The cost of love: financial consequences of insecure attachment in antisocial youth

Contingency in maternal sensitivity and quality of child attachment

Patterns of mothers' contingent responses to their 8-month-old infants were studied across three groups based on the attachment style that children developed at 15 months, assessed with the Strange Situation Procedure: insecure-avoidant, secure, and insecure-resistant. The participants were 78 mother-infant dyads who interacted in a free-play setting. The interactions were assessed using the Early Mother-Child Interaction Coding System-Revised, an observational system that allows real-time coding. Two dimensions of maternal sensitivity, appropriateness and promptness, were analyzed from the perspective of the infants: appropriateness in terms of proportion of different maternal responses, interfering and not interfering (qualitative profile), and the frequency of them (quantitative), and promptness as the latency of the contingent responses. Results showed that infants in the secure attachment group received a lower proportion of interfering behaviors when interacting with their mothers than their insecure attached counterparts. They also experienced higher frequency of non-interfering maternal contingent responses and quicker, protective-intrusive responses. Therefore, the secure attachment group of children experienced less interruption and more attentive responses from their mothers.

Understanding the Economic Value of Interventions Addressing Perinatal Mental Health Problems: A Literature Review and Methodological Considerations

OBJECTIVES

Economic evaluations of mental health problems typically only include short-term measures from an individual healthcare perspective. In perinatal mental health, which spans generations, this is likely to lead to an underestimation of interventions' potential benefits. We sought to understand the spectrum of outcomes of perinatal mental health problems that have economic consequences and how they are captured in economic evaluations.

METHODS

We conducted a systematic search of the peer-reviewed literature to identify 2 types of evidence: (1) synthesized evidence (ie, systematic reviews and meta-analyses) or recent cohort studies that measured the outcomes of perinatal mental health problems and (2) economic evaluations. After presenting the evidence narratively, we derive an overview of different types of outcomes to include in economic evaluations.

RESULTS

Evidence on the many, wide-ranging adverse outcomes with short- and long-term economic consequences is rich, ranging from those that can be measured during the perinatal period (eg, mother's employment), those that require a longer-term follow-up period (eg, children's mental health service use), and those that can be used as predictors in modeling studies (eg, birth weight). Only a small subset of economic consequences and their predictors (eg, child maltreatment and poor attachment) are currently measured in economic evaluations. We make some recommendations on how more and new types of economic evaluations might start addressing the gap in knowledge.

CONCLUSIONS

To inform decisions about reducing the costs of perinatal mental health problems, economic evaluations that provide knowledge of the ability of interventions to reduce short- and long-term economic consequences are urgently needed.

Evaluating the Effect on Infants and Parents Attending the Parent-Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security

The foremost index of caregiving quality is child attachment, as supported by attachment theory. Research supports the relevance of early parenting interventions in improving child outcomes in attachment quality to promote public health because of their long-term effects on mental health and functioning. This study aimed at evaluating the impact on both parenting and child outcomes of the Parent-Child Psychological Support Programme® (PCPS), a community-based program individually tailored to parents and their infants during periodic center-based visits to promote attachment security. The evaluation involved two cohorts from "vulnerable populations" and used the resources embedded in the program design without interfering with the normal functioning of the service. From an evaluative research approach, the effects on mothers and children were assessed using a quantitative approach. Pre- and post-test measures (parenting questionnaires) and child attachment quality assessments through the Strange Situation Procedure were examined. The equivalence of the cohorts was verified and used as a baseline for parenting outcomes. PCPS participants demonstrated increased parental competence and self-efficacy, as well as reduced levels of parenting stress. Analysis of the two cohorts showed a significant difference in the number of visits and proxies for intervention, which were associated with the expected pre-post changes in parenting dimensions. The proportion of securely attached children was significantly higher in the "medium-high intervention" group than in the "no/low intervention" group (72.7% vs 54.5%). Furthermore, compared with international baselines, this proportion showed no differences in the "no-/low-intervention" group but demonstrated expected significant differences in the "medium-high intervention" group.

Secure attachment predicts lower societal cost amongst severely antisocial adolescents

BACKGROUND

Social and economic costs associated with antisocial behaviour are well-established, but little is known about the potential costs savings/benefits of secure attachment in this high-risk group. We aimed to provide the first test of attachment quality as a distinct predictor of economic costs.

METHODS

111 adolescents (10-17 years of age, M = 15.0, SD = 1.6; 71% male) referred to young offender services due to high levels of antisocial behaviour were included. Costs were measured by detailed service-use interview, and attachment security to mother and father elicited through the Child Attachment Interview