Child Abuse Review Vol.

23: 426–439 (2014)

Published online 14 March 2014 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/car.2313

Laura Kerr* Attachment Interventions

Jill Cossar
Section of Clinical and Health
Psychology, The University of
with Foster and Adoptive
Parents: A Systematic
Edinburgh Medical School, UK

Review
Children who have been adopted or fostered are at high risk of experiencing
interpersonal difficulties and placement breakdown may occur if these difficulties are
not addressed through interventions. The aim of this review was to identify the impact
of attachment interventions with foster and adoptive parents on children’s behavioural,
emotional and relational functioning. A systematic search process was undertaken;
electronic databases were searched; key journals were hand searched; reference lists of
included articles were searched; and authors who have published work in the field were
‘Ten studies met the contacted. Ten studies met the inclusion criteria. There is some evidence to support the
positive impact of these interventions for children, particularly young children aged six
inclusion criteria’ months to six years. However, overall, the studies were of relatively poor methodological
quality, making conclusions about the efficacy of these interventions difficult. Further
research is therefore required to draw clearer conclusions about the impact of attachment
interventions for fostered and adopted children. Copyright © 2014 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGES:

• A number of the reviewed studies reported positive outcomes in child behavioural
functioning and to a lesser degree in emotional and relational functioning following
intervention.
• Interventions focused on constructs such as parental sensitivity, attunement to the
child and the impact of abuse and neglect on attachment to new caregivers.
‘Two studies focused • When quality criteria were applied, two studies focused on children aged six months
to six years were found to be methodologically strong, providing some evidence for
on children aged six the benefit of early attachment-based interventions within this population.
months to six years
KEY WORDS: adoption; attachment; foster care; interventions
were found to be
methodologically
Fostered and Adopted Children
strong’
he use of foster care for children who have been abused and/or neglected
T within their family of origin is common practice across Western societies
(Warman and Roberts, 2003). Children who are adopted, whether internationally
‘These children
(Zeanah et al., 2009) or domestically from within child welfare systems, are also
experience more likely to have been exposed to abuse and/or neglect (Rees and Selwyn, 2009). These
emotional and children experience more emotional and behavioural difficulties than those who are
behavioural difficulties not fostered or adopted (Meltzer et al., 2003; Simmel et al., 2001; Wiik et al., 2011).
than those who are not
* Correspondence to: Laura Kerr, Section of Clinical and Health Psychology, The University of Edinburgh
fostered or adopted’ Medical School, Teviot Place, Edinburgh EH8 9AG, UK. E-mail: laurakerr4@nhs.net

Copyright © 2014 John Wiley & Sons, Ltd. Accepted: 11 September 2013
 Attachment Interventions with Foster and Adoptive Parents 427

Breakdown of placements occurs in ten to 50 per cent of foster and non-infant

adoptive placements (Rees and Selwyn, 2009; Rushton, 2003; Ward, 2009) and is
associated with poorer psychosocial outcomes for children (Barber and Delfabbro,
2003). As a result of their early experiences and the negative consequences
associated with placement breakdown, interventions specifically targeting the needs
of fostered and adopted children are necessary (Barth et al., 2005).

Intervening Through Caregivers

The use of parenting interventions has become commonplace in the treatment of

child emotional and behavioural difficulties, and comprehensive reviews indicate
the efficacy of such interventions (Barlow et al., 2010; Furlong et al., 2012).
However, where these interventions have been trialled with foster or adoptive ‘Where these
parents specifically, the results suggest limited value (Everson-Hock et al., interventions have
2011; Turner et al., 2009). The theoretical basis of the interventions reviewed to
date has been cognitive-behavioural and the format has been a skills-based been trialled with
approach. However, the fostered/adopted population of children is different from foster or adoptive
children residing with their biological parents due to the prevalence of trauma parents specifically,
symptomology (Hoksbergen et al., 2003; Oswald et al., 2010) and therefore it
has been argued that these interventions alone should not be expected to impact
the results suggest
as positively in this more complex population (Hodges, 2005). limited value’

