483337

2013
PED20Supp. 210.1177/1757975913483337Original ArticleS. Tereno et al.

Original Article

Implementation and assessment of an early home-based

intervention on infant attachment organisation: the CAPEDP
attachment study in France
Susana Tereno1, Nicole Guedeney2, Romain Dugravier3, Tim Greacen4,
Thomas Saïas5,6, Florence Tubach7 and Antoine Guédeney8

Abstract: Attachment is a long-term emotional link between infants and their mothers. Attachment
quality influences subsequent psychosocial relationships, the ability to manage stress and, consequently,
later mental health. Home intervention programmes targeting infant attachment have been
implemented in several contexts with varying degrees of efficacy. Within the CAPEDP study (Parental
Skills and Attachment in Early Childhood: reduction of risks linked to mental health problems and
promotion of resilience), a subsample of 120 families were recruited with the objective of assessing
the impact of this home-visiting programme on infant attachment organisation using the Strange
Situation Procedure. The present paper describes the methodology used in this ancillary study. (Global
Health Promotion, 2013; 20 Supp. 2: 71–75).

Keywords: children, youth, health promotion, maternal, mental health, prevention, risk factors

Introduction psychological functioning of individuals (4). Quality

Infant mental health is a public health priority both
internationally (1) and in France (2). Furthermore,
the prevalence of psychiatric disorders in young
children appears to be on the increase: a 1994
epidemiological study in France indicated a prevalence
rate of 12.3% (3), but the World Health Organization
estimates that child psychiatric disorders have
increased by up to 50% in recent years (1).
Developmental theories recognise that the social
and family environment has long-term effects on the
early relationships allow infants to explore their
environment safely and contribute to the establishment
of a broad range of social skills. Moreover, infants are
particularly sensitive to contexts that generate stress
within the family. Their parents’ psychological
problems and the vulnerable social contexts into
which they are born can both have a deleterious effect
on their later development (5,6).
Attachment is considered a vital component of
social and emotional development in the early years,
and the quality of attachment relationships is believed

1. Institut de Psychologie, Université Paris Descartes, Sorbonne Paris Cité, Laboratoire de Psychologie et Processus de
Santé (LPPS-EA4057), Paris, France.
2. Institut Mutualiste Montsouris, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
3. AP-HP, Hôpital Bichat-Claude Bernard, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
4. Laboratoire de Recherche, Etablissement public de santé Maison Blanche, Paris, France.
5. Institut national de prévention et d’éducation pour la santé (Inpes), Paris, France.
6. Département de Psychologie, Université du Québec, Montréal, Canada.
7. AP-HP, Hôpital Bichat, Département d’Epidemiologie et Recherche Clinique, Paris, France; Université Paris Diderot,
Sorbonne Paris Cité, Paris, France; INSERM CIE 801, Paris, France.
8. AP-HP, Hôpital Bichat-Claude Bernard, Université Paris Diderot, Sorbonne Paris Cité, INSERM U669 PSIGIAM,
Paris, France. Correspondence to: Antoine Guedeney, Policlinique Ney, 124 blvd Ney, 75018 Paris, France. Email:
antoine.guedeney@bch.aphp.fr

(This manuscript was submitted on 15 February 2012. Following blind peer review it was accepted for publication on 5
August 2012)

