
Stacks et al. Parents (N=75) 57.30% White, 42.70% Black; M=9.64 months Cohort Socially IMH-HV Home-based
(2021), USA 77.33% not married; low SES (SD=8.39) disadvantaged/
high risk
families 1-2 hours of home visiting/
week by trained home
visitor; from pregnancy to 3
years.

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Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Developmental Individual-Difference, Relationship-Based/Floortime (DIR/FT)
Sealy & Caregivers 45% high school, 32.5% Age ranges from RCT Child symptoms DIR/FT Outpatient
Glovinsky receiving DIR/FT university, 17.5% college, 5% 2 to 6 years 11
(2016), (N=20) or in the primary school months
Barbados control group (neuro- 24 hours of individual
(N=20); fathers developmental therapy with trained
(N=5) mothers disability) therapist over average of 12
(N=33), weeks
grandmother
(N=1), aunt
(N=1)

The Clinician Assisted Videofeedback Exposure Session (CAVES)

Schechter et Mothers (N=32) 88% Hispanic, largely of M=32 months; Cohort Parental mental CAVES Outpatient
al. (2006), USA Dominican or Puerto Rican age ranges from health
origin, 12% African American; 8 to 50 months
61% immigrants; 52% had less Single session of video-
than a high-school education; feedback and semi-
75% received public assistance structured interview with
or were eligible for it; 67% clinician-researcher
single mothers

Nurture And Play (Nap)

Salo et al. Mothers NaP: 50% low educational Age ranges from RCT Parental mental NaP Outpatient
(2019), Finland receiving NaP level, 17.4% single 1 to 12 months health
(N=24) or TAU
TAU: 71.4% high educational
(N=21) 4 biweekly pregnancy groups
level, no single mother
+ 7 weekly postnatal groups
(1.5 hours each)

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Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Mentalization Based Ultrasound Sessions
Jussila et al., Mothers (N=90) 41% low SES Prenatal RCT Parental Mentalization-based Outpatient
(2021), Finland substance abuse intervention ultrasound
sessions

3 ultrasound sessions +
mentalization focused diary

Lighthouse Parenting Programme

Byrne et al. Parents (N=16) 88% white, 12% other; 81% <2 years Observatio Socially Lighthouse Parenting Outpatient
(2019), UK unemployed nal disadvantaged/ Programme
high risk
families
20 weekly parent 90 min
group sessions and 10
fortnightly 60 min individual
MBT sessions

DUET Parenting Model

Menashe- Mothers 28% low SES M=4.3 years; Cohort Community DUET Outpatient
Grinber et al. age ranges from sample
(N=30)
(2021), Israel 1 to 6 years
12 session group
intervention

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Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Attachment-Based Interventions
Banking Time
Williford et al. Teachers 53% White, 41% Black, 6% M=4 years; age RCT Community Banking Time School
(2017), USA (N=183) other ranges from 3 to sample
4 years (N=470)
One-to-one meetings (10-15
(schools) minutes) between teacher
and child, 2-3 times per
week for 7 weeks.

Mom Power (MP)

Muzik et al. Mothers (N=99) 48.4% Caucasian, 44.1 % M=21.5 months Cohort Parental mental MP Home-based
(2015), USA African American, and 7.5 % (SD=17.2) health
Biracial/Hispanic; 73 %
reported direct interpersonal 13 sessions (3 individual, 10
trauma; low SES group) with trained
community clinicians
Rosenblum et Mothers 31% White, 61.9% Black, 4.8% MP: M=15.07 RCT Socially MP Outpatient
al. (2018), USA receiving MP mixed, 2.4% other; over a half months disadvantaged/
(N=42) or in the single; over a half exposed to (SD=12.22); high risk
control group interpersonal trauma; low SES Control: families As above
(N=33) M=21.50
months
(SD=19.26)

Parental Training for Lone Mothers Guided By Educators (PALME)

Franz et al. Lone Mothers Single mothers (unmarried, Age ranges from RCT Socially PALME Outpatient
(2011), (N=88) separated, or divorced); low 3 to 6 years disadvantaged/
Germany SES high risk
families 20 weekly group sessions (90
minutes)

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Weihrauch et Lone Mothers Single mothers (unmarried, Age ranges from RCT Socially PALME Outpatient
al. (2014), completed separated, or divorced); about 4 to 6 years disadvantaged/
Germany intervention a half are unemployed high risk
N=26), families As above
completed
control
condition
(N=35)

Circle Of Security Parenting (CoS-P)

Huber et al. Biological 39% single parents; 24% from M=47 months; Controlled Community COS Outpatient
(2015a, parents culturally or linguistically age ranges from sample
2015b), diverse backgrounds; 4% 13 to 88 months
(N=73), foster or
Australia indigenous Australians 20 weekly parent group
adoptive
sessions of 90 minutes
parents (N= 5),
kinship carers
(N= 5)
Kohlhoff et al. Mother (N=15) 100% married or in a < 24 months Cohort Community COS-P Outpatient
(2016), relationship, 66% university or sample
Australia tertiary education; 50%
moderate to high income 8 weekly parent group
sessions, 90-120 minutes
each.
Maupin et al. Mothers 44% Hispanic, 29% Caucasian, M=4.11 years; Observatio Socially COS-P Outpatient
(2017), USA (N=117), other 13% African American or age ranges from nal disadvantaged/
relatives (N=3), Black, 2% Asian, and 12% 0 to 6 years high risk
adoptive other; 60% low SES families As above
mother (N=1),
others (N=10)

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Maxwell et al. Mothers 81% Australian; 67% high SES <72 months Controlled Community COS-P Outpatient
(2021), (N=221) sample
Australia
As above

Sadowski et al. Parents 71.4% single parents; 78.5% N/A Observatio Community COS-P Outpatient
(2021), receiving born in Australia; 71.4% had nal sample and home-
Australia GCCOS-P (N=7) less than a university based
or IHCOS-P certificate Group center-based COS-P
(N=7) (GCCOS-P)- 8 sessions

Individual home-based COS-

P (IHCOS-P), 8 -14 sessions)

Video-Feedback Intervention- Representations (VIPP-R)

Velderman et Mothers The majority are at low M=6 months Cohort Community VIPP (including VIPP-R) Home-based
al, (2006), educational level sample
(N=55)
Netherlands
4 home visits of 3 hours

Psychodynamic/Psychoanalytic Psychotherapy
New Beginnings
Bain (2014), Mothers Black population; low SES Age ranges from RCT Socially New beginnings Temporary
South Africa receiving 9 days to 2 disadvantaged/ accommodatio
treatment years and 6 high risk n
(N=16) or in the months families 12-session group parent-
control group infant psychotherapy
(N=6)

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Sleed et al. Mothers Intervention group: Intervention RCT Socially New beginnings Temporary
(2013b), UK receiving group: age disadvantaged/ accommodatio
43.2% White, 42% Black, 4.8%
treatment ranges from 2 to high risk n (prisons)
Asian, 8% Mixed
(N=88) or in the 23 months, families 8-session group parent-
control group Control group: 68% White, (M=4.9, SD=4.5) infant psychotherapy
(N=75) 20% Black, 5.3% Asian, 5.3% delivered over 4 weeks
Control group:
Mixed, 1.3% Other
age ranges from
1 to 18.5
months,
(M=4.4, SD=4.6)

Child–Parent Psychotherapy (CPP)

Ghosh Ippen Mothers (N=75) 38.7% mixed ethnicity Age ranges from RCT Socially CPP Outpatient
et al. (2011), (predominantly Latino/White), 3 to 5 years old disadvantaged/
Weekly mother-child
USA 28% Latino, 14.7% African high risk
sessions with therapist for
American, 9.3% White, 6.7% families
50 weeks.
Asian, and 2.6% other; low SES
Hagan et al. Parents 54.0% Hispanic, 19.7% M=49.14 Observatio Socially CPP Outpatient
(2017), USA Caucasian, 9.1% African months nal disadvantaged/
(N= 199) Weekly hour-long mother-
American, 7.6% Asian high risk
child sessions with therapist,
American, 5.6% multiracial, families
average 21 sessions.
3.5% other; low SES
Lavi et al., Mothers 86% Latina; low SES <6 months Observatio Parental mental Perinatal CPP Outpatient
(2015), USA nal health
(N=64) Weekly hour-long parent
sessions antenatally,
followed by weekly parent-
infant sessions with
therapist, average 27
sessions.

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Lieberman et Mothers (N=75) 38.7% mixed ethnicity M=4.06 years; Observatio Socially CPP Outpatient
al. (2005, (predominantly latino/white); age ranges from nal disadvantaged/
Weekly mother-child
2006), USA 28% Latino; 14.7% African 3 to 5 years high risk
sessions with therapist for
American; 9.3% white; 6.7% families
50 weeks.
Asian; 2.6% other ethnicity;
low SES
Paris et al. Mothers (N=66) 79% Caucasian, 17% African M=21.05 Observatio Parental CPP + additional support Temporary
(2015), USA American, 22% Hispanic, 2% months nal substance abuse (Project BRIGHT) accommodatio
Native American, 1% Asian n
American; low SES
6-22 sessions, 1- 1.5 hours
with therapist and mother or (Residential
mother-infant treatment)
Toth et al. Mothers An ethnic minority, high-risk, M=13.30 RCT Socially CPP Home-based
(2015), USA receiving CPP and low-income population months disadvantaged/
(N=44), PPI (SD=0.80) high risk
(N=34), families Mother-child sessions with
community therapist over 12 months
services (N=27),
or in a non-
maltreated
comparison
group (N=52)
Stronach et al. Mothers 74.6% from minority ethnic M=13.31 RCT Socially CPP Home-based
(2013), USA (N=189) groups, 12.7% married. The months disadvantaged/
majority (79.4%) reported that (SD=0.81) high risk
they had been maltreated families Weekly home visits for 12
when they were children, 89.9 months by a trained master’s
% reported experiencing at level therapist
least one traumatic event.

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Waters et al. Pregnant 86.5% Latina; 48.1% single, M=6.57 months Cohort Socially CPP Outpatient
(2015), USA women (N=52) separated, or divorced; low (SD=0.72); age disadvantaged/
SES ranges from high risk
4.53 to 8.28 families Average of 5 prenatal and 14
months postnatal sessions with
therapist
Zarnegar et al. Adoptive 80% Caucasian M=35 months; Cohort Child symptoms CPP + mindful parenting Outpatient
(2016), USA caregivers age ranges from education
(N=16) 10 to 53 months
(fetal alcohol
spectrum Twice weekly sessions with
disorder) parent and child for 6-12
months

Toddler-Parent Psychotherapy (TPP)

Cicchetti et al. Mothers 95% Caucasian; 74% high SES M=20.4 months RCT Parental mental TPP Outpatient
(1999), USA health
(N=63)
Joint mother-child sessions
with therapist over
approximately 12 months
Cicchetti et al. Mothers 92.4% Caucasian; 73.4% high M=20.47 RCT Parental mental TPP Outpatient
(2000), USA (N=158) SES months health
As above

Toth et al. Mothers with 72.7% high SES; 54.5% college M=20.34 RCT Parental mental TPP Outpatient
(2006) & Guild depression graduates; 92.9% European months health
et al. (2021), receiving TPP American ethnicity; 87.9% (SD=2.50)
USA (N=130) ,non- married. As above
depressed
comparison
group (N=68)
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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Parent/Mother–Infant Psychotherapy (PIP/ MIP)
Fonagy et al. Mothers (N=76) 58% White; 40% low SES <12 months RCT Parental mental PIP Outpatient
(2016), UK health

Joint mother-child sessions

with therapist over
approximately 12 months
Ransley et al. Mothers (N=61) 62% white British, 15% Black, M=4.29 months Observatio Parental mental PIP Outpatient
(2019), UK 13% Asian, 7% Mixed-race, 3% nal health
Arabic; 57% low SES
As above
Salomonsson Mothers MIP: 11% immigrant; 5% MIP: M=4.4 RCT Parental mental MIP Outpatient
et al. (2011a, receiving MIP single months health
2011b, 2015a, (N=38) or CHCC (SD=2.4)
CHCC: 22% immigrant; 8%
2015b), (N=37) Average of 29 sessions with
single CHCC:
Sweden mother, infant and therapist
M=5.9 months
(SD=3.8)
Tambelli et al. Intervention 88% middle SES; 92% intact Age ranges from RCT Parental mental Relationship-based PIP with Outpatient
(2015), Italy involving both family groups in which the 3 to 12 months health mother and baby or mother,
parents (N = child was the firstborn for father, and baby
22), and both parents; 91% Caucasian;
involving only 71% more than one income
the mother (N = 15 hour-long sessions, twice
22) a month

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Dyadic Group Psychotherapy
Belt et al, Mothers Low SES <12 months Cohort Parental Mother-infant group Outpatient
(2012), Finland substance abuse psychotherapy
(N=101)

20-24 weekly 3-hour group

sessions starting prenatally
Meschino et Mothers (N=70) 92.3% married Age ranges from Observatio Parental mental Mother-infant dyadic group Outpatient
al. (2016), 6 to 12 months nal health therapy
Canada