Attachment Theory

Attachment theory has become an increasingly popular framework for understanding

the difficulties experienced by fostered and adopted children (Zeanah et al., 2011). It
proposes that infants require a relationship with an emotionally sensitive caregiver
who provides consistent, predictable and attuned care throughout their early years
(Bowlby, 1988). When such a caregiver is present and responds sensitively to the
child, an internal working model of the carer as safe, containing and trustworthy is
developed. This ‘secure base’ allows the child to feel safe in his/her exploration of
the environment (Bowlby, 1988). Both the early disruptions in care, which fostered
and adopted children experience within their family of origin, and the frequency of ‘Frequency of
placement moves once within the child welfare system mean that this ‘secure base’ placement moves
is unlikely to have been established (Van den Dries et al., 2009).
The impact of abusive and neglectful parenting on child neurodevelopment also once within the
provides answers as to why fostered/adopted children experience relational child welfare
difficulties in new placements. Such experiences impact negatively on the developing system mean that
stress regulatory system of the brain, meaning that children with early experiences of
abuse and neglect find it more difficult to regulate their emotions (Perry et al., 1995).
this ‘secure base’
Where the caregiving relationship itself is a source of stress, for example, in is unlikely to have
abusive/neglectful parenting, the experience of interacting with a caregiver can been established’
trigger distress (Schore, 2001), suggesting that accepting care from new adults,
in the form of both nurture and limits and boundaries, may be a difficult process.

Caregiver Attachment

The impact of caregivers′ attachment style on fostered and adopted children′s

attachment has also been the subject of recent study. Kaniuk et al. (2004) found
that adoptive mothers with secure attachment styles had more successful adoptions
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
428 Kerr and Cossar

than those with insecure attachment styles, and Pace et al. (2012) found that mothers
who were classified as secure-autonomous were more likely to have securely attached
adopted children six months post placement. In a fostered population, Dozier et al.
(2001) found that attachment styles were concordant between infants and their
‘Insecurely attached carers three months post placement, suggesting that insecurely attached infants
infants may shift to a may shift to a secure attachment pattern when placed with secure-autonomous adults.
secure attachment Attachment Theory-Based Interventions
pattern when placed
with secure- These threads of research have led to the development of attachment theory-
based interventions which target carer/parent attachment style and/or the
autonomous adults’ attachment between carer/parent and child. However, despite the extensive
use of attachment theory in the fields of fostering and adoption (Barth et al.,
2005), there has been no systematic review of the impact of such interventions.

Review Aims

The current review aimed to establish the impact of attachment theory-based

interventions with fostered and adopted children. As attachment theory is
concerned with relational functioning and the ability of caregivers to help children
regulate emotions, interventions which target children alone are not in keeping
with the principles of the theory (Zeanah et al., 2011). Therefore, only studies
which target parents/carers alone or those which target parent/carers and children
‘Three outcome factors were included in the review. Three outcome factors were considered in the review:
were considered in the children’s behavioural functioning was included due to the finding that
behavioural difficulties are predictive of placement breakdown (Oosterman
review: children’s et al., 2007); child emotional functioning was included due to the link between
behavioural functioning; attachment theory and emotion regulation; and child relational functioning was
child emotional also considered owing to the relational nature of the interventions.
functioning; and child Methods
relational functioning’
The review was conducted in line with the Centre for Reviews and Dissemination
(CRD) (http://www.york.ac.uk/inst/crd/) guidance on systematic review
methodology and reporting.

Inclusion and Exclusion Criteria

Population
Studies were included if their target population was foster carers and/or
adoptive parents of a child between birth and 18 years.

‘Studies were included if
they used a quantitative
evaluative design’
Design
Studies were included if they used a quantitative evaluative design. This
included pre and post intervention studies, longitudinal follow-up, controlled
studies and randomised controlled studies, but excluded single-case
descriptions or evaluations of interventions without quantitative analysis.