Global Health Promotion 1757-9759; Vol 20 Supp. 2: 71­–75; 483337 Copyright © The Author(s) 2013, Reprints and permissions:
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72 S. Tereno et al.
to be an important early indicator of infant mental
health (4), amongst other reasons because it
influences the child’s ability to manage situations of
alarm or distress. Intervention programmes targeting
psychosocially high-risk populations have been
developed in North America and in other contexts
from as early as the 1960s. Since Olds’ initial work
in Elmira (7), other studies have confirmed the
efficacy of home-based preventive interventions.
With high-risk mothers, several studies have shown
that home-based interventions conducted jointly by
nurses and infant mental health workers yield the best
results, particularly with regard to reducing
externalising behaviour problems (8). Moss et al. (9)
underline the fact that extensive training of those
providing the intervention, backed up by frequent
supervision, are essential ingredients for the success of
this kind of programme. A meta-analysis on the impact
of attachment-focused interventions by Bakermans-
Kranenburg et al. (10) showed that these interventions
can indeed increase attachment security through
enhancing maternal sensitivity, although generally
with a small effect size. According to these authors,
short interventions with precise goals seem to be more
effective than lengthy, multifocal interventions. Despite
these encouraging results, little is known concerning
the mechanisms behind these effects: is reducing
postnatal depression the key issue, or is it rather a
question of reducing disorganising behaviour (8)?
The CAPEDP study, a randomised controlled trial
promoting infant mental health, began in Paris in
2006. The study aimed to reduce the incidence of
infant mental health problems by reducing maternal
postpartum depression and promoting parenting
skills, infant–mother attachment security and social
and professional integration. Within the main
CAPEDP study, an ancillary study, the CAPEDP
Attachment (CAPEDP-A) study, evaluated a
subsample of families using more specific measures
of child disorganisation and attachment status as
well as maternal disorganising behaviour and
mentalising abilities. The present paper describes the
methodology used in this ancillary study.
Method
Participants
Participants in the main CAPEDP study were
recruited at maternity wards in 10 public hospitals
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in Paris area from December 2006 to March 2009.
Participation in the study was proposed to eligible
future mothers prior to a maternity check-up at the
hospitals. To be eligible for inclusion, women had to
be i) under 26 years old, ii) less that 27 weeks
pregnant, iii) able to speak French well enough to
give truly informed consent to participate in the
study and to benefit from the intervention, and iv)
present one or more of the following psychosocial
vulnerability factors: low income, low educational
level and/or intending to bring up the child without
the child’s father. Women who already had a social
or medical follow-up for another reason than the
above criteria – for example, a mental disorder such
as schizophrenia calling for a close long-term
follow-up – were not included, to avoid bias on the
effect of intervention. Similarly, women or families
who refused to participate or who were going to be
impossible to follow up (typically, who intended
moving away from the Paris area in the short term)
were not included.
The families were then randomly assigned to
either the control group, receiving care as usual, or
to the intervention group, receiving the
supplementary CAPEDP home visits. Randomisation
was centralised by fax in the clinical research unit to
ensure allocation concealment, using a computer-
generated randomisation sequence. All participants
received assessment visits at the 27th week of
pregnancy, and then when the child was three, six,
12, 18 and 24 months old.
When their child reached 12 months of age, all
families participating in the main CAPEDP trial (N
= 440) were consecutively invited to participate in
the CAPEDP-A study. The mothers were informed
about this ancillary study, and if they accepted to
participate with their child, they signed an informed
consent form and an appointment was given to
them for a two hour assessment procedure within
the following two weeks. Inclusion was terminated
when the required 120 mother–infant dyads had
accepted to participate. Mothers received 50 euros
gratification for participating in the CAPEDP-A
assessment.
CAPEDP-A received ethical approval from the
Comité de Protection des Personnes Ile de France IV
Institutional Review Board and from the Commission
nationale de l’Informatique et des Libertés (CNIL,
907255), with the Clinical Trial registration number:
NCT00392847.
 Original Article
Intervention
The content of the manualised CAPEDP
intervention is described elsewhere (11). In short, the
programme was designed so that psychologists could
visit families six times during the antenatal period,
eight times in the first three months of the child’s life,
15 times between the child’s fourth and 12th months
of age and another 15 times during the child’s second
year, resulting in a total of 44 home visits during the
whole intervention. The intervention was manualised
but tailored to each family’s needs. Between visits,
phone calls could be made as often as necessary.
A major specificity of the CAPEDP project was to
address child mental health promotion in families
that already have free access to one of the most
comprehensive social and health care systems in the
Western world, based around mother–child support
and prevention services with no out-of-pocket
payment, known as the Protection maternelle et
infantile (Mother and Child Protection Services or
PMI). In addition to direct access to PMI centres
from the beginning of pregnancy right through to
their child’s third birthday, families can also access
child community mental health centres, distributed
nation wide and free of charge. Usual care in the
CAPEDP study thus involved free access to both the
PMI and community mental health networks, free
antenatal maternity screenings, as well as a number
of social benefits. Additionally, the intervention
group benefited from home visits by specially trained
and supervised psychologists as of the last trimester
of pregnancy, on a weekly basis, then decreasing in
frequency, until the child reached the age of two.
In addition to the general training provided to the
team of psychologists employed to conduct the
CAPEDP home-visiting intervention (11), team
members were all given specific training on
promoting maternal sensitivity and mentalising
skills, as well as on detecting and preventing atypical
maternal behaviour and disorganised attachment in
infants. Specific tools were developed to support the
intervention team with regard to attachment issues:
• A brochure drafted by the research team and
focusing on the emotional development of young
children was distributed to families when the
child was three months old, with the aim of
making families aware of the importance of
early attachment bonds.
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73
• Video-feedback was used to encourage parents
to reflect on their parenting practices and
experiences at two points in time: when the child
was between six and nine months old (two
videos focusing on attachment) and then