12 weekly 2-hour group

sessions
Sleed et al. Mothers in the 32.2% White, 39% Black, PIP Hostel: Controlled Socially PIP group Temporary
(2013a), UK PIP Hostel 25.4% Asian, 3.4% Other M=7.5 months disadvantaged/ accommodatio
(N=30) or in the ethnicity; 57.7% GCSE or less, (SD=3.9); high risk n
7.7% high school, 21.2% NVQ; comparison families Weekly drop-in parenting
Comparison
13.5% higher education group: M=9.4 group in homeless hostel,
Hostel (N=29)
months facilitated by parent-infant
(SD=4.7) (Homeless) psychotherapist

Brief Mother/Parent–Infant Psychotherapy (Brief-MIP/PIP)

Cohen et al. Mothers Low-medium SES M=21 months Controlled Child symptoms Brief PIP & Watch, Wait & Outpatient
(1999), receiving OR parental Wonder
Canada mental health
PIP (N=33) or
WWW (N=34)
Average 14-15 weekly 1-
(Functional and hour sessions with parent,
behavioural infant and therapist
disturbances)

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Cohen et al. Mothers Low-medium SES Age ranges from Controlled Child symptoms Brief PIP & Watch, Wait & Outpatient
(2002), receiving 10 to 30 months OR parental Wonder
Canada mental health
PIP (N=31) or
WWW (N=26)
Average 14-15 weekly 1-
(Functional and hour sessions with parent,
behavioural infant and therapist
disturbances)

Cramer et al. Mothers 22% professional, 41% <30 months RCT Child symptoms Brief-MIP Outpatient
(1990), Italy employed, 35% laborers
(N=38)
(Functional and
behavioural
Up to10 one-hour sessions
disturbances)
with parent-infant and
therapist
Georg et al. Mothers 86.36% German origin; Age ranges from RCT Child symptoms Focused- PIP Outpatient
(2021), (N=154) 77.92% married; 73.37% had 4 to 15 months
One 90-minute session and
Germany high school or higher
three 50-minute sessions
education (Early regulatory
with one or both parents
disorders)
and infant
Murray et al. Mothers 30% low SES <18 weeks RCT Parental mental Brief psychodynamic Home-based
(2003), UK health psychotherapy
(N=193)

10 weekly sessions with

trained therapist

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Nanzer et al. Mothers 16% non-European origin in <6 months Cohort Parental mental Psychotherapy centred on Outpatient
(2012), receiving PCP the treatment group and 8% health parenthood (PCP)
Switzerland (N=40) or in the in the control group; 68% with
control group employment in the treatment
(N=88) group and 83% in the control 4 individual sessions- two
group antenatal and two postnatal
Pozzi-Monzo Mothers (N=7), N/A M=45 months Observatio Child symptoms Brief -MIP Outpatient
et al. (2012), fathers (N=7) nal
UK
(Referred to Up to 5 weekly sessions with
CAMHS) mother, infant and therapist
Robert-Tissot Mothers (N=75) Majority Caucasian; 58% M=15.6 months Observatio Parental mental Brief-MIP Outpatient
et al. (1996), medium-high SES nal health
France
Average 5-6 weekly sessions
with mother, infant and
therapist
Salomonsson SPIPIC: SPIPIC: 14% immigrant; M=15 SPIPIC: Controlled Parental mental Short-term Psychodynamic Outpatient
et al. (2021), (SD=2.8) education years health Infant–Parent Interventions
mothers children’s age
Sweden at Child Health Centers
(N=100), Norm group: 6% immigrant; ranged from 1
(SPIPIC)
M=15 (SD=2.5) education to 23 months,
fathers (N=59)
years with a mean of
Norm group 4.8 months
4 weekly or biweekly 45-
(nonclinical): (SD=4.5)
minute therapy sessions with
mothers (N=81), Norm group: a mother and (optionally)
fathers (N=60) mean of 5.2 infant and/or father
months

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Other Psychodynamic/Psychoanalytic Psychotherapies
Kurzweil Mothers (N=14) 99% Caucasian; 100% lower to Age ranges from Observatio Parental mental PLAYSPACE Outpatient
(2008a), USA upper middle-class SES 5 months to 3 nal health
years
Open-ended, minimum 6
months of bi-monthly
sessions, parallel parent
group and infant group
Kurzweil Mothers Majority are Caucasian; <6 months Observatio Parental mental Relational-Developmental Outpatient
(2008b), USA middle-class SES nal health psychodynamic therapy
(N=49)

Open-ended, minimum 6
months of bi-monthly
sessions, parallel parent
group and infant group
Kurzweil, Mothers 70% Caucasian; middle-class <7 years Observatio Parental mental Psychodynamic therapy Outpatient
(2012), USA SES nal health
(N=58)
Psychotherapy for mother;
Average 4 hours/month over
average of 17 months
Lowell et al. Mothers 57% Latino, 32% African Age ranges from RCT Child symptoms Child FIRST Home-based
(2011), USA American, 9% Caucasian, 1% 6 to 36 months
(N=157)
Other; 65% unemployed
(social/ Weekly visits from clinician
emotional/ and/or care coordinator,
behavioural average 22 weeks
problems)

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Anna Freud National Centre for Children and Families

Author, Study Presenting Delivery

Caregiver Demographic Infant Therapy
country design problem setting
Muller et al. Mothers 30.9 % completed 9 years of M=4.33 years Observatio Child symptoms Multi-modal behavioural and Outpatient
(2015), secondary school, 39.7 % nal psychodynamic treatment
(N=185)
Germany completed 10 years of
secondary school, and 24.3 % (Children with
completed 12–13 years of psychiatric Average 51 treatment days
school disorders) in hospital, delivered in
intensive blocks 3 days at a
time
Rosen et al. N/A All Caucasian and from Age ranges from RCT Community Psychodynamic child Outpatient
(1994), USA middle- or upper-middle-class 4 to 6 years sample psychotherapy
families (N=14)

Weekly 30-minute session

with child and therapist for 8
weeks
Target & Not reported Not reported Age ranges from Observatio Child symptoms Child psychotherapy Outpatient
Fonagy (1994), 2 to 5.11 years nal
UK (N=127)
(Children with Delivered 1-5 times/week for
mental health an average of 1.6 years.
problems)

Thome et al. Mothers (N=33), About one third (39.4%) of Age ranges from Cohort Child symptoms Family-centered intervention Inpatient
(2005), Iceland fathers (N=30) mothers worked at home 6 to 23 months for infant sleep
during the daytime, 15.2% (N=33)
worked all day outside the (Infant sleep
home, and the rest had part- disorders) 4 family sessions (2-3 hours
time jobs or were each) delivered by paediatric
unemployed; most (83.3%) nurses
fathers worked all day outside
the home

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Characteristics of families
As shown in Table 1, the included 77 studies comprise 5660 caregivers as participants, most
of whom were mothers. Ten studies (Stacks et al., 2019; Stacks et al., 2021; Sealy &
Glovinsky, 2016; Byrne et al., 2019; Huber et al., 2015a, 2015b; Maupin et al., 2017; Hagan
et al., 2017; Zarnegar et al., 2016; Tambelli et al., 2015; Thome et al., 2005) involved fathers,
foster or adoptive parents, kinship carers, or other caregivers in addition to mothers. One
study (Williford et al., 2017) was delivered by teachers in schools, and two studies (Target &
Fonagy, 1994; Rosen et al., 1994) evaluated psychoanalytic psychotherapy that was
delivered primarily to the child alone.

Most interventions were delivered postnatally, usually when the children were under 3
years of age. One intervention was delivered during pregnancy (Jussila et al., 2021), and ten
studies evaluated perinatal interventions that began in pregnancy and then continued into
the postnatal period (Belt et al., 2012; Condon et al., 2021; Lavi et al., 2015; Nanzer et al.,
2012; Ordway et al., 2014; 2018; Rosenblum et al., 2020; Sadler et al., 2013; Salo et al.,
2019; Slade et al., 2020; Stacks et al., 2019; 2021; Waters et al., 2015).

The reasons why the participants were invited/referred to take part in the treatment were
diverse. Many intervention programmes targeted high-risk families with high external stress
(e.g., chronic poverty, minoritized ethnic groups, social and educational disadvantage,
family disruption such as separation, abandonment, trauma, maltreatment concerns,
community and domestic violence) (N=23). Other target populations included parents with
mental health conditions (mostly depression, anxiety, and PTSD) (N=22), parents with
substance abuse (e.g., drug and/or alcohol) difficulties (N=6), and children with social,
behavioural, emotional, regulatory or neurodevelopmental difficulties (N=11). Only a small
group of programmes were universal interventions serving community samples (N=8).

Most studies were conducted in Western countries, including the United States (N = 34),
Europe (N=23), Australia (N=4) and Canada (N=4). One study took place in Israel, one in
South Africa, and one in Barbados. Despite this over-representation of research from
Western countries, the families who participated in the interventions were ethnically and
socially diverse. Many studies had higher numbers of parents and children from minoritized
ethnic backgrounds than is representative of those country populations. As many of the
interventions specifically targeted socially disadvantaged groups, these families were also
well represented in the research. Only a small handful of studies reported having primarily
Caucasian and upper to middle class families in the sample. More recent studies appeared
more likely to have more diversity and targeted interventions for socially disadvantaged
groups than those conducted less recently.
Anna Freud National Centre for Children and Families

Description of interventions
Interventions varied with regard to their setting, their target group and their theoretical
underpinnings. With regards to setting, the interventions identified in this review were
mostly delivered in outpatient (e.g., clinic-based) settings (N = 46) or were home-visiting
programmes delivered in the families’ own homes (N = 15). Four interventions were
delivered in temporary accommodation settings (prisons and hostels), one intervention was
delivered in a hospital inpatient setting (Thome et al., 2005), and one intervention was
provided in schools (Williford et al., 2017).

Most interventions were trans-diagnostic and aimed to improve a range of outcomes for
children and their caregivers. The results are therefore presented by therapeutic technique
rather than by presenting problems.

Psychoanalytic and psychodynamic interventions are grounded in a range of theoretical

models, some of which also draw on ideas from other disciplines, including developmental
psychology, neuroscience and attachment theory. The interventions roughly fell into three
categories: contemporary psychodynamic, mentalization-based interventions;
psychodynamically-informed attachment-based interventions; and dyadic (or triadic)
psychoanalytic and psychodynamic psychotherapies. The results are presented in these
clusters, although it is important to highlight that they are not mutually exclusive and many
interventions could fall into all three clusters.

Contemporary psychodynamic, mentalization-based interventions

Mentalization-based treatment (MBT) is a contemporary psychodynamic approach, which
was originally developed for the treatment of adults with borderline personality disorder,
focusing on addressing difficulties identifying personal thoughts and feelings, as well as
those of others (Fonagy and Bateman, 2007). With a strong developmental model, drawing
on attachment theory and Anna Freud’s concept of ‘developmental lines’, MBT was quickly
adapted for the treatment of children and young people (Midgley & Vrouva, 2013), with a
particular focus on early interventions targeting the parent-child dyad, where the focus is on
promoting the parent or carer’s capacity to mentalize the child. The capacity to mentalize is
an awareness of mental states in oneself and in others, particularly in explaining people’s
behaviours (Bateman & Fonagy, 2013). The mentalization-based approach has been used to
inform a range of interventions, with a range of formats, and delivered by a wide range of
professionals.

A widely implemented type of mentalization-based intervention found in this review was

home visiting programmes. The Michigan model of infant mental health home visiting (IMH-
HV, Rosenblum et al, 2020; Stacks et al, 2019; 2021) is one approach that has been
delivered by community mental health services in Michigan for the last 40 years and is built

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Anna Freud National Centre for Children and Families

on a comprehensive and multifaceted framework that has informed many other

programmes worldwide. The model is delivered by trained infant mental health therapists in
the families’ homes. A central focus of the intervention is the relationship between parents
and infants and between parents and practitioners. A key goal of this programme is to
strengthen and support the caregivers’ capacity to mentalize. Infant-parent psychotherapy
is provided alongside a package of other types of support, including the provision of
material needs, life-course planning, and guidance on infant development. It has been
implemented in high-risk community samples and integrated successfully in baby/toddler
courts where there are parental maltreatment concerns. Minding the Baby (Condon et al.,
2021; Ordway et al., 2014; 2018; Sadler et al., 2013; Slade et al., 2020) is also an intensive
home visiting programme for first time parents. Families receive weekly visits from a trained
paediatric nurse and a social worker starting in the third trimester of pregnancy to the end
of the child’s first year, then biweekly until the child is two years old. To date, the
intervention has mostly been delivered to socially deprived and ethnically diverse
communities. The overarching aim of the intervention is to strengthen the parent’s capacity
to mentalize and provide sensitive caregiving. The evaluations have focused on parental
mentalizing, child attachment and parenting behaviour, but have also shown promising
outcomes in reducing childhood obesity (Ordway et al., 2014). A less intensive home visiting
model is the Attachment and Child Health (ATTACH) programme (Anis et al., 2020;
Lertournou et al., 2020). This is a structured programme of psychoeducation and
experiential support to enhance parental mentalizing, delivered in ten sessions at the
family’s home.