Intervention
Studies were included if they aimed to evaluate the impact of ‘attachment theory
based’ interventions on fostered or adopted children’s emotional, behavioural or
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
 Attachment Interventions with Foster and Adoptive Parents 429

relational functioning. Interventions were defined as ‘attachment theory based’ if

they met one of the following criteria:

• described the use of attachment theory as underpinning their development;

• aimed to improve the understanding of attachment theory in carers;
• aimed to improve the attachment relationship between the carer and child;
• aimed to improve the carer’s understanding of his/her own attachment style;
• aimed to improve the ability of the carer to manage the child’s difficulties using
attachment theory as a guiding principle.

Interventions which were described as psychoeducational, experiential, ‘Interventions which

therapeutic, group based or individual were included. Didactic training interventions, were described as
with no input from carers or parents, interventions focused solely on children and
interventions based on residential treatment of children were excluded. psychoeducational,
experiential,
Outcome Measures
therapeutic, group
Studies were included if they measured children′s emotional, behavioural or
relational functioning pre and post intervention. based or individual
were included’
Search Strategy
Literature searching consisted of electronic database searching, hand searching
of selected journals, communication with authors in the field and reference list
searching of articles selected for inclusion in the review (see Figure 1).

Database Searches
The following databases were searched using the search terms (foster care* or foster
parent* or adoptive parent* or looked after child* or adopted child* or foster child*)
AND (intervention or training or treatment or therapy) AND (attachment or
attachment theory) within the domains of title, abstract and keyword/subject heading:

• PsychINFO (1987–2013 Jan week 5)

• Embase
• Medline
• Cumulative Index of
Nursing and Allied Health
Literature plus
• Sociological Abstracts
• Applied Social Science
Index and Abstracts
(1980–2013 Jan week 5)
(1946–2013 Jan week 5)
(1937–2013 Jan week 5)
(1960–2013 Jan week 5)
(1987–2013 Jan week 5)

Hand Searching of Selected Journals

Articles published within the following journals between the years of 2006 and
2013 (January) were hand searched for relevant article titles:
• Adoption and Fostering
• Infant Mental Health ‘Five authors in the
• Clinical Child Psychology and Psychiatry
• Attachment & Human Development
field of adoption and
fostering who have
Communication with Published Authors published work on
Five authors in the field of adoption and fostering who have published work on
attachment were contacted in order to increase access to unpublished studies attachment were
and therefore reduce the effects of publication bias. contacted’
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
430 Kerr and Cossar

Figure 1. Schematic diagram of the search strategy.

Reference List Searching

The reference lists of the studies found to meet the inclusion criteria for the
current review were searched.

‘Criteria considered
particularly important
in appraising the
validity and reliability
of intervention studies
fall within five
categories’
Copyright © 2014 John Wiley & Sons, Ltd.
Included Studies
Two articles (Dozier et al., 2006, 2009) were found to report on the same sample
and as such are considered as one study. Similarly, three articles (Juffer et al.,
1997, 2005; Stams et al., 2001) were found to be follow-ups of the same sample
and are therefore also considered here as one study. In total, ten studies (13 articles)
were included in the review. One article (Benjamin, 2010) could not be accessed in
full text and has therefore not been screened for inclusion in the review.
Quality Rating of Studies
Quality criteria for intervention studies based on guidance from the CRD
(2008) were used to assess the included studies. Criteria considered
particularly important in appraising the validity and reliability of intervention
studies fall within five categories – design and risk of bias, outcome measures,
quality of intervention, statistical issues and external validity.
The rating system from the Scottish Intercollegiate Guidelines Network
(2011) (SIGN 50 - Annex C) for randomised controlled trials (RCTs) and
Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
 Attachment Interventions with Foster and Adoptive Parents 431

cohort studies was used to provide each study with a quality rating score. This
guidance suggests the use of the following descriptors and numerical scoring
system: well covered (2 points), adequately addressed (1 point), poorly
addressed, not addressed, not reported and not applicable (all 0 points). The
definition for each criterion and related rating was developed and used to guide
the quality assessment process (see Supporting Information). All ten studies
were rated by the first author using these criteria. A 50 per cent sample of
the studies was also rated by the second author, and exact agreement between
the authors was achieved on 80 per cent of the quality criteria (56/70 items
compared). The ratings differed by one point (e.g. well covered vs adequately
addressed) on 11 per cent (8/70) of items and by two points (e.g. well covered
vs poorly addressed) on nine per cent (6/70) of items. The criteria with
differences between raters were discussed until a consensus rating was achieved.