between 12 and 15 months (two videos focusing
on oppositional behaviour). For each of these
four video-feedback sessions, during a home
visit, the intervention psychologist would
propose to film a short sequence of mother–child
interaction, for example at bath-time, meal-time,
free play or nappy change. At the following
home visit, the mother and the home-visiting
psychologist would watch and discuss that
specific sequence together.
• Home-visiting psychologists were provided with
two manuals aiming at structuring their home
visit interventions: the first, for the period when
the child was between six and 12 months of age,
focused on attachment issues, and the second,
for the period between 12 and 15 months, on
oppositional behaviour.
Measures and coding procedures
In the CAPEDP-A Study, a specific attachment
assessment team received training on the procedures
and instruments used to evaluate attachment in
mother–infant dyads (N = 120).
Infant attachment organisation was assessed using
the Strange Situation Procedure (SSP) (12), maternal
disrupting behaviour with the Atypical Maternal
Behavior Instrument for Assessment and
Classification (AMBIANCE) Scale (13) and parental
auto-reflexive capacity using the Insightfulness
Assessment Interview (14). These measures were
chosen because of their high validity and fidelity in
assessing infant attachment, maternal disrupting
behaviours and mentalisation abilities, confirmed
by their use in major international studies in
this field (10). The assessment team worked
independently from the three coding teams. Coders
for the AMBIANCE were different from SSP coders
and IA coders, and all were blind to the randomisation
group of the families being assessed.
The SSP is a standardised assessment procedure
evaluating infant attachment organisation. It
consists of a fixed sequence of eight episodes,
IUHPE – Global Health Promotion Vol. 20, Supp. 2 2013
74
designed to activate and/or intensify the attachment
behaviour of one-year-old infants. The procedure
involves two brief separations and two reunions
between the infants and their attachment figure, in
the present case, their mother.
The Strange Situation identifies three categories
of attachment behaviour patterns. The insecure-
avoidant group (A) is characterised by the infant
avoiding manifesting attachment behaviour towards
the attachment figure. The secure group (B) includes
infants who evidence active proximity-seeking and
interaction with the attachment figure, especially in
reunion episodes. The insecure resistant/ambivalent
group (C) is characterised by the coexistence of
active contact resistance behaviour and proximity-
seeking or contact-maintaining behaviour with the
attachment figure. The disorganised/disoriented
group (D) includes infants that, in the context of the
Strange Situation, show seemingly misdirected or
undirected behavioural responses in the presence of
the attachment figure.
The assessment team implemented and filmed the
SSP for each family. Coding was conducted using
these video clips of the parent–child interactions.
Coders had no direct contact with any dyad and
were not aware of the group (intervention or
control) to which the dyads belonged. Two
independent coders coded a random selection of
30% of the cases. Inter-observer concordance
calculated using Cohen’s Kappa coefficient was
satisfactory (Kappa = 0.79). Disagreements were
discussed and a consensus category was attributed
to the dyads in question.
The AMBIANCE scale is a five-dimension scale
scored on the SSP procedure video. Higher scores
reflect mothers’ lack of self-reflection and the
quality of mothers’ responses when attachment
issues are raised. The scoring team was trained by
Karlen Lyons Ruth and Elisa Bronfmann in a
training session in Paris (2008) and demonstrated
full reliability.
The Insightfulness Assessment (IA) is a semi-
structured interview assessing the mother’s
mentalising abilities after she has viewed a video clip
of herself with her child (nappy changes, free play,
feeding or SSP). The IA is scored using 10 scales, and
results in a classification into four categories. Each
dyad was videotaped for SSP, nappy change, feeding
and free play. The IA coders achieved reliability on
IA rating during specific training sessions during
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S. Tereno et al.
2007 with the team that created the instrument (14).
The IA interviews took place at the same time as the
SSP, when the infant was from 12 to 15 months of
age.
Discussion
The present study describes the methodology used
in the first French study of infant attachment quality
in a multi-risk population. It is also the first in France
to evaluate the impact of an early preventive home-
based intervention on infant attachment security.
The study presents several limitations. Firstly, the
control group cannot be considered to have received
no intervention, ‘care as usual’ being particularly
generous in the French health and social care system.
In future studies in such contexts, closer monitoring
of the use of existing community services and of the
nature of the input from these services would clarify
the intervention effects of the current programme.
Secondly, at the point during the project at which
mother–infant dyads were assessed for infant
attachment quality, the home-visiting team had
completed only two-thirds of the total number of
planned home visits. In the second phase of the
project (CAPEDP-A II), which will monitor families
up to the child’s fourth birthday, it is possible that
benefiting from the entire intervention and the
existence of a possible sleeper effect may well have
an impact on the attachment distribution.
Furthermore, it must be remembered that women
who were not fluent enough in French to give
informed consent to participate or who were already
receiving other types of clinical interventions were
not eligible for inclusion in the present study.
Generalising from results from this study to all
mother–child dyads in multi-risk social situations
would therefore be hazardous. Future work should
take into account the fact that socially vulnerable
populations include large numbers of different
immigrant populations. Developing intervention and
research programmes that take into account their
cultural and linguistic specificities is an essential step
towards addressing their specific needs.
Conclusion
A primary pathway to enhancing children’s well-
being is through interventions designed to increase
the quality of their parents’ parenting skills.
 Original Article
Perfecting study designs to detect the mechanisms in
play is crucial if these interventions are to succeed.
Acknowledgements
The authors would like to thank the CAPEDP study group,
the 120 families who accepted to participate in the study,
the assessment and coding teams, the members of the
home-visiting team and the research assistants, without
whom this project would have been impossible.
Funding
CAPEDP was supported by research grants from the
French Ministry of Health (Hospital Clinical Research
Programme: PHRC AOM05036), the French National
institute for prevention and health education (Inpes), the
French National Institute of Health and Medical Research
(INSERM), and the French Public Health Research
Institute (IReSP, PREV0702).
Conflict of interest
None declared.
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E, Tereno S, et al, the CAPEDP Study Group.
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116 Resúmenes