A brief mentalization-based intervention which is delivered on an outpatient basis is

Mothering from the Inside Out (Suchman et al., 2016; 2017), initially known as the Mothers
and Toddlers Programme (Suchman et al., 2008; 2010; 2011; 2012). This is a 12-session
manualised programme that explicitly aims to improve parental mentalizing, i.e., the
parent’s capacity to notice and make sense of their own and their child’s internal emotional
and cognitive experiences. It has mostly been used to support parents with substance
misuse disorders and ultimately aims to strengthen the attachment relationship.

Some programmes make use of video feedback techniques to strengthen parental

mentalizing. The Developmental Individual Difference-Floor Time (DIR/FT; Sealy &
Glovinsky, 2016) is a programme for toddlers with neurodevelopmental disorders. The
therapist aims to help the parent tune-in to their own and their child’s sensory, motor and
emotional experiences. Parents’ mentalizing capacities are targeted through video-feedback
of play sessions where the parent is encouraged to reflect on the child’s internal
experiences. Clinician-assisted video feedback (CAVES) is another intervention that aims to
improve parental mentalizing by applying parent-infant psychotherapy techniques while
using video-feedback (Schechter, 2006). This intervention, developed specifically for
mothers with violence-related post-traumatic stress disorder (PTSD), also introduces

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Anna Freud National Centre for Children and Families

controlled exposure to child separation distress as a potential trigger for posttraumatic

stress via video feedback, followed by the modelling and stimulation of parental mentalizing
with the therapist. It is delivered in a single session which is both the intervention and a
follow-up data collection.

Several mentalization based interventions are delivered in group settings. For example,
Nurture and Play (NaP, Salo et al.; 2019) is a brief manualised intervention for expectant
mothers with depressive symptoms. It begins in pregnancy and continues until the infant is
around 7 months old. The programme is very structured and designed to be easily taught to
frontline practitioners, including psychologists, nurses and family workers. A key focus of
the intervention is to support parental mentalizing and sensitive parent-infant interactions.
The DUET parenting programme is a structured group-based programme that aims to
improve parental mentalizing. It has been delivered and evaluated in a non-clinical
community parent population. The Lighthouse Parenting Programme (Byrne et al., 2020)
similarly aims to enhance parental mentalizing capacities through a combination of
psychoeducation, group discussion and exercises. This manualised group programme has
been developed specifically for parents who have the involvement of child protection
services and are considered at risk of maltreating their children. The theoretical
underpinning is that child maltreatment always occurs in the context of mentalizing failures.
The course introduces concepts of attachment and mentalization and gradually helps
parents to consider how their own attachment experiences may influence their mentalizing
capacity, their ability to regulate their affect and their parenting.

A novel approach to support expectant mothers with substance use disorders is to provide
4D ultrasound scans and a pregnancy diary specifically to promote mentalizing (Jussilla,
2020). This work is supported by infant mental health specialists and aims to evoke the
mother’s interest in the child and their perspective and to support mother-foetus
attachment.

Psychodynamically-informed attachment-based interventions

The pioneering work of John Bowlby, Mary Ainsworth, and others has put attachment
theory at the heart of most early interventions for very young children and their caregivers.
Many programmes highlight the importance of strengthening the child’s attachment
security and the quality of the parent-child attachment. Not all such “attachment-based”
interventions self-define as psychoanalytic and psychodynamic, and often the focus is on
improving parental behaviour (usually maternal sensitivity) rather than working with
internal working models of attachment. Examples of such interventions include VIPP (Juffer)
and Attachment and Biobehavioral Catch-up (Dozier). However, a cluster of attachment-
based interventions that were explicitly defined as psychoanalytic or psychodynamic were
included in the review. These tend to be very structured, manualised psychoeducational

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programmes that have some “teaching” element, but they also address intergenerational
attachment experiences and parents’ own internal working models of attachment that play
a role in their parenting.

The Circle of Security (CoS) is one of the most widely implemented attachment-based
interventions (Marvin et al., 2002). It is a structured manualised group programme,
originally delivered over 20 sessions. The CoS-Parenting (CoS-P) is an 8-session version of
the model which can be delivered in a group setting or can be home-based. The programme
provides video clips of parent-child interactions and handouts to demonstrate child
attachment behaviour and teach the fundamentals of attachment. Guided reflection and
group discussion encourages parents to apply these principles to their own child and their
relationship with them (Huber et al., 2015a; 2015b; Kohlhoff et al., 2016; Maupin et al.,
2017; Maxwell et al., 2021; Sadowski et al., 2021).

Similarly, Mom Power (Musik et al., 2015; Rosenblum et al., 2018) is a multifamily
attachment-theory focused group intervention. The attachment-based parenting curriculum
is provided alongside peer support, self-care practice, guided parent-infant interactions, and
connecting to other services. PALME (Weihrauch et al., 2014) is a structured, group-based
parental training program, specifically developed for single mothers and their preschool
children. The 20-week programme, which is delivered by trained qualified kindergarten
teachers or social workers, is based on attachment theory and psychodynamic-interactional
approaches. The structured programme is focused on mobilising affect and the emotional
interactions between mother and child, using psychodynamic techniques and moderate
regression.

Video-Feedback Intervention to Promote Positive Parenting (VIPP) has become a widely

used tool in infant mental health support services (Juffer et al., 2018). As the intervention is
primarily focused on behavioural interactions between parents and their babies, most
studies would not be considered psychoanalytic and did not meet inclusion criteria for this
review. However, VIPP with a representational focus (VIPP-R) is an elaboration of the model
that explicitly aims to affect the parent’s attachment representations (Velderman et al.,
2006). The parent watches back selected video-recorded interactions with their infant
alongside the clinician. In this model, the parent is also invited to have further discussions
with the clinician to reflect and make links between their own attachment representations,
their representations of their infant, and their parenting.

A different approach to strengthening the child’s attachment relationships with significant

adults is Banking time (Williford et al., 2017), an original intervention delivered by teachers
within early years school settings. Teachers are trained and supervised to provide support to
the pupils in their class. They have brief one-to-one meetings with the preschool children
over several weeks where they observe and narrate/ label the child’s behaviours and
emotions and make relational links to strengthen the quality of teacher-child relationships.

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Dyadic (or triadic) Psychoanalytic Psychotherapies

The mentalization-based and attachment interventions described above tend to be
integrative, drawing on psychodynamic and psychoanalytic ideas, whilst integrating them
with other traditions of thought. These interventions tend to be flexible in their settings,
their format (e.g., mixing experiential and psychoeducational elements) as well as who
delivers the intervention. Another set of studies identified in this review positioned
themselves more directly as psychoanalytic or psychodynamic therapies, and tended to be
delivered in more traditional therapeutic formats, by practitioners with a core
psychoanalytic or psychodynamic therapy training background. Whilst some of these are
more long-term, there are also adaptations described, below, which are briefer
interventions, sometimes adapted to be delivered in non-clinical settings.

A range of psychoanalytic psychotherapies were identified in this review that share common
underlying theories and intervention techniques. Child-parent psychotherapy, toddler-
parent psychotherapy, and parent-infant psychotherapy are all psychoanalytic approaches
that target the parent-child relationship as the focus of treatment. The approaches build
upon on the early work of Selma Fraiberg and her colleagues (1975) and incorporate the
premise that the parent’s own childhood attachment experiences can play an important
role in the current parent-child relationship. The interventions tend to be non-didactic and
the focus is on the parent and child free play interactions in the sessions and concerns
brought by the parent. The therapist attends simultaneously to the behavioural interactions
between parent and child, and the parental representations. They may also make links to
help the parent understand the influence of their own childhood experiences on their
parenting. Through empathic observation and linking, the therapist aims to help the parent
to better notice, make sense of and respond sensitively to the child’s needs. The
interventions tend to be offered mostly to mothers and their unborn baby or
infant/toddler/child, although co-parents may also join in the sessions.

There are more similarities than differences in the theoretical underpinnings and
therapeutic techniques of these various interventions. However, there may be subtle
differences in orientation to the infant/child. For example, mother-infant psychotherapy, as
described by Salomonsson (2014), involves direct work between the analyst and the infant
in the presence of the mother. Another slightly more infant-focused intervention is Watch,
Wait and Wonder (WWW; Cohen et al., 1999; 2002). In this approach, the first half of the
session is dedicated to allowing the baby to take the lead in the interaction while the parent
observes and responds in a non-directive way. In the second half of the session, the
therapist and parent discuss their observations. At this stage, as with other parent-infant
psychotherapies, links are made with the parent’s representations and observations in the
session.

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These interventions are primarily offered to families where there are complex difficulties.
For example, the included studies include work with parental trauma (e.g. Gosh Ippen et al.,
2011; Lavi et al., 2015), parental psychopathology (Fonagy et al., 2016), the risk of
maltreatment (e.g. Toth et al., 2015), parental substance misuse disorders (Paris et al.,
2015), and families with adopted children with Fetal Alcohol Syndrome Disorder (Zarnegar,
2016). In accordance with the complexity of difficulties addressed with these approaches,
the interventions tend to be open-ended and relatively intensive, with most therapies being
offered weekly for at least six months and often up to a year or beyond.

However, brief versions of the model have been developed (Robert-Tissot, 1996; Pozzi-
Monzo, 2012). In these brief therapies, the therapist works with the parent and baby to
identify and name the core relationship conflicts, maternal representations and projections,
and similar conflicts in the parent’s own childhood. The brief model has been adapted for
specific populations, such as depressed women in the perinatal period (Nanzer et al., 2012)
and dyads where the infant has early regulatory disorders (Georg, 2021). A similar approach
has been developed for supporting parents and infants in universally available child health
clinics in Sweden (Salomonsson et al., 2021). Specialist psychodynamic psychotherapists are
based within these centres and provide brief (4 session) interventions for mothers identified
by nurses as needing additional support. Nurses are also given supervision to support
perinatal mental health in these settings. All of these brief approaches share the same
principles and techniques as the more intensive mother/parent-infant/toddler/child
psychotherapies, but they remain relatively focused on singling out and quickly addressing
the core difficulties in the dyad.

The dyadic psychodynamic psychotherapies have also been adapted for different settings
and populations to provide accessible and acceptable parent-infant support for families who
may not attend individual therapy in traditional clinic or home settings. For example,
parenting groups which are facilitated by experienced parent-infant psychotherapists have
been developed for parents living in homeless hostels (Bain, 2014; Sleed et al., 2013a) and
in mother-baby units in prisons (Sleed et al. 2013b). Others have also adapted the model to
be delivered in multifamily groups to support parents with depression (Meschino et al.,
2016) or substance misuse disorders (Belt et al., 2012). These group-based adaptations
facilitate peer support within communities and facilitate accessibility when parents come
from different cultural and language backgrounds. Although they have a very different
mode of delivery and intensity, these adapted interventions also aim to help parents to
recognise and respond sensitively to their babies’ cues, and also to make links with their
own experiences and how these influence their parenting.

Two slightly different programmes are multimodal hospital-based interventions that draw
on psychodynamic principles alongside other clinical interventions. These include a brief 4-
day inpatient intervention for infant sleep problems in Iceland (Thome et al., 2005) and an
intensive and multifaceted hospital outpatient treatment in Germany (average 51 hospital

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days) for infant psychiatric disturbances (Muller et al., 2015). Although both interventions
are informed by behaviourist and/or social learning approaches, they also apply
psychoanalytic techniques to address the parents’ representations of their infant and their
difficulties.

Outcomes of interventions
Most studies evaluated outcomes in at least one of these domains: Parent-infant
interaction, parental reflective functioning, parental depression, infant development, infant
social/emotional/behavioural functioning, infant attachment, and parenting stress. The
direction of the outcomes (improvement over time, no/ mixed effect over time/
deterioration over time) on these domains is presented in Table 2. These are assessed pre-
to post-intervention for all studies. As not all studies had control groups, the outcomes
reported here pertain only to the psychoanalytic/psychodynamic intervention groups.

The outcomes in all domains being measured showed change in a positive direction.
Parental Reflective Functioning, a measure of the parents’ capacity to mentalize, was
primarily assessed with Reflective Functioning coding scale applied to the Pregnancy
Interview or the Parent Development Interview (Slade et al. 2004; 2007) and a small number
of studies used the Parental Reflective Functioning Questionnaire (Luyten et al., 2017).
Nineteen of the 27 (70%) studies that measured this outcome reported positive changes,
with the remaining showing no significant changes in either direction.

The quality of parent-infant interactions was measured in 27 studies, using many different
measures, mostly coding systems applied to video-recorded interactions between parent
and infant. Twenty of these studies (74%) reported positive changes, with the remaining
studies showing no significant change.

Parental depression was assessed in 26 studies through self-report questionnaires, most

often the Beck Depression Inventory, the Edinburgh Postnatal Depression Scale, or the
Centre for Epidemiological Studies Depression Scale. Of these, nineteen (73%) showed
positive changes, one study (Bain, 2014) reported a deterioration with maternal depression
increasing over time, and the remaining studies showing no change in either direction.
Similarly, parental stress levels were usually assessed through self-reported questionnaires
such as the Parenting Stress Index. Out of the fifteen studies measuring this outcome,
eleven (73%) showed positive changes and the rest reported no significant change.