Results

Quality of Included Studies

Supporting Information Table 1 presents an overview of the ratings assigned to
each study for each quality criterion. The rating scale does not allow for direct
comparison across studies; however, it does indicate the relative
methodological strength of each. Overall, most studies were of relatively poor ‘Overall, most studies
methodological quality. Based on the quality ratings, the results of the studies were of relatively poor
by Juffer et al. (1997, 2005)/Stams et al. (2001), Sprang (2009) and Wassall
et al. (2011) can be considered to be the stronger studies of those included. methodological quality’

Sample Characteristics
Supporting Information Table 2 presents an overview of each study and
summarises the main findings. Two studies (Dozier et al., 2006, 2009; Juffer
et al., 1997, 2005/Stams et al., 2001) included infants who were not reported to
be displaying any difficulties, but were considered to be at high risk for future
difficulties. In the sample in Dozier et al. (2006, 2009), infants were recruited at
the start of initial foster care placement, while in Juffer et al., (1997, 2005)/Stam
et al.’s (2001) sample, internationally adopted infants at six months of age were
followed up over seven years. Three studies (Gurney-Smith et al., 2010; Holmes
and Silver, 2010; Laybourne et al., 2008) described index children as
experiencing attachment difficulties and potential placement disruption. One
study described index children as having experienced abuse or neglect and
displaying challenging behaviour (Golding and Picken, 2004) and one study
described children as experiencing ‘behaviour difficulties’ (Carnes-Holt, 2010).
Two studies described children as having been diagnosed with attachment
disorders (Becker-Weidman, 2006; Sprang, 2009). One study used a sample of
fostered and adopted children recruited through self-selection of foster/adoptive ‘Six studies evaluated
parents or referral by professional (Wassall et al., 2011).
group interventions
Attachment-Based Interventions
which involved direct
work with parents/
Six studies evaluated group interventions which involved direct work with
parents/carers only. The fostering attachments group was evaluated in four carers only’
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
432 Kerr and Cossar

studies (Golding and Picken, 2004; Gurney-Smith et al., 2010; Laybourne

et al., 2008; Wassall et al., 2011). This intervention comprises three modules
which take participants from a theoretical understanding of attachment theory
to a practical understanding of how this can influence the way in which
fostered and adopted children present. Specific focus is given to how carers/
parents help children experience their home as a secure base and maintain a
secure relationship, while managing difficult behaviour. Holmes and Silver
(2010) evaluated the managing behaviour with attachment in mind group
which focuses on increasing parent/carer awareness of the impact of early
abuse/neglect on child development and attachment style. This intervention
provides behavioural management strategies that are underpinned by empathy
and attunement to the child. The course also provides relaxation training and
psychoeducational material for schools. Carnes-Holt (2010) evaluated a
child-parent relationship therapy group in which adoptive parents were taught
play therapy skills including reflective listening, recognising and responding to
children’s feelings, and empathetic limit setting.
‘The remaining four The remaining four studies used an individual therapy format, which involved
studies used an direct work with parents/carers alongside index children. Two studies evaluated
the Attachment and Biobehavioural Catch-Up (ABC) intervention (Dozier et al.,
individual therapy 2006, 2009; Sprang, 2009). This intervention aims to help carers increase their
format, which involved infant’s emotional regulatory capacities by encouraging child-led play, the use
direct work with of nurturing touch and adult recognition and labelling of emotions. A further
focus is the identification of barriers to the provision of nurturing care, such as
parents/carers infant/carer insecure attachment styles. Sessions are conducted within foster
alongside index carers’ homes and video footage of carer-infant interactions is used to facilitate
children’ reflective discussions between the carer and therapist.
Becker-Weidman (2006) evaluated Dyadic Developmental Psychotherapy
which involves direct work with children and carers/parents within a clinic setting.
The aim of this intervention is to provide children with adults (therapist, carer/
parent) who are attuned to their emotional experiences. The therapist uses a model
referred to as PACE (being playful, accepting, curious and empathetic towards the
child) to engage with children and help them experience co-regulation of difficult
emotions. Carers and parents are coached in the use of PACE so as to become
effective co-regulating adults.
‘The final study The final study (Juffer et al., 1997, 2005/Stams et al., 2001) evaluated two
evaluated two interventions based on promoting parental sensitivity, which was defined as the
ability to respond appropriately to infants’ proximity seeking and exploratory
interventions based on behaviour. The first of these involved written information regarding parental
promoting parental sensitivity, while the second involved written information plus three sessions of
sensitivity’ direct work with parents and the use of video footage of parent-child interactions.