problemas de salud mental en familias en situación de vulnerabilidad. El Proyecto CAPEDP, en el que

participaron 440 mujeres y sus familias, se llevó a cabo en París y en sus barrios periféricos de 2006 a 2011.
Para poder participar en el proyecto, las mujeres tenían que: (i) tener menos de 26 años; (ii) estar embarazadas
menos de 27 semanas; (iii) expresarse en francés lo suficientemente bien para participar en el estudio y dar
su consentimiento con conocimiento de causa, así como para beneficiarse de la intervención; y (iv) debían
concurrir además uno o varios de los siguientes factores de vulnerabilidad social: ingresos bajos, nivel
educativo bajo y/o intención de criar al hijo sin el padre. La intervención consistió en 44 visitas a domicilio
desde el tercer trimestre del embarazo hasta el segundo cumpleaños del niño. El objetivo de la intervención
era promover la salud mental infantil y reducir la incidencia de problemas de salud mental en el niño a la
edad de 2 años. La intervención prestaba especial atención a la depresión puerperal, a la promoción de
habilidades parentales y de la seguridad del apego, concretamente mediante el uso del video en las visitas a
domicilio. Uno de los principales escollos fue la adaptación de las recomendaciones de mejores prácticas
internacionales, relativas a los programas de visitas a domicilio, a las particularidades del sistema de atención
sanitaria y social existentes en Francia. Una de las originalidades de la intervención fue que empleó psicólogos
clínicos formados para las visitas a domicilio. (Global Health Promotion, 2013; 20 Supp. 2: 66–70).