Despite the clinical importance placed on infant attachment in relation to their caregivers,
only seven studies measured this. This may be due to the resource intensive nature of the
gold standard procedure for assessing attachment, the Strange Situation Procedure
(Ainsworth, Blehar, Waters, & Wall, 1978). Of these studies, five (71%) showed improved

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attachment security and/or decreased attachment insecurity and disorganization over time,
and two studies showed no significant changes.

Children’s social, emotional and behavioural wellbeing, most often measured through
parent-report questionnaires such as the Child Behavior Checklist, was measured in twelve
studies. Of these, ten (83%) showed positive change, and two found no significant changes.
Infant development (cognitive, motor and/or language) was measured in 10 studies, seven
(70%) of which showed positive change and the rest reporting no significant change in
either direction.

Very few studies explicitly examined potential mediators or moderators of change, although
some controlled for some socioeconomic variables in their analyses (e.g., Fonagy et al.,
2016, Menashe-Grinberg et al., 2021), suggesting that outcomes may not be equivalent for
all participants of the studies. Where potential mediators or moderators of change were
investigated, studies mostly showed better outcomes for those with more severe parental
or parent-infant relational difficulties at the outset (e.g., Huber et al., 2015a; 2015b; Slade et
al., 2020; Suchman et al., 2017). One exception is the study by Schechter and colleagues
(2006) which showed that better outcomes were associated with higher maternal reflective
functioning at baseline.

As the full range of studies included in this review were of varying quality and many did not
report effect sizes, only the controlled studies were selected for the meta-analysis
synthesising outcomes in the key domains.

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Table 2. Summary of the outcomes by grouped by intervention model description.

Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Mentalization Based Interventions
Attachment & Child Health (Attach)
Anis et al. (2020) & “+” “+” “0” “0” n/a n/a “+” n/a n/a
Letourneau et al. (2020),
Canada
Mothering From The Inside Out (MIO)/ Mothers And Toddlers Program (MTP)
Suchman et al. (2008), USA “+” “0” n/a n/a n/a n/a n/a n/a n/a

Suchman et al. (2010, “+” “+” n/a n/a n/a n/a n/a n/a Maternal
2011, 2012), USA Reflective
Functioning
Suchman et al. (2016), USA “+” “0” “+” n/a “+” n/a n/a n/a n/a

Suchman et al. (2017), USA “+” “+” n/a “0” n/a n/a “0” Addiction n/a
severity
Minding The Baby
Condon et al. (2021), USA “n/r” n/a n/a n/a n/a n/a n/a n/a n/a
Ordway et al. (2014), USA “0” n/a “0” n/a n/a “+” n/a n/a n/a
Ordway et al. (2018), USA “0” n/a “0” n/a “0” n/a n/a n/a n/a
Sadler et al., (2013), USA “+” “+” (in teen “0” “+” n/a n/a n/a n/a n/a
mothers only)
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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Slade et al. (2020), USA “n/r” “n/r” “n/r” “n/r” n/a n/a n/a Disrupted n/a
communica-
tion
Infant Mental Health Home Visiting (IMH-HV) – “The Michigan Model”
Rosenblum et al. (2020), “+” n/a n/a n/a n/a n/a n/a n/a n/a
USA
Stacks et al. (2019), USA “+” “+ partial” n/a n/a n/a n/a n/a n/a n/a
Stacks et al. (2021), USA n/a “0” n/a n/a n/a n/a “+” n/a n/a
Developmental Individual-Difference, Relationship-Based/Floortime (DIR/FT)
Sealy & Glovinsky (2016), “+” n/a n/a n/a n/a n/a n/a n/a
Barbados
The Clinician Assisted Videofeedback Exposure Session (CAVES)
Schechter et al. (2006), n/a n/a n/a n/a n/a n/a n/a Higher n/a
USA baseline RF
was
associated
with better
outcomes
Nurture And Play (Nap)
Salo et al. (2019), Finland “+” “+” “+” n/a n/a n/a n/a n/a n/a

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Mentalization Based Ultrasound Sessions
Jussila et al., (2021), n/r n/a n/r n/a n/a n/a n/a n/a n/a
Finland
Duet Parenting Model
Menashe-Grinberg et al. “+” “+” n/a n/a n/a “+” n/a SES, child n/a
(2021), Israel sex, and
parental
well-being
Lighthouse Parenting Programme
Byrne et al. (2019), UK “0” “0” “0” n/a “+” n/a n/a n/a n/a

Attachment Based Interventions

Banking Time
Williford et al. (2017), USA n/a “+” n/a n/a n/a “+” n/a n/a Quality of the
teacher–child
interactions
Mom Power (MP)
Muzik et al. (2015), “+” n/a “+” n/a n/a n/a n/a n/a n/a
USA
Rosenblum et al. (2018), “+” n/a n/a n/a n/a n/a n/a n/a n/a
USA

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Parental Training For Lone Mothers Guided By Educators (PALME)
Franz et a. (2011), n/a n/a n/a n/a n/a “+” n/a n/a n/a
Germany
Weihrauch et al. (2014), n/a n/a n/r n/a n/a n/r n/a n/a n/a
Germany
Circle Of Security Parenting (CoS-P)
Huber et al. (2015a, “+” n/a n/a “+” n/a n/a n/a Severity of n/a
2015b), Australia baseline
presenting
problems
Kohlhoff et al., 2016, “0” n/a n/a n/a “+” n/a n/a n/a n/a
Australia
Maupin et al. (2017), USA “0” n/a “+” n/a n/a n/a n/a n/a n/a
Maxwell et al. (2021), “+” n/a “+” n/a n/a n/a n/a n/a n/a
Australia
Sadowski et al. (2021), “+” n/a n/a n/a “+” n/a n/a n/a n/a
Australia

Video-Feedback Intervention- Representations (VIPP-R)

Velderman et al, (2006), n/a n/r n/a n/r n/a n/r n/a n/a Maternal
Netherlands Sensitivity

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Psychodynamic/Psychoanalytic Psychotherapy
New Beginnings
Bain (2014), South Africa “0” “+” “-“ n/a n/a n/a “+” n/a n/a
Sleed et al. (2013b), UK “+” “+ partial” “0” n/a n/a n/a n/a n/a n/a
Child–Parent Psychotherapy (CPP)
Ghosh Ippen et al. (2011), n/a n/a n/a n/a n/a “+” n/a n/a n/a
USA
Hagan et al. (2017), USA n/a n/a n/a n/a n/a n/a n/a n/a n/a
Lavi et al., (2015), USA n/a n/a “+” n/a n/a n/a n/a Maternal- n/a
fetal
attachment,
dosage
Lieberman et al. (2005, n/a n/a n/a n/a n/a “+” n/a n/a n/a
2006), USA
Paris et al. (2014), USA “+ n/a n/a n/a n/a “+ partial n/a n/a n/a
partial
”
Toth et al. (2015), USA n/a n/a n/a n/a “+” n/a n/a n/a n/a

Stronach et al. (2013), USA n/a n/a n/a “+” n/a “0” n/a n/a n/a

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Waters et al. (2015), USA n/a “+” n/a n/a n/a n/a n/a n/a n/a

Zarnegar et al. (2016), USA n/a n/a n/a n/a “+” n/a “+” n/a n/a

Toddler-Parent Psychotherapy (TPP)

Cicchetti et al. (1999), USA n/a n/a “+” “+” n/a n/a n/a n/a n/a

Cicchetti et al. (2000), USA n/a n/a “+” n/a n/a n/a n/a n/a n/a

Toth et al. (2006) & Guild n/a n/a “+” “+” n/a n/a n/a n/a n/a
et al. (2021), USA

Parent/Mother–Infant Psychotherapy (PIP/MIP)

Fonagy et al. (2016), UK “0” “0” “+” “0” “+” n/a “0” n/a n/a
Ransley et al. (2019), UK “+” “+” “0” n/a “0” n/a n/a n/a Treatment
expectation
Salomonsson et al. (2011a, n/a “+” “+” n/a “0” “0” n/a Infant and n/a
2011b, 2015a, 2015b), maternal
Sweden types
Tambelli et al. (2015), Italy n/a “+” n/a n/a n/a n/a n/a n/a n/a

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Dyadic Group Psychotherapy
Belt et al, (2012), Finland n/a “+” “+” n/a n/a n/a n/a n/a n/a

Meschino et al. (2016), n/a n/a “+” n/a “0” n/a n/a n/a n/a
Canada
Sleed et al. (2013a), UK n/a “0” n/a n/a n/a n/a “+” n/a n/a
Brief Mother/Parent–Infant Psychotherapy (Brief-MIP/PIP)
Cohen et al. (1999), Canada n/a “+” “+” “+” “+” n/a “+” n/a n/a

Cohen et al. (2002), Canada n/a “+” “+” “+” “+” n/a “+” n/a n/a

Cramer et al. (1990), Italy n/a “+” “+” n/a n/a n/a n/a n/a n/a

Georg et al. (2021), “0” “0” “+” n/a “+” n/a n/a n/a n/a
Germany
Murray et al. (2003), UK n/a “+” n/a “0” n/a n/a “0” n/a n/a
Nanzer et al. (2012), n/a n/a “+” n/a n/a n/a n/a n/a n/a
Switzerland
Pozzi-Monzo et al. (2012), n/a n/a n/a n/a n/a n/a n/a n/a n/a
UK

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Intervention effectiveness of pre-post intervention in the treatment group

Author, country PRF Parent-infant Parental Infant Parenting Infant social- Infant Moderator Mediator
interaction depression Attachment Stress emotional- develop-
behavioural ment
Robert-Tissot et al. (1996), n/a “+” n/a n/a n/a n/a n/a n/a n/a
France
Salomonsson et al. (2021), n/a n/a “+” n/a n/a “+” n/a n/a n/a
Sweden

Other Psychodynamic/Psychoanalytic Psychotherapies

Kurzweil (2008), USA n/a n/a n/a n/a n/a n/a n/a n/a n/a
Kurzweil (2008), USA n/a n/a n/a n/a n/a n/a n/a n/a n/a
Kurzweil, (2012), USA n/a n/a n/a n/a n/a n/a n/a n/a n/a
Lowell et al. (2011), USA n/a n/a “+” n/a “+” “+” n/a n/a n/a
Muller et al. (2015), n/a n/a n/a n/a n/a “+” n/a n/a n/a
Germany
Rosen et al. (1994), USA n/a n/a n/a n/a n/a n/a n/a n/a n/a
Target & Fonagy (1994), UK n/a n/a n/a n/a n/a n/a n/a n/a n/a
Thome et al. (2005), n/a n/a “0” n/a “+” n/a n/a n/a n/a
Iceland

Notes: “+” = Statistically significant improvement over time; “0” = No or Mixed effect over time; “–“ = Statistically significant deterioration over time; “n/r” =
Outcome collected but pre-post data not reported; “n/a” = Outcome in this domain not collected

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Comparison with control interventions - meta-analysis results
Meta-analyses were conducted in order to explore any differences in effectiveness between
the psychodynamic/psychoanalytic interventions and those in the ‘control’ groups who
were offered an alternative intervention. In most cases the interventions were compared
with active control conditions, either “usual care” involving locally available services, or
specified alternative therapeutic interventions. Only a small handful of studies compared
the interventions to “no treatment” or waiting list control conditions.

The meta-analyses showed statistically significant effects of the psychoanalytic and

psychodynamic interventions, compared to control interventions, on a range of outcomes,
including parental reflective functioning (95%CI -0.68 to -0.06, p = 0.02; I2 = 82%; SMD = -
.37), maternal depression (95%CI 0.13 to 0.45, p<0.000; I2 = 44%; SMD = -.29), infant
behaviour (95%CI 0.00 to 0.43, p=0.04; I2 = 35%; SMD = -.22), and infant attachment (95%CI
-0.95 to -0.19, p<0.00; I2 = 49%; SMD = -.57). There was a moderate effect size for infant
attachment, and all other significant results showed relatively small effect sizes (SMD < .50)
Although psychodynamic interventions showed improved parent-infant interactions relative
to controls, these differences were not statistically significant (95%CI -0.56 to 0.03, p=0.08;
I2 = 71%; SMD = -.26). No statistically significant differences between psychodynamic
interventions and control interventions were found on parental stress (95%CI -0.09 to 0.31,
p = 0.26; I2 = 0%; SMD = -.11) (See Figures 2-7).
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Figure 2 Forest plot of comparison: intervention vs control group on parental reflective

functioning

Figure 3 Forest plot of comparison: intervention vs control group on maternal depression

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Figure 4 Forest plot of comparison: intervention vs control group on infant behaviour

Figure 5 Forest plot of comparison: intervention vs control group on infant attachment

security

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Figure 6 Forest plot of comparison: intervention vs control group on parent-infant

interaction

Figure 7 Forest plot of comparison: intervention vs control group on parental stress

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Study Quality
The quality assessment ratings showed that less than half of the studies demonstrated good
quality design and reporting (see Table S3 and Table S4 in the supplementary material). Of
the 33 controlled studies (i.e., 27 RCTs and 6 quasi-experimental studies), only 8 were rated
as “good” and 15 as “fair”, and the remaining 10 were rated as “poor”. The most common
problems identified through the quality assessments were high drop-out rates, lack of
descriptions of therapists’ adherence to the intervention, lack of reporting on whether or
not intention-to-treat analysis was used and, most notably, insufficiently powered studies
(i.e., the number of participants was too small to have complete confidence in the results).
Of the 15 pre-post evaluations (where the psychodynamic therapies were evaluated, but
the outcomes not compared to a ‘control’ group), 7 were rated as “good”, 3 as “fair” and 5
as “poor". Although the quality of these studies was generally higher than the controlled
studies the lack of control group means that we cannot be sure to what degree the
outcomes identified can be attributed to the psychodynamic intervention.