Effect Sizes
Effect sizes for statistically significant findings were recalculated using the
formula for Cohen’s d (difference between means/pooled standard deviation).
Of the ten included studies, all measured behavioural functioning and seven of
these reported statistically significant improvements; eight measured relational
functioning and six reported statistically significant improvements; and seven
measured child emotional functioning; with five reporting statistically significant
improvements (see Supporting Information Table 3).
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
 Attachment Interventions with Foster and Adoptive Parents 433

Discussion

Main Findings
There is some evidence that attachment theory-based interventions targeting
foster and adoptive parents and their children may have a positive impact on child
behavioural, emotional and relational functioning. However, despite the high ‘Despite the high
number of positive outcomes reported, the results should be interpreted with
number of positive
caution due to the poor methodological strength of the majority of included studies.
Using the quality criteria outlined here, the strongest studies with positive outcomes reported,
outcomes (Juffer et al., 1997, 2005/Stams et al., 2001; Sprang, 2009) support the results should be
the use of interventions which focus on increasing parental attunement to young interpreted with
children (6 months–6 years) in foster or adoptive care. The parental sensitivity
intervention (Juffer et al., 1997, 2005/Stams et al., 2001) and the ABC caution’
intervention (Sprang, 2009) share some key components. Both involve direct
sessions between therapists, carers and children at home alongside the use of video
recording of carer-child interactions. Each also has a short-term focus on
behavioural goals, such as increased child-led play or exploratory behaviour.
The ABC intervention is a longer intervention, providing seven more sessions than
the parental sensitivity intervention and focusing on issues such as child avoidant/
ambivalent attachment and the impact that this has on parental responsivity. As a
result of their focus on young children who are considered to be at risk of future
difficulties by virtue of early experiences of abuse and or neglect, these
interventions can be described as early preventative attachment interventions.
The remaining interventions focused on older children, the majority of ‘The remaining
whom demonstrated clinical levels of emotional and behavioural difficulties interventions focused
prior to intervention. The methodologically strongest of these was the
controlled trial of the fostering attachments group by Wassall and colleagues on older children, the
(2011), an intervention which was also evaluated in three other studies majority of whom
(Golding and Picken, 2004; Gurney-Smith et al., 2010; Laybourne et al., demonstrated clinical
2008). Using a robust design, Wassall and colleagues (2011) reported no
statistically significant outcomes. The authors conclude that the fostering
levels of emotional
attachments intervention may not be an intensive enough intervention to assert and behavioural
change in the difficulties presented by this population of children. The Dyadic difficulties’
Developmental Psychotherapy intervention evaluated by Becker-Weidman
(2006) provided large effect sizes across a range of outcomes and merits future
evaluation within a randomised controlled trial. This intervention is of
particular interest due to its focus on the reintegration of trauma experiences
using an attachment theory framework and its provision of direct therapeutic
work with older children (Becker-Weidman and Hughes, 2010).