Implementación y evaluación de una intervención precoz a domicilio para la

organización del apego en el lactante: el estudio CAPEDP sobre el apego en Francia

S. Tereno, N. Guedeney, R. Dugravier, T. Greacen, T. Saïas, F. Tubach y A. Guédeney

El apego es un vínculo emocional a largo plazo entre los lactantes y sus madres. La calidad del apego
incide en las relaciones psicosociales ulteriores, en la habilidad de manejar el estrés, y, consecuentemente,
en la salud mental futura. Programas de intervención a domicilio, dirigidos a generar este apego, han
sido aplicados en contextos diversos y con diversos grados de eficacia. Dentro del estudio CAPEDP
(Habilidades parentales y apego en la primera infancia: Reducción de los riesgos relacionados con
problemas de salud mental y promoción de la resiliencia), se tomó una muestra de 120 familias con el
fin de evaluar el impacto de este programa de visitas a domicilio sobre el apego del lactante, empleando
el “Procedimiento de la Situación Extraña.” El artículo describe la metodología utilizada en este estudio
adicional. (Global Health Promotion, 2013; 20 Supp. 2: 71–75).

Evaluación del proceso de una estrategia de detección o selección para prevenir

el sobrepeso y la obesidad entre adolescentes en el entorno escolar

E. Bonsergent, N. Thilly, K. Legrand, N. Agrinier, S. Tessier, E. Lecomte, E. Aptel, J.-F. Collin y

S. Briançon, por el grupo de prueba PRALIMAP
El ensayo PRALIMAP (Promoción de la Alimentación y de la Actividad Física) ilustra la efectividad de
implementar una estrategia de detección en las escuelas para prevenir el sobrepeso/la obesidad en los
adolescentes. La estrategia incluye tres pasos: (i) mediciones corporales para detectar sobrepeso/obesidad en
los adolescentes; (ii) una entrevista médica con cada adolescente identificado, para comentar los resultados
y (iii) una gestión adaptada de la atención, que consiste en siete sesiones educativas en grupo. Se llevó a cabo
una evaluación del proceso del ensayo PRALIMAP, para evaluar la implementación efectiva de las actividades
de la estrategia de detección, así como la participación de los adolescentes y de los profesionales de la
escuela, desde un punto de vista cuantitativo y cualitativo. El artículo describe el proceso y la implementación
de la estrategia, tal como se realizó en el ensayo PRALIMAP, y comenta la viabilidad de una intervención
de estas características entorno de la educación secundaria. La habilidad de los profesionales sin formación
específica para implementar el programa mejoró con el apoyo de un especialista. La participación de los

IUHPE – Global Health Promotion Vol. 20, No. Supp. 2 2013

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485690
2013
PED20Supp. 210.1177/1757975913485690RésumésRésumés