Discussion

This is the first systematic review and meta-analysis summarizing the evidence for
psychoanalytic and psychodynamic interventions for children under 5 and their caregivers.
The review identified 77 studies, comprising 5660 caregivers as participants, most of whom
were mothers. Most interventions were delivered for children aged under three, in a wide
range of settings using different formats. Interventions could broadly be identified as one of
three types: contemporary psychodynamic, mentalization-based treatments;
psychodynamically-informed attachment interventions; and dyadic (or triadic)
psychodynamic and psychoanalytic psychotherapies.

Overall, the review showed that the majority of these interventions demonstrated impact
on a range of validated outcome domains, including parental reflective functioning, parental
depression, infant socio-emotional and behavioural wellbeing, and infant attachment,
parent-infant interactions or parenting stress. When outcomes were systematically
compared to a control intervention, a small but significant effect size in favour of the
psychoanalytic and psychodynamic interventions for was shown for most of these same
outcome domains, with the largest differential impact for infant attachment; however no
significant differences were found when comparing psychodynamic treatments to control
interventions for parent-infant interaction or parenting stress. It should be highlighted that
the parent-infant interaction quality was assessed using a wide range of different measures,

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some of which are not widely used and have little psychometric validation. Future studies
should ensure that assessments of parent-infant interaction quality are made by trained and
reliable coders of well-validated instruments. The lack of significant effects on parenting
stress is interesting given that other caregiver-specific outcomes such as parental
depression and parental reflective functioning did improve. However, none of the studies
explicitly stated this to be a primary target of the interventions. It may be that at least some
moderate parental stress is expectable in the perinatal period and this may not impinge on
other important relational outcomes for the infant and their caregiver.

Although the effect sizes for the positive findings are moderate to small, when compared to
other interventions in the studies, they indicate that psychodynamic and psychoanalytic
interventions can help young children and their caregivers make important shifts that can
lead to a number of downstream improvements in their lives. For example, the long-term
benefits of early parent-infant attachment security and the risks of early attachment
disorganization are now well documented (Lyons-Ruth et al., 2016; Waters et al., 2000).
Similarly, the alleviation of depressive symptoms in the postnatal period can not only help
new parents cope with the demands of parenting, but can offset a range of detrimental
outcomes for the infant in the longer-term (Sanger et al., 2015).

The synthesis of all evaluations (of all quality) indicated that most studies reported positive
outcomes in relation to the key parental and child domains. Where pre- to post-intervention
outcomes on any one of the key domains were measured, they were reported to be positive
for 70-80% of the studies. However, most studies did not have a control condition and these
improvements could be accounted for by any number of factors, not least rapid changes
that happen in the early perinatal period regardless of intervention. However, the fact that
the meta-analyses of controlled studies found similarly positive findings suggest that the
interventions do seem to be effective in helping young children and their caregivers.

Despite these encouraging findings, certain cautions do need to be kept in mind. The quality
of most studies, those with control groups and those without, was relatively low. The most
common methodological limitation was the small sample sizes for almost all studies, which
led to low statistical power. This means that the synthesis of results may be distorted by
random error and the effect sizes detected in the meta-analyses were relatively small.

However, we believe this review provides a significant step forward in the development of
our knowledge in this field. This review not only synthesised evidence for the effectiveness
of psychoanalytic and psychodynamic interventions supporting infants and their caregivers,
but it also provided the first integrated view on the range of such interventions available (at
least those that have published some type of systematic outcome evaluation). Interventions
varied in terms of their theoretical underpinning, their format and intensity, as well as in the
type of practitioner delivering the intervention and the target population. Despite the
diversity in how the programmes are delivered, most were underpinned by the principle

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that the infant’s wellbeing is best understood in the context of their social environment, and
particularly their relationships with their primary caregivers or other significant adults. For
this reason, most interventions were aimed at either strengthening the parent-infant/child
relationship and/or overcoming parental risk factors (for example, mental health problems,
intergenerational trauma, social adversity, substance misuse) to prevent any impact of
these factors on the infant.

Some individual interventions are clearly designed to address specific target problems - for
example parental depression, maltreatment, substance misuse or specific child problems.
However, most approaches were transdiagnostic and many have been implemented in a
broad variety of settings and for a broad range of problems. This is perhaps unsurprising
given the relational and intergenerational foci of most programmes, but it is helpful when
thinking about the real-world implementation of these interventions. For example, maternal
depression may be the main referral criterion to an intervention. However, the theory
underpinning the intervention model might suggest that maternal depression can be related
to early relational and social difficulties in the mother’s history, and these early experiences
and current depressive symptoms can relate to relational difficulties with the infant or
young child, which may in turn relate to regulatory, social, emotional, and behavioural
difficulties in the infant; these issues might be further compounded by biopsychosocial risk
factors. Using a psychodynamic or psychoanalytic approach appears to lead to changes
across a wide range of these domains. Thus, many of the interventions described in this
review are relevant to supporting families where there are complex difficulties. Infant
mental health is understood in the context of the child’s relationships with their primary
caregivers, which are – in turn - understood in the context of past and current relational and
social factors.

Similarly, despite the differences outlined above, there are many theoretical and technical
overlaps between the different interventions described in this review. Most interventions
were informed by certain core psychodynamic principles, such as the impact of early
experience on later development; the way in which ‘ghosts in the nursery’ can inform the
relationship between parents and their children; and the way in which unconscious
dynamics may get played out both in the parent-infant relationship and within the
therapeutic setting (Salomonsson, 2014; Raphael-Leff, 2019). In all interventions, the
relational world of the young child is prioritised, and the internal representations that the
caregivers have of their infants – which are influenced by their own attachment experiences
- play a key role in their capacity to provide sensitive and “good enough” caregiving that can
foster attachment security. The caregiver’s capacity to see and make sense of their baby’s/
young child’s internal experiences and understand their emotions, i.e., their ability to
mentalize - is thought to be one of the key mechanisms by which attachment security can
develop. Thus, many interventions explicitly or implicitly target parental mentalizing as a
mechanism of change and/or important outcome. As the representational world of

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caregivers and infants are the focus of most of this work, the interventions set out here
generally draw on psychoanalytic techniques whereby the therapist facilitates the
identification and working through of current and past defences and conflicts.

An encouraging finding of the review was that the many of the psychodynamic or
psychoanalytic interventions being delivered and evaluated worldwide are reaching
disadvantaged and diverse communities. Cumulative risk factors - including socioeconomic
deprivation and racial discrimination - have a powerful influence on infant mental health
and developmental outcomes, and any intervention should not dismiss these influences on
families’ lives. Flexible and creative approaches have been taken to make programmes
accessible to disadvantaged communities. This includes training and supervising community
members to deliver programmes, providing home-based support, and delivering the
psychotherapeutic interventions as part of a wider package of social, economic, and
psychoeducational support. However, it is noteworthy that almost all studies included in
this review were conducted in Westernised countries.

Although some studies (10 of the 77) included fathers and other caregivers in the
interventions and studies, almost all of them were clearly targeting biological mothers and
their infants or young children as the primary recipients. Recent research has highlighted
the important role of fathers in the young child’s development (Amodia-Bidakowska et al.,
2020). Future research should actively address the exclusion of fathers who may also
experience mental health difficulties in the perinatal period (Fisher et al., 2021). Certainly
there is a burgeoning focus on fathers in the more recent clinical literature (Baradon et al.,
2019), but evaluations of such father-oriented interventions are still lacking.

There are some limitations to this review. Firstly, as we only included studies where some
form of empirical evaluation has been published, the review does not cover the full range of
psychodynamic and psychoanalytic interventions that have been developed for use with
infants and young children under five. Empirical research within the psychoanalytic field is
still relatively under-developed, including among child psychotherapists (Midgley et al.,
2009), so many promising interventions would not have been identified in the literature
search conducted here. Furthermore, the inclusion of studies was based on study authors’
definitions of whether or not an intervention should be considered psychoanalytic or
psychodynamic. This means that some interventions were excluded, even if in practice they
are very similar and employ some of the same clinical techniques to those that were
included. The exclusion of some well-established but behaviourally-focused attachment-
based interventions, whilst other psychodynamically-informed attachment interventions
were included, is particularly arguable. In contrast, other studies that self-defined as
psychoanalytically-informed may have made limited use of psychoanalytic techniques in
practice. The review includes some extremely brief - sometimes even single session -
interventions as well as highly intensive programmes that are delivered over a year or even
longer. Similarly, some programmes were delivered by lay-practitioners with very little

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psychological training, while others were delivered by highly trained, experienced, and
supervised psychoanalytic psychotherapists. Thus, the heterogeneity of interventions is also
a limitation that makes generalization difficult.

As well as variation with regard to intervention design, there was significant variation on
how research studies were conducted. There were not enough high-quality studies with
large enough sample sizes for us to do secondary analyses of particular types or features of
interventions (such as intensity or practitioner experience) in relation to outcome. Similarly,
very few studies examined mediators or moderators of treatment effects and this review
could not extract rich information about what works best for whom. In general, the
intervention models are complex and varied and the families that they aim to help have
complex difficulties. Thus, it is difficult to disentangle specific intervention techniques that
are effective for specific problems. This is a common feature of complex interventions
(Datta & Petticrew, 2013) and highlights the depth of psychoanalytic psychotherapy and the
ability for therapists to be able to work with and untangle complexity.

One of the most significant limitations of the review and meta-analysis is that there are very
few high-quality studies in the field. More randomized controlled trials that adhere to good
practice reporting guidelines are needed. Future studies should especially focus on the
recruitment of much larger numbers of families and retaining them in longer term follow-
ups. As the evidence base builds, future systematic reviews and meta-analyses could focus
on particular types of interventions and/or presenting difficulties to unpick the most
effective ways of working with different populations and can help us understand the longer-
term impact of such interventions on children.

Despite these limitations, this review is the first of its kind and has demonstrated that
psychodynamic and psychoanalytic interventions may be effective in improving outcomes
for very young children and their caregivers, across a range of outcome domains. Although
effect sizes, when compared to a control intervention, were generally small, this does not
lessen the real-world significance of these findings; a positive shift in the developmental
trajectory of the young child may have wide-reaching and longstanding benefits to the child,
the family and society.

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References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Strange situation procedure.
Clinical Child Psychology and Psychiatry.

Amodia-Bidakowska, A., Laverty, C., & Ramchandani, P. G. (2020). Father-child play: A

systematic review of its frequency, characteristics and potential impact on children’s
development. Developmental Review, 57, 100924.

Anis, L., Letourneau, N., Benzies, K., Ewashen, C., & Hart, M. J. (2020). Effect of the
attachment and child health parent training program on parent–child interaction
quality and child development. Canadian Journal of Nursing Research, 52(2), 157–
168. https://doi.org/10.1177/0844562119899004

Assink, M., Spruit, A., Schuts, M., Lindau er, R., van der Put, C. E., & Stams, G. J. J. (2018).
The intergenerational transmission of child maltreatment: A three-level meta-
analysis. Child abuse & Neglect, 84, 131-145.

Bain, K. (2014). “New Beginnings” in South African shelters for the homeless: piloting of a
group psychotherapy intervention for high‐risk mother–infant dyads. Infant Mental
Health Journal, 35(6), 591-603. https://doi.org/10.1002/imhj.21457

Baradon, T., Fonagy, P., Bland, K., Lénárd, K., & Sleed, M. (2008). New Beginnings–an
experience-based programme addressing the attachment relationship between
mothers and their babies in prisons. Journal of Child Psychotherapy, 34(2), 240-258.
https://doi.org/10.1080/00754170802208065

Baradon, T. E., Salomonsson, B. C., & von Klitzing, K. C. (2019). Working with fathers in
psychoanalytic parent-infant psychotherapy. Routledge/Taylor & Francis Group.

Barlow, J., Bennett, C., Midgley, N., Larkin, S. K., & Wei, Y. (2016). Parent–infant
psychotherapy: a systematic review of the evidence for improving parental and
infant mental health. Journal of Reproductive and Infant Psychology, 34(5), 464-482.

Barlow, J., Sleed, M., & Midgley, N. (2021). Enhancing parental reflective functioning
through early dyadic interventions: A systematic review and meta‐analysis. Infant
Mental Health Journal, 42(1), 21-34.

Bateman, A., & Fonagy, P. (2013). Mentalization-based treatment. Psychoanalytic inquiry,

33(6), 595-613.