Outcome Measures
Overall, there is more evidence to indicate a positive impact of the included
‘Emotional
interventions on child behavioural functioning compared with evidence functioning was
regarding emotional and relational functioning. This is the result of both fewer commonly assessed
studies including specific measures of emotional and relational functioning and
via subscales of
the limited validity and reliability of the measures used to evaluate these domains.
In the studies reviewed, emotional functioning was commonly assessed via primarily behavioural
subscales of primarily behavioural measures (Child Behaviour Checklist, measures’
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DOI: 10.1002/car
434 Kerr and Cossar

Strengths and Difficulties Questionnaire) such as the Child Behaviour Checklist

(CBCL, Achenbach, 1991) and the Strengths and Difficulties Questionnaire
(SDQ, Goodman, 2001) which were not analysed individually in some studies
(Carnes-Holt, 2010; Golding and Picken, 2004).
The measurement of child relational functioning varied widely between
studies. One study (Juffer et al., 1997, 2005/Stams et al., 2001) used the
Strange Situation Procedure (SSP) (Ainsworth et al., 1978) which focuses on
an infant’s behavioural response following separation and reunion with his/
her caregiver. These interactions are videotaped and coded by trained
researchers and inter-rater reliability is assessed. Dozier and colleagues
(2006, 2009) used the Parent Attachment Diary (PAD) in which parents/carers
record child responses to separation, feeling scared and experiencing pain (e.g.
after a fall) over the course of a day. The responses are coded by researchers
using the SSP classifications of secure, avoidant and ambivalent behaviours,
and the validity of the PAD has been positively assessed against SSP ratings
(Stovall and Dozier, 2000). Inter-rater reliability of the PAD is also acceptable.
Overall, these measures of attachment which focus on behavioural responses to
stress in infants can be considered to be clinically valid and reliable means of
assessing infant attachment.
‘The measurement of The measurement of attachment for older children is more problematic.
attachment for older Two studies used measures focused on the behavioural presentation of
attachment disorder rather than assessing children’s internal representations
children is more of relationships. The Randolph (2000) Attachment Disorder Questionnaire
problematic’ was used by one study (Becker-Weidman, 2006) and is based on the author’s
definition of attachment disorder. While internal reliability for this measure is
adequate, its validity as an attachment rather than behavioural disturbance
measure has been questioned (Cappelletty et al., 2005). The Relationships
Problem Questionnaire (RPQ) (Minnis et al., 1999) is a behavioural checklist
based on the Diagnostic and statistical manual of mental disorders 4th Edition
(American Psychiatric Association, 2000) criteria for reactive attachment
disorder. The RPQ has been shown to provide a valid measure of behavioural
disturbances associated with early abuse and neglect (Vervoort et al., 2011).
As a result of their behavioural focus, these measures have limited ability to
assess change in children’s internal working model following intervention. Four
studies (Golding and Picken, 2004; Gurney-Smith et al., 2010; Holmes and
Silver, 2010; Laybourne et al., 2008) used the Carer Intervention Questionnaire
which was developed by Golding and Picken (2004) to assess the impact of the
fostering attachments group on aspects of the carer-child relationship. No
psychometric data for this scale are available as of yet and it was also scored in
a number of different ways (see Supporting Information Table 2). Finally, one
study (Wassall et al., 2011) measured child attachment using child self-report.
The Sense of Security Scale (Kerns et al., 1996) used by Wassall and colleagues
demonstrates adequate internal and test-retest reliability, however, there are no
psychometric data available regarding the measure’s validity. While the
‘None of the studies measurement of attachment representations for older children is notoriously
reviewed made use of difficult, none of the studies reviewed made use of the most valid and reliable
the most valid and measures for school-aged children (e.g. the Child Attachment Interview (Target
et al., 2003), the Manchester Child Attachment Story Task (Green et al., 2000),
reliable measures for the MacArthur Story Stem Battery (Bretherton et al., 2003) and the Attachment
school-aged children’ Story Completion Task (Bretherton et al., 1990)) and instead favoured short
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
 Attachment Interventions with Foster and Adoptive Parents 435

self-report questionnaires. The limitations of the outcome measures used in the

reviewed studies highlight a current difficulty for the evaluation of attachment
theory-based interventions. If these interventions work as hypothesised, by
improving carer/child emotion regulation and use of a ‘safe base’ in response
to stress, then being able to measure this outcome in a valid way is an
important consideration.