Résumés

Soutenir les familles en situation difficile : le projet CAPEDP

T. Saïas, T. Greacen, F. Tubach, R. Dugravier, E. Marcault, S. Tereno, R. E. Tremblay, A. Guédeney
et le groupe d’étude CAPEDP
Bien que la France dispose de l’un des systèmes sanitaires et sociaux les plus généreux du monde occidental
pour ce qui est du bien-être maternel et infantile, les professionnels se préoccupent de plus en plus du
nombre croissant d’enfants qui consultent pour des problèmes de santé mentale. Le présent article décrit le
premier programme de visites à domicile mis en œuvre en France pour cibler spécifiquement les questions
de santé mentale au sein des familles qui vivent dans des contextes vulnérables. Le projet CAPEDP, qui
impliquait 440 femmes et leurs familles, s’est déroulé à Paris et dans sa proche banlieue entre 2006 et 2011.
Pour être admissibles dans cette étude, les femmes devaient être (i) âgées de moins de 26 ans, (ii) enceintes
de moins de 27 semaines, (iii) suffisamment à l’aise en français pour pouvoir donner un consentement
pleinement éclairé afin de participer à l’étude et de bénéficier de l’intervention, et (iv) elles devaient aussi
présenter au moins l’un des facteurs de vulnérabilité sociale suivants : de faibles revenus, un faible niveau
d’études et/ou envisager d’élever l’enfant sans le père de celui-ci. L’intervention consistait en 44 visites à
domicile, depuis le troisième trimestre de la grossesse jusqu’au deuxième anniversaire de l’enfant. Le but de
cette intervention était de promouvoir la santé mentale de l’enfant et de réduire l’incidence des problèmes
de santé mentale chez l’enfant à l’âge de deux ans. L’intervention a accordé une attention toute particulière
à la dépression maternelle postnatale ainsi qu’à la promotion des compétences parentales et de la sécurité
de l’attachement, en particulier à l’aide de vidéos durant les visites à domicile. Une des préoccupations
principales était d’adapter les recommandations internationales en matière de meilleures pratiques pour les
programmes de visites à domicile aux particularités du système sanitaire et social français existant. Un
élément original de cette intervention était le recours à des psychologues cliniciens formés pour effectuer
l’ensemble des visites à domiciles. (Global Health Promotion, 2013; 20 Supp. 2: 66–70).

Mise en œuvre et évaluation d’une intervention précoce à domicile sur

l’organisation de l’attachement du nourrisson : l’étude CAPEDP sur
l’attachement en France
S. Tereno, N. Guedeney, R. Dugravier, T. Greacen, T. Saïas, F. Tubach et A. Guédeney
L’attachement est un lien émotionnel durable entre les nourrissons et leurs mères. La qualité de
l’attachement influence les relations psychosociales des enfants, la capacité à gérer le stress et par
conséquent, la future santé mentale. Des programmes d’interventions à domicile ciblant l’attachement du
nourrisson ont été mis en œuvre dans plusieurs contextes et avec divers degrés d’efficacité. Dans l’étude
CAPEDP (Compétences parentales et attachement dans la petite enfance : réduction des risques liés aux
problèmes de santé mentale et promotion de la résilience), un sous-échantillon de 120 familles a été
recruté dans le but d’évaluer l’impact de ce programme de visites à domicile sur l’organisation de
l’attachement du nourrisson à l’aide de la procédure de la situation étrange. Cet article décrit la
méthodologie utilisée dans cette étude ancillaire. (Global Health Promotion, 2013; 20 Supp. 2: 71–75).

Évaluation de processus d’une stratégie de dépistage du surpoids et de l’obésité

en milieu scolaire chez les adolescents
E. Bonsergent, N. Thilly, K. Legrand, N. Agrinier, S. Tessier, E. Lecomte, E. Aptel, J.-F. Collin et S.
Briançon, pour le groupe d’essai PRALIMAP
L’essai PRALIMAP (PRomotion de l’ALIMentation et de l’Activité Physique) met en évidence l’efficacité de
la mise en œuvre d’une stratégie de dépistage dans des établissements d’enseignement secondaire afin de
Global Health Promotion 1757-9759; Vol 20 Supp. 2: 59­–61; 485690 Copyright © The Author(s) 2013, Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913485690 http://ghp.sagepub.com

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