56 www.annafreud.org
Anna Freud National Centre for Children and Families

Belt, R. H., Flykt, M., Punamäki, R. L., Pajulo, M., Posa, T., & Tamminen, T. (2012).
Psychotherapy groups and individual support to enhance mental health and early
dyadic interaction among drug-abusing mothers. Infant mental health journal, 33(5),
520–534. https://doi.org/10.1002/imhj.21348

Brazelton, T. B. (1978). The Brazelton Neonatal Behavior Assessment Scale:

Introduction. Monographs of the Society for research in Child Development, 43(5-6),
1-13.

Byrne, G., Sleed, M., Midgley, N., Fearon, P., Mein, C., Bateman, A., & Fonagy, P. (2019).
Lighthouse Parenting Programme: Description and pilot evaluation of mentalization-
based treatment to address child maltreatment. Clinical child psychology and
psychiatry, 24(4), 680–693. https://doi.org/10.1177/1359104518807741

Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The efficacy of toddler-parent
psychotherapy for fostering cognitive development in offspring of depressed
mothers. Journal of abnormal child psychology, 28(2), 135–148.
https://doi.org/10.1023/a:1005118713814

Cicchetti, D., Toth, S. L., & Rogosch, F. A. (1999). The efficacy of Toddler-Parent
Psychotherapy to increase attachment security in off-spring of depressed
mothers. Attachment and Human Development, 1(1), 34-
66. https://doi.org/10.1080/14616739900134021

Cohen, N. J., Lojkasek, M., Muir, E., Muir, R., & Parker, C. J. (2002). Six‐month follow‐up of
two mother–infant psychotherapies: Convergence of therapeutic outcomes. Infant
Mental Health Journal: Official Publication of The World Association for Infant
Mental Health, 23(4), 361-380. https://doi.org/10.1002/imhj.10023

Cohen, N. J., Muir, E., Parker, C. J., Brown, M., Lojkasek, M., Muir, R., & Barwick, M. (1999).
Watch, wait and wonder: Testing the effectiveness of a new approach to mother-
infant psychotherapy. Infant Mental Health Journal, 20(4), 429–451.

Condon, E. M., Tobon, A. L., Holland, M. L., Slade, A., Mayes, L., & Sadler, L. S. (2022).
Examining Mothers' Childhood Maltreatment History, Parental Reflective
Functioning, and the Long-Term Effects of the Minding the Baby® Home Visiting
Intervention. Child maltreatment, 27(3), 378–388.
https://doi.org/10.1177/1077559521999097

Cramer, B., Robert‐Tissot, C., Stern, D. N., Serpa‐Rusconi, S., De Muralt, M., Besson, G., ... &
D'Arcis, U. (1990). Outcome evaluation in brief mother‐infant psychotherapy: A
preliminary report. Infant Mental Health Journal, 11(3), 278-300.

57 www.annafreud.org
Anna Freud National Centre for Children and Families

Cuijpers, P., Weitz, E., Cristea, I. A., & Twisk, J. (2017). Pre-post effect sizes should be
avoided in meta-analyses. Epidemiology and Psychiatric Sciences, 26(4), 364-368.

Datta, J., & Petticrew, M. (2013). Challenges to evaluating complex interventions: a content
analysis of published papers. BMC public health, 13(1), 1-18.

de Camps Meschino, D., Philipp, D., Israel, A., & Vigod, S. (2016). Maternal-infant mental
health: postpartum group intervention. Archives of women's mental health, 19(2),
243–251. https://doi.org/10.1007/s00737-015-0551-y

Felitti, V. J. (2009). Adverse childhood experiences and adult health. Academic Pediatrics,
9(3), 131-132.

Fisher, S. D., Cobo, J., Figueiredo, B., Fletcher, R., Garfield, C. F., Hanley, J., ... & Singley, D. B.
(2021). Expanding the international conversation with fathers’ mental health:
Toward an era of inclusion in perinatal research and practice. Archives of Women's
Mental Health, 24(5), 841-848.

Fonagy, P., & Bateman, A. W. (2007). Mentalizing and borderline personality disorder.
Journal of Mental Health, 16(1), 83-101.

Fonagy, P., Sleed, M., & Baradon, T. (2016). Randomized Controlled Trial Of Parent-Infant
Psychotherapy For Parents With Mental Health Problems And Young Infants. Infant
Mental Health Journal, 37(2), 97–114. https://Doi.Org/10.1002/Imhj.21553

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the Nursery: A Psychoanalytic
Approach to the Problems of Impaired Infant-Mother Relationships. Journal of the
American Academy of Child Psychiatry, 14(3), 387-421.

Franz, M., Weihrauch, L., & Schäfer, R. (2011). PALME: a preventive parental training
program for single mothers with preschool aged children. Journal of Public
Health, 19(4), 305-319. https://doi.org/10.1007/s10389-011-0396-4

Freud, A. (1965). Normality and Pathology in Childhood. London: Hogarth Press.

Gach, E. J., Ip, K. I., Sameroff, A. J., & Olson, S. L. (2018). Early cumulative risk predicts
externalizing behavior at age 10: The mediating role of adverse parenting. Journal of
Family Psychology, 32(1), 92.

Geissmann, P. & Geissmann, C. (1997) A History of Child Psychoanalysis. London: Routledge.

Georg, A. K., Cierpka, M., Schröder-Pfeifer, P., Kress, S., & Taubner, S. (2021). The efficacy of
brief parent− infant psychotherapy for treating early regulatory disorders: A

58 www.annafreud.org
Anna Freud National Centre for Children and Families

randomized controlled trial. Journal of the American Academy of Child & Adolescent
Psychiatry, 60(6), 723-733.https://doi.org/10.1016/j.jaac.2020.06.016

Ghosh Ippen, C., Harris, W. W., Van Horn, P., & Lieberman, A. F. (2011). Traumatic and
stressful events in early childhood: can treatment help those at highest risk?. Child
abuse & neglect, 35(7), 504–513. https://doi.org/10.1016/j.chiabu.2011.03.009

Goodman, S. H., Rouse, M. H., Connell, A. M., Broth, M. R., Hall, C. M., & Heyward, D.
(2011). Maternal depression and child psychopathology: A meta-analytic review.
Clinical Child and Family Psychology Review, 14(1), 1-27.

Guild, D. J., Alto, M. E., Handley, E. D., Rogosch, F., Cicchetti, D., & Toth, S. L. (2021).
Attachment and affect between mothers with depression and their children:
longitudinal outcomes of child parent psychotherapy. Research on Child and
Adolescent Psychopathology, 49(5), 563-577. https://doi.org/10.1007/s10802-020-
00681-0

Hagan, M. J., Browne, D. T., Sulik, M., Ippen, C. G., Bush, N., & Lieberman, A. F. (2017).
Parent and Child Trauma Symptoms During Child-Parent Psychotherapy: A
Prospective Cohort Study of Dyadic Change. Journal of traumatic stress, 30(6), 690–
697. https://doi.org/10.1002/jts.22240

Huber, A., Mcmahon, C. A., & Sweller, N. (2015). Efficacy Of The 20-Week Circle Of Security
Intervention: Changes In Caregiver Reflective Functioning, Representations, And
Child Attachment In An Australian Clinical Sample. Infant Mental Health
Journal, 36(6), 556–574. https://Doi.Org/10.1002/Imhj.21540

Huber, A., McMahon, C., & Sweller, N. (2015). Improved child behavioural and emotional
functioning after Circle of Security 20-week intervention. Attachment & human
development, 17(6), 547–569. https://doi.org/10.1080/14616734.2015.1086395

Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., ... & Dunne, M.
P. (2017). The effect of multiple adverse childhood experiences on health: a
systematic review and meta-analysis. The Lancet Public Health, 2(8), e356-e366.

Juffer, F., Bakermans-Kranenburg, M. J., & Van Ijzendoorn, M. H. (2018). Video-feedback

intervention to promote positive parenting and sensitive discipline. Handbook of
Attachment-Based Interventions. New York: Guilford.

Jurist, E., Slade, A., Bergner, S. (eds). (2008) Mind to Mind: Infant Research, Neuroscience
and Psychoanalysis. London: Other Press

Jussila, H., Ekholm, E., & Pajulo, M. (2021). A new parental mentalization focused ultrasound
intervention for substance using pregnant women. Effect on self-reported prenatal

59 www.annafreud.org
Anna Freud National Centre for Children and Families

mental health, attachment and mentalization in a randomized and controlled

trial. International Journal of Mental Health and Addiction, 19(4), 947-970.
https://doi.org/10.1007/s11469-019-00205-y

Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood

experiences: A systematic review. Journal of the American Association of Nurse
Practitioners, 27(8), 457-465.

Klein Velderman, M., Bakermans-Kranenburg, M. J., Juffer, F., Van IJzendoorn, M. H.,
Mangelsdorf, S. C., & Zevalkink, J. (2006). Preventing preschool externalizing
behavior problems through video-feedback intervention in infancy. Infant mental
health journal, 27(5), 466–493. https://doi.org/10.1002/imhj.20104

Kohlhoff, J., Stein, M., Ha, M., & Mejaha, K. (2016). The circle of security parenting (COS-P)
intervention: Pilot evaluation. Australian Journal of Child and Family Health
Nursing, 13(1), 3-7.

Kurzweil, S. (2008a). Relational-developmental therapy group for postnatal

depression. International journal of group psychotherapy, 58(1), 17–34.
https://doi.org/10.1521/ijgp.2008.58.1.17

Kurzweil, S. (2008b). Playspace: A preventive intervention for infants and young children at
risk from postnatal depression. International Journal of Mental Health
Promotion, 10(1), 5-15. https://doi.org/10.1080/14623730.2008.9721752

Kurzweil, S. (2012). Psychodynamic therapy for depression in women with infants and young
children. American journal of psychotherapy, 66(2), 181–199.
https://doi.org/10.1176/appi.psychotherapy.2012.66.2.181

Lavi, I., Gard, A. M., Hagan, M., Van Horn, P., & Lieberman, A. F. (2015). Child-parent
psychotherapy examined in a perinatal sample: Depression, posttraumatic stress
symptoms and child-rearing attitudes. Journal of Social and Clinical
Psychology, 34(1), 64. https://doi.org/10.1521/jscp.2015.34.1.64

Letourneau, N. L., Dennis, C. L., Cosic, N., & Linder, J. (2017). The effect of perinatal
depression treatment for mothers on parenting and child development: A systematic
review. Depression and Anxiety, 34(10), 928-966.

Letourneau, N., Anis, L., Ntanda, H., Novick, J., Steele, M., Steele, H., & Hart, M. (2020).
Attachment & Child Health (ATTACH) pilot trials: Effect of parental reflective function
intervention for families affected by toxic stress. Infant mental health journal, 41(4),
445-462. https://doi.org/10.1002/imhj.21833

60 www.annafreud.org
Anna Freud National Centre for Children and Families

Lieberman, A. F., Ippen, C. G., & Van Horn, P. (2006). Child-parent psychotherapy: 6-month
follow-up of a randomized controlled trial. Journal of the American Academy of Child
& Adolescent Psychiatry, 45(8), 913-918.
https://doi.org/10.1097/01.chi.0000222784.03735.92

Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment:
child-parent psychotherapy with preschoolers exposed to marital violence. Journal
of the American Academy of Child and Adolescent Psychiatry, 44(12), 1241–1248.
https://doi.org/10.1097/01.chi.0000181047.59702.58

Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs-Gowan, M. J. (2011). A randomized
controlled trial of Child FIRST: a comprehensive home-based intervention translating
research into early childhood practice. Child development, 82(1), 193–208.
https://doi.org/10.1111/j.1467-8624.2010.01550.x

Lyons-Ruth, K., Pechtel, P., Yoon, S. A., Anderson, C. M., & Teicher, M. H. (2016).
Disorganized attachment in infancy predicts greater amygdala volume in
adulthood. Behavioural brain research, 308, 83-93.

Lyons‐Ruth, K., Todd Manly, J., Von Klitzing, K., Tamminen, T., Emde, R., Fitzgerald, H., ... &
Watanabe, H. (2017). The worldwide burden of infant mental and emotional
disorder: report of the task force of the world association for infant mental
health. Infant Mental Health Journal, 38(6), 695-705.

Maupin, A. N., Samuel, E. E., Nappi, S. M., Heath, J. M., & Smith, M. V. (2017). Disseminating
a parenting intervention in the community: Experiences from a multi-site
evaluation. Journal of Child and Family Studies, 26(11), 3079-3092.
https://doi.org/10.1007/s10826-017-0804-7

Maxwell, A. M., McMahon, C., Huber, A., Reay, R. E., Hawkins, E., & Barnett, B. (2021).
Examining the effectiveness of Circle of Security Parenting (COS-P): A multi-site non-
randomized study with waitlist control. Journal of Child and Family Studies, 30(5),
1123-1140. https://doi.org/10.1007/s10826-021-01932-4

Menashe-Grinberg, A., Shneor, S., Meiri, G., & Atzaba-Poria, N. (2022). Improving the
parent-child relationship and child adjustment through parental reflective
functioning group intervention. Attachment & human development, 24(2), 208–228.
https://doi.org/10.1080/14616734.2021.1919159

Midgley, N., Anderson, J., Grainger, E., Nesic, T. and Urwin, C. (eds.) (2009), Child
Psychotherapy and Research: New Directions, Emerging Findings, London:
Routledge.

61 www.annafreud.org
Anna Freud National Centre for Children and Families

Midgley, N., & Vrouva, I. (Eds.). (2013). Minding the child: Mentalization-based
interventions with children, young people and their families. Routledge.

Midgley, N., Mortimer, R., Cirasola, A., Batra, P., & Kennedy, E. (2021). The evidence-base
for psychodynamic psychotherapy with children and adolescents: A narrative
synthesis. Frontiers in Psychology, 12, 1188.

Mikton, C., & Butchart, A. (2009). Child maltreatment prevention: a systematic review of
reviews. Bulletin of the World Health Organization, 87, 353-361.

Müller, J. M., Averbeck-Holocher, M., Romer, G., Fürniss, T., Achtergarde, S., & Postert, C.
(2015). Psychiatric treatment outcomes of preschool children in a family day
hospital. Child Psychiatry and Human Development, 46(2), 257–269.
https://doi.org/10.1007/s10578-014-0465-3

Murray, L., Cooper, P. J., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and
long-term effect of psychological treatment of post-partum depression: 2. Impact on
the mother-child relationship and child outcome. The British Journal of Psychiatry:
the journal of mental science, 182, 420–427.

Music, G. (2016). Nurturing natures: Attachment and children's emotional, sociocultural and
brain development. London, Routledge.

Muzik, M., Rosenblum, K. L., Alfafara, E. A., Schuster, M. M., Miller, N. M., Waddell, R. M., &
Stanton Kohler, E. (2015). Mom Power: preliminary outcomes of a group
intervention to improve mental health and parenting among high-risk
mothers. Archives of women's mental health, 18(3), 507–521.
https://doi.org/10.1007/s00737-014-0490-z

Nanzer, N., Sancho Rossignol, A., Righetti-Veltema, M., Knauer, D., Manzano, J., & Palacio
Espasa, F. (2012). Effects of a brief psychoanalytic intervention for perinatal
depression. Archives of women's mental health, 15(4), 259–268.
https://doi.org/10.1007/s00737-012-0285-z

Ordway, M. R., Sadler, L. S., Dixon, J., Close, N., Mayes, L., & Slade, A. (2014). Lasting effects
of an interdisciplinary home visiting program on child behavior: preliminary follow-
up results of a randomized trial. Journal of pediatric nursing, 29(1), 3–13.
https://doi.org/10.1016/j.pedn.2013.04.006

Ordway, M. R., Sadler, L. S., Holland, M. L., Slade, A., Close, N., & Mayes, L. C. (2018). A
Home Visiting Parenting Program and Child Obesity: A Randomized
Trial. Pediatrics, 141(2), e20171076. https://doi.org/10.1542/peds.2017-1076

62 www.annafreud.org
Anna Freud National Centre for Children and Families

Paris, R., Herriott, A., Holt, M., & Gould, K. (2015). Differential responsiveness to a parenting
intervention for mothers in substance abuse treatment. Child abuse & neglect, 50,
206–217. https://doi.org/10.1016/j.chiabu.2015.09.007

Parsons, C. E., Young, K. S., Murray, L., Stein, A., & Kringelbach, M. L. (2010). The functional
neuroanatomy of the evolving parent–infant relationship. Progress in Neurobiology,
91(3), 220-241.

Pozzi-Monzo, M., Lee, A., & Likierman, M. (2012). From reactive to reflective: evidence for
shifts in parents' state of mind during brief under-fives psychoanalytic
psychotherapy. Clinical child psychology and psychiatry, 17(1), 151–164.
https://doi.org/10.1177/1359104511403682

Ransley, R., Sleed, M., Baradon, T., & Fonagy, P. (2019). “What support would you find
helpful?” The relationship between treatment expectations, therapeutic
engagement, and clinical outcomes in parent–infant psychotherapy. Infant Mental
Health Journal, 40(4), 557-572. https://doi.org/10.1002/imhj.21787

Raphael-Leff, J. (2019). Parent-Infant Psychodynamics: Wild Things, Mirrors and Ghosts.

Routledge.

Rosen, C., Faust, J., & Burns, W. J. (1994). The evaluation of process and outcome in
individual child psychotherapy. International Journal of Play Therapy, 3(2), 33–
43. https://doi.org/10.1037/h0089031

Rosenblum, K. L., Muzik, M., Jester, J. M., Huth‐Bocks, A., Erickson, N., Ludtke, M., ... & the
Michigan Collaborative for Infant Mental Health Research. (2020). Community‐
delivered infant–parent psychotherapy improves maternal sensitive caregiving:
Evaluation of the Michigan model of infant mental health home visiting. Infant
Mental Health Journal, 41(2), 178-190. https://doi.org/10.1002/imhj.21840

Rosenblum, K., Lawler, J., Alfafara, E., Miller, N., Schuster, M., & Muzik, M. (2018).
Improving Maternal Representations in High-Risk Mothers: A Randomized,
Controlled Trial of the Mom Power Parenting Intervention. Child psychiatry and
human development, 49(3), 372–384. https://doi.org/10.1007/s10578-017-0757-5

Roubinov, D., Browne, D., LeWinn, K. Z., Lisha, N., Mason, W. A., & Bush, N. R. (2022).
Intergenerational transmission of maternal childhood adversity and depression on
children's internalizing problems. Journal of Affective Disorders, 308, 205-212.

Sadler, L. S., Slade, A., Close, N., Webb, D. L., Simpson, T., Fennie, K., & Mayes, L. C. (2013).
Minding the Baby: Enhancing reflectiveness to improve early health and relationship

63 www.annafreud.org
Anna Freud National Centre for Children and Families

outcomes in an interdisciplinary home visiting program. Infant mental health

journal, 34(5), 391–405. https://doi.org/10.1002/imhj.21406

Sadowski, C., Goff, R., & Sawyer, N. (2022). A Mixed-Methods Study of Two Modes of the
Circle of Security. Research on Social Work Practice, 32(1), 49–60.
https://doi.org/10.1177/10497315211009315

Salo, S., Flykt, M., Mäkelä, J., Biringen, Z., Kalland, M., Pajulo, M., & Punamäki, R. (2019). The
effectiveness of Nurture and Play: A mentalisation-based parenting group
intervention for prenatally depressed mothers. Primary Health Care Research &
Development, 20, E157. https://doi.org/10.1017/S1463423619000914

Salomonsson, B. (2014). Psychodynamic therapies with infants and parents: A critical review
of treatment methods. Psychodynamic Psychiatry, 42(2), 203-233.

Salomonsson, B., & Sandell, R. (2011). A randomized controlled trial of mother-infant

psychoanalytic treatment: II. Predictive and moderating influences of qualitative
patient factors. Infant mental health journal, 32(3), 377–404.
https://doi.org/10.1002/imhj.20302

Salomonsson, B., & Sandell, R. (2011). A randomized controlled trial of mother-infant

psychoanalytic treatment: I. Outcomes on self-report questionnaires and external
ratings. Infant mental health journal, 32(2), 207–231.
https://doi.org/10.1002/imhj.20291

Salomonsson, B., Kornaros, K., Sandell, R., Nissen, E., & Lilliengren, P. (2021). Short-term
psychodynamic infant-parent interventions at child health centers: outcomes on
parental depression and infant social-emotional functioning. Infant mental health
journal, 42(1), 109–123. https://doi.org/10.1002/imhj.21893

Salomonsson, M. W., Sorjonen, K., & Salomonsson, B. (2015). A long-term follow-up study of
a randomized controlled trial of mother-infant psychoanalytic treatment: outcomes
on mothers and interactions. Infant mental health journal, 36(6), 542–555.
https://doi.org/10.1002/imhj.21536

Salomonsson, M. W., Sorjonen, K., & Salomonsson, B. (2015). A long-term follow-up of a

randomized controlled trial of mother-infant psychoanalytic treatment: outcomes on
the children. Infant mental health journal, 36(1), 12–29.
https://doi.org/10.1002/imhj.21478

Sanger, C., Iles, J. E., Andrew, C. S., & Ramchandani, P. G. (2015). Associations between
postnatal maternal depression and psychological outcomes in adolescent offspring: a
systematic review. Archives of women's mental health, 18(2), 147-162.

64 www.annafreud.org
Anna Freud National Centre for Children and Families

Sameroff, A. J., & Rosenblum, K. L. (2006). Psychosocial constraints on the development of

resilience. Annals of the New York Academy of Sciences, 1094(1), 116-124.

Sameroff, A. J., & Seifer, R. (1995). Accumulation of environmental risk and child mental
health. In Hi.E. Fitzgerald, B.M. Lester & B. Zuckerman. Children of Poverty (pp. 233-
258). New York: Routledge.

Schechter, D. S., Myers, M. M., Brunelli, S. A., Coates, S. W., Zeanah, C. H., Davies, M.,
Grienenberger, J. F., Marshall, R. D., McCaw, J. E., Trabka, K. A., & Liebowitz, M. R.
(2006). Traumatized mothers can change their minds about their toddlers:
Understanding how a novel use of videofeedback supports positive change of
maternal attributions. Infant mental health journal, 27(5), 429–447.
https://doi.org/10.1002/imhj.20101

Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of
emotional development. Mahwah, NJ: Erlbaum.

Schore, A. N. (2002). The neurobiology of attachment and early personality organization.

Journal of Prenatal and Perinatal Psychology and Health, 16, 249-264.

Sealy, J., & Glovinsky, I. P. (2016). Strengthening the reflective functioning capacities of
parents who have a child with a neurodevelopmental disability through a brief,
relationship-focused intervention. Infant mental health journal, 37(2), 115–124.
https://doi.org/10.1002/imhj.21557

Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO
framework to improve searching PubMed for clinical questions. BMC medical
informatics and decision making, 7(1), 1-6.

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and
the childhood roots of health disparities: building a new framework for health
promotion and disease prevention. JAMA, 301(21), 2252-2259.

Slade, A., Bernbach, E., Grienenberger, J., Levy, D., & Locker, A. (2004). Addendum to
Fonagy, Target, Steele, & Steele reflective functioning scoring manual for use with
the Parent Development Interview. Unpublished Manuscript, The City College and
Graduate Center of the City University of New York, New York, New York.

Slade, A., Holland, M. L., Ordway, M. R., Carlson, E. A., Jeon, S., Close, N., Mayes, L. C., &
Sadler, L. S. (2020). Minding the Baby®: Enhancing parental reflective functioning
and infant attachment in an attachment-based, interdisciplinary home visiting
program. Development and psychopathology, 32(1), 123–137.
https://doi.org/10.1017/S0954579418001463

65 www.annafreud.org
Anna Freud National Centre for Children and Families

Slade, A., Patterson, M., & Miller, M. (2007). The Pregnancy Interview manual. The
Psychological Center, The City College of New York, New York.

Sleed, M., Baradon, T., & Fonagy, P. (2013). New Beginnings for mothers and babies in
prison: a cluster randomized controlled trial. Attachment & human
development, 15(4), 349–367. https://doi.org/10.1080/14616734.2013.782651

Sleed, M., James, J., Baradon, T., Newbery, J., & Fonagy, P. (2013). A psychotherapeutic
baby clinic in a hostel for homeless families: practice and evaluation. Psychology and
psychotherapy, 86(1), 1–18. https://doi.org/10.1111/j.2044-8341.2011.02050.x

Stacks, A. M., Barron, C. C., & Wong, K. (2019). Infant mental health home visiting in the
context of an infant—toddler court team: changes in parental responsiveness and
reflective functioning. Infant mental health journal, 40(4), 523-540.
https://doi.org/10.1002/imhj.21785

Stacks, A. M., Jester, J. M., Wong, K., Huth-Bocks, A., Brophy-Herb, H., Lawler, J., Riggs, J.,
Ribaudo, J., Muzik, M., & Rosenblum, K. L. (2022). Infant mental health home
visiting: intervention dosage and therapist experience interact to support
improvements in maternal reflective functioning. Attachment & human
development, 24(1), 53–75. https://doi.org/10.1080/14616734.2020.1865606

Stronach, E. P., Toth, S. L., Rogosch, F., & Cicchetti, D. (2013). Preventive interventions and
sustained attachment security in maltreated children. Development and
psychopathology, 25(4 Pt 1), 919–930. https://doi.org/10.1017/S0954579413000278

Suchman, N. E., DeCoste, C. L., McMahon, T. J., Dalton, R., Mayes, L. C., & Borelli, J. (2017).
Mothering From the Inside Out: Results of a second randomized clinical trial testing a
mentalization-based intervention for mothers in addiction treatment. Development
and psychopathology, 29(2), 617–636. https://doi.org/10.1017/S0954579417000220

Suchman, N. E., DeCoste, C., Castiglioni, N., McMahon, T. J., Rounsaville, B., & Mayes, L.
(2010). The Mothers and Toddlers Program, an attachment-based parenting
intervention for substance using women: post-treatment results from a randomized
clinical pilot. Attachment & human development, 12(5), 483–504.
https://doi.org/10.1080/14616734.2010.501983

Suchman, N. E., Decoste, C., Mcmahon, T. J., Rounsaville, B., & Mayes, L. (2011). The
mothers and toddlers program, an attachment‐based parenting intervention for
substance‐using women: Results at 6‐week follow‐up in a randomized clinical
pilot. Infant mental health journal, 32(4), 427-449.
https://doi.org/10.1002/imhj.20303

66 www.annafreud.org
Anna Freud National Centre for Children and Families

Suchman, N. E., Decoste, C., Rosenberger, P., & McMahon, T. J. (2012). Attachment-based
intervention for substance-using mothers: a preliminary test of the proposed
mechanisms of change. Infant mental health journal, 33(4), 360–371.
https://doi.org/10.1002/imhj.21311

Suchman, N. E., Ordway, M. R., de Las Heras, L., & McMahon, T. J. (2016). Mothering from
the Inside Out: results of a pilot study testing a mentalization-based therapy for
mothers enrolled in mental health services. Attachment & human
development, 18(6), 596–617. https://doi.org/10.1080/14616734.2016.1226371

Suchman, N., Berg, A., Abrahams, L., Abrahams, T., Adams, A., Cowley, B., Decoste, C.,
Hawa, W., Lachman, A., Mpinda, B., Cader-Mokoa, N., Nama, N., & Voges, J. (2020).
Mothering from the Inside Out: Adapting an evidence-based intervention for high-
risk mothers in the Western Cape of South Africa. Development and
psychopathology, 32(1), 105–122. https://doi.org/10.1017/S0954579418001451

Suchman, N., Decoste, C., Castiglioni, N., Legow, N., & Mayes, L. (2008). The mothers and
toddlers program: preliminary findings from an attachment-based parenting
intervention for substance-abusing mothers. Psychoanalytic psychology: the official
journal of the Division of Psychoanalysis, American Psychological Association,
Division 39, 25(3), 499–517. https://doi.org/10.1037/0736-9735.25.3.499

Tambelli, R., Cerniglia, L., Cimino, S., & Ballarotto, G. (2015). Parent-infant interactions in
families with women diagnosed with postnatal depression: A longitudinal study on
the effects of a psychodynamic treatment. Frontiers in Psychology, 6, Article
1210. https://doi.org/10.3389/fpsyg.2015.01210

Target, M., & Fonagy, P. (1994). The efficacy of psychoanalysis for children: prediction of
outcome in a developmental context. Journal of the American Academy of Child and
Adolescent Psychiatry, 33(8), 1134–1144. https://doi.org/10.1097/00004583-
199410000-00009

Thome, M., & Skuladottir, A. (2005). Evaluating a family-centred intervention for infant
sleep problems. Journal of advanced nursing, 50(1), 5–11.
https://doi.org/10.1111/j.1365-2648.2004.03343.x

Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler-parent
psychotherapy to reorganize attachment in the young offspring of mothers with
major depressive disorder: a randomized preventive trial. Journal of consulting and
clinical psychology, 74(6), 1006–1016. https://doi.org/10.1037/0022-006X.74.6.1006

Toth, S. L., Sturge-Apple, M. L., Rogosch, F. A., & Cicchetti, D. (2015). Mechanisms of change:
Testing how preventative interventions impact psychological and physiological stress

67 www.annafreud.org
Anna Freud National Centre for Children and Families

functioning in mothers in neglectful families. Development and

psychopathology, 27(4 Pt 2), 1661–1674.
https://doi.org/10.1017/S0954579415001017

Waters, S. F., Hagan, M. J., Rivera, L., & Lieberman, A. F. (2015). Improvements in the Child‐
Rearing Attitudes of Latina Mothers Exposed to Interpersonal Trauma Predict
Greater Maternal Sensitivity Toward Their 6‐Month‐Old Infants. Journal of traumatic
stress, 28(5), 426-433. https://doi.org/10.1002/jts.22043

Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment security
in infancy and early adulthood: A twenty‐year longitudinal study. Child
development, 71(3), 684-689.

Weihrauch, L., Schäfer, R., & Franz, M. (2014). Long-term efficacy of an attachment-based
parental training program for single mothers and their children: A randomized
controlled trial. Journal of Public Health, 22(2), 139–
153. https://doi.org/10.1007/s10389-013-0605-4

Williford, A. P., LoCasale, C. J., Whittaker, J. V., DeCoster, J., Hartz, K. A., Carter, L. M.,
Wolcott, C. S., & Hatfield, B. E. (2017). Changing Teacher-Child Dyadic Interactions to
Improve Preschool Children’s Externalizing Behaviors. Child Development, 88(5),
1544–1553. https://doi.org/10.1111/cdev.12703

Winnicott, D.W. (1977). Anxiety associated with insecurity 1952. In D.W. Winnicott & M.
Khan. Through paediatrics to psycho-analysis. New York, Basic Books, 1977. p.97-
101.

Zarnegar, Z., Hambrick, E. P., Perry, B. D., Azen, S. P., & Peterson, C. (2016). Clinical
improvements in adopted children with fetal alcohol spectrum disorders through
neurodevelopmentally informed clinical intervention: a pilot study. Clinical Child
Psychology and Psychiatry, 21(4), 551-567.
https://doi.org/10.1177/1359104516636438

Supplementary material
Table S3. Quality Assessment of Controlled Intervention Studies

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Author, Item Quality

country 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Rating

Mentalization Based Interventions

Anis et al. Y Y Y N Y Y Y Y NR Y Y NR Y Y Poor
(2020) &
Letourneau et
al. (2020)
Suchman et al. Y Y Y N Y NR Y Y Y Y Y NR Y NR Poor
(2010, 2011,
2012), USA
Suchman et al. Y Y Y N Y Y Y Y Y Y Y NR Y Y Good
(2017), USA
Ordway et al. Y Y Y N Y N Y Y NR Y Y NR Y NR Fair
(2014), USA
Ordway et al. Y Y Y N NA Y N Y NR Y Y NR Y Y Fair
(2018), USA
Sadler et al., Y Y Y N Y Y N Y NR Y Y NR Y NR Fair
(2013), USA
Slade et al. Y Y Y N Y Y N Y Y Y Y NR Y Y Fair
(2020), USA
Sealy & Y Y Y N Y Y Y Y NR Y Y NR NR NR Fair
Glovinsky
(2016),
Barbados
Salo et al. Y Y Y N NR Y Y Y NR Y Y NR Y NR Poor
(2019), Finland
Jussila et al., Y Y Y N NR Y Y Y NR Y Y NR Y Y Good
(2021), Finland

Attachment Based Interventions

Williford et al. Y Y Y N Y Y Y Y Y Y Y Y Y Y Good
(2017), USA
Rosenblum et Y Y Y N Y Y N Y Y Y Y N Y NR Fair
al. (2018), USA
Franz et al. Y Y Y N NR N N N Y Y Y NR N Y Poor
(2011),
Germany

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Author, Item Quality

country 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Rating
Weihrauch et Y Y Y N Y N N N Y Y Y N Y NR Fair
al. (2014),
Germany
Huber et al. N N N N Y N Y Y Y Y Y NR Y NR Poor
(2015a,
2015b),
Australia
Maxwell et al. N N N N N N N N Y Y Y NR Y N Fair
(2021),
Australia

Psychodynamic/Psychoanalytic Psychotherapy
Bain (2014), Y N N N N Y N N N NR Y N NR N Poor
South Africa
Sleed et al. Y Y N N Y N N N NR Y Y NR NR Y Fair
(2013b), UK
Lieberman et Y Y Y N Y Y Y Y Y Y Y N Y Y Fair
al. (2005,
2006) & Ippen
et al. (2011),
USA
Toth et al. Y Y Y N NR Y Y Y Y Y Y NR Y Y Good
(2015), USA
Cicchetti et al. Y Y Y N Y N N N Y Y Y NR Y NR Fair
(1999), USA
Cicchetti et al. N Y Y N Y Y N N Y Y Y NR Y NR Fair
(2000), USA
Toth et al. Y Y Y N Y Y Y Y Y Y Y NR Y Y Good
(2006) & Guild
et al. (2021),
USA
Fonagy et al. Y Y Y N Y Y Y Y Y Y Y Y Y Y Fair
(2016), UK
Georg et al. Y Y Y N Y Y Y Y Y Y Y Y Y Y Good
(2021),
Germany

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Author, Item Quality

country 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Rating
Sleed et al. N N N N Y Y Y Y NR Y Y NR Y NR Poor
(2013a), UK
Cramer et al. N N N N N Y Y Y NR Y Y NR N NR Poor
(1990), Italy
Salomonsson Y Y Y N Y NR Y Y Y Y Y NR Y Y Fair
et al. (2011a,
2011b, 2015a,
2015b),
Sweden
Salomonsson N N N N N N Y Y N Y Y NR N NR Poor
et al. (2021),
Sweden
Lowell et al. Y Y Y N N Y Y Y Y Y Y NR Y Y Good
(2011), USA
Murray et al. N Y Y N Y NR Y Y NR Y Y NR Y NR Good
(2003), UK
Rosen et al. N Y Y N Y NR Y Y Y Y Y NR N NR Poor
(1994), USA
Cohen et al. N Y Y N Y Y Y Y NR Y Y NR Y N Fair
(1999, 2002),
Canada

Notes: The 14 items for Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or
an RCT?
2. Was the method of randomization adequate (i.e., use of randomly generated
assignment)?
3. Was the treatment allocation concealed (so that assignments could not be predicted)?

4. Were study participants and providers blinded to treatment group assignment?

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5. Were the people assessing the outcomes blinded to the participants' group assignments?
6. Were the groups similar at baseline on important characteristics that could affect
outcomes (e.g., demographics, risk factors, co-morbid conditions)?
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number
allocated to treatment?
8. Was the differential drop-out rate (between treatment groups) at endpoint 15
percentage points or lower?
9. Was there high adherence to the intervention protocols for each treatment group?
10. Were other interventions avoided or similar in the groups (e.g., similar background
treatments)
11. Were outcomes assessed using valid and reliable measures, implemented consistently
across all study participants?
12. Did the authors report that the sample size was sufficiently large to be able to detect a
difference in the main outcome between groups with at least 80% power?
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before
analyses were conducted)?
14. Were all randomized participants analyzed in the group to which they were originally
assigned, i.e., did they use an intention-to-treat analysis?
Quality Rating (Good, Fair, or Poor)

*CD, cannot determine; NA, not applicable; NR, not reported

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Table S4. Quality Assessment for Pre-Post Studies with No Control Group

Item Quality
Author, country
1 2 3 4 5 6 7 8 9 10 11 12 Rating
Mentalization Based Interventions
Suchman et al. (2008),
Y Y Y Y N N Y NR N Y N NA Poor
USA
Suchman et al. (2016),
Y Y Y Y N Y Y Y Y Y N NA Poor
USA
Rosenblum et al.
Y Y Y N Y Y Y N N Y N NA Good
(2020), USA
Stacks et al. (2019),
Y Y Y Y N Y Y N NR Y N NA Poor
USA
Stacks et al. (2021),
Y Y Y N Y Y Y Y NR Y N NA Good
USA
Schechter et al. (2006),
Y Y Y N N Y Y NR NR Y N NA Fair
USA

Attachment Based Interventions

Muzik et al. (2015),
Y Y Y N Y Y Y Y NR Y N Y Good
USA
Kohlhoff et al. (2016) Y Y Y Y N Y Y NR Y Y N NA Poor
Velderman et al,
Y Y Y NR Y Y Y Y NR Y N NA Good
(2006), Netherlands

Psychodynamic/Psychoanalytic Psychotherapy
Waters et al. (2015),
Y Y Y N N Y Y NR NR Y N NA Good
USA
Zarnegar et al. (2016),
Y Y Y N N Y Y Y NR Y N NA Poor
USA
Belt et al, (2012),
Y N Y NR N Y Y Y NR Y N NA Good
Finland
Menashe-Grinber et al.
Y N Y NR Y Y Y Y NR Y N Y Fair
(2021), Israel
Nanzer et al. (2012),
Y Y Y NR N Y Y NR NR Y N NA Fair
Switzerland
Thome et al. (2005),
Y Y Y NR N Y Y NR NR Y N NA Good
Iceland

Notes: The 12 items for Quality Assessment Tool for Before-After (Pre-Post) Studies with
No Control Group

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Anna Freud National Centre for Children and Families

1. Was the study question or objective clearly stated?

2. Were eligibility/selection criteria for the study population prespecified and clearly
described?
3. Were the participants in the study representative of those who would be eligible for the
test/service/intervention in the general or clinical population of interest?
4. Were all eligible participants that met the prespecified entry criteria enrolled?
5. Was the sample size sufficiently large to provide confidence in the findings?
6. Was the test/service/intervention clearly described and delivered consistently across the
study population?
7. Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed
consistently across all study participants?
8. Were the people assessing the outcomes blinded to the participants'
exposures/interventions?
9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up
accounted for in the analysis?
10. Did the statistical methods examine changes in outcome measures from before to after
the intervention? Were statistical tests done that provided p values for the pre-to-post
changes?
11. Were outcome measures of interest taken multiple times before the intervention and
multiple times after the intervention (i.e., did they use an interrupted time-series design)?
12. If the intervention was conducted at a group level (e.g., a whole hospital, a community,
etc.) did the statistical analysis take into account the use of individual-level data to
determine effects at the group level?
Quality Rating (Good, Fair, or Poor)

*CD, cannot determine; NA, not applicable; NR, not reported

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