Strengths of the Review

The review used a comprehensive search strategy which included a number of ‘The review used a
methods of searching. Attempts were also made to reduce the impact of comprehensive
publication bias by contacting authors in the field for unpublished work.
search strategy which
Limitations of the Review included a number of
The review had a narrow remit: to evaluate the impact of interventions on three methods of searching’
key child outcome variables. These variables were selected following
consideration of the theoretical underpinning of the interventions and the
typical difficulties that this population presents in clinical settings (Meltzer
et al., 2003). It was decided to focus on child outcomes solely because the
ultimate aim of these interventions is to improve child functioning. However,
given the relational nature of the interventions, inclusion of carer outcomes
may have been valuable. Of the studies included in the review, two (Gurney-
Smith et al., 2010; Wassall et al., 2011) used a carer reflective function
measure, one (Carnes-Holt, 2010) used a measure of caregiver empathy, two
used a measure of parenting stress (Laybourne et al., 2008; Sprang, 2009)
and one used a measure of potential for child abuse (Sprang, 2009). Future
syntheses of the literature should focus on the mediating and moderating
impact of such carer variables on child outcomes.
A final limitation relates to the difficulty in appraising studies which ‘The difficulty in
demonstrated significant heterogeneity in terms of their design, population appraising studies
and interventions. Specifically, the use of quality criteria for randomised
controlled trials being applied to uncontrolled evaluation studies resulted which demonstrated
in a number of the included studies receiving not applicable ratings for significant
criteria such as randomisation, confounding variables and attrition between heterogeneity in
groups. The quality criteria also did not provide weightings across ratings,
meaning that all aspects of the quality criteria were given equal importance. terms of their
While this is in keeping with the guidance provided by the CRD (2008), it design, population
may have resulted in some studies with poor internal validity (e.g. and interventions’
uncontrolled evaluations) receiving high ratings based on other aspects of
their design, such as the use of a manualised intervention and inclusion of
fidelity checks.

Implications for Future Research

In order to establish the efficacy of attachment theory-based interventions with
fostered and adopted children, more methodologically sound studies are
required. This should include more randomised controlled trials, with follow-
up spanning several years and more clinically relevant reporting of outcomes.
An example of this would be detailing the proportion of children who benefit
from the interventions, as well as the differential profiles of this group and
Copyright © 2014 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 23: 426–439 (2014)
DOI: 10.1002/car
436 Kerr and Cossar

the group that does not benefit (Tarren-Sweeney, 2013). A further

consideration for future research would be the evaluation of attachment
theory-based interventions which have proven efficacy within biological
parent-child dyads. Examples of such interventions include Mellow Parenting
(Puckering et al., 1994), Child-Parent Psychotherapy (Lieberman et al., 2005)
and the Circle of Security (Marvin et al., 2002).

Implications for Clinical Practice

‘A key clinical A key clinical implication arising from the current review relates to the timing of
implication arising from attachment-based interventions with fostered and adopted children. The most
valid studies with positive findings indicated the benefit of earlier interventions
the current review which are preventative rather than reactive in nature. This is perhaps unsurprising
relates to the timing of given both the focus of attachment processes in the early years and the
attachment-based neurodevelopmental research indicating the importance of the first three years of
life in later relational functioning (Perry et al., 1998). This evidence suggests that
interventions’ interventions focused on child relational functioning should be undertaken early in
new placements in order to maximise outcomes. Beyond this, it also supports the
proposal to place children with long-term foster carers/adoptive parents earlier and
reduce ‘foster care drift’, where children have a significant number of carers before
being placed permanently (e.g. Minnis et al., 2010; Zeanah et al., 2001).

Conclusions

There is some evidence to suggest that interventions that target foster and
‘Some evidence to adoptive parents using attachment theory can impact positively on children’s
suggest that behavioural functioning. There is a smaller amount of evidence to indicate
interventions that positive outcomes on children’s emotional and relational functioning, although
further consideration of this in intervention studies is warranted. Future
target foster and
research should seek to address the methodological limitations described above
adoptive parents using before firm conclusions can be made.
attachment theory can
impact positively on References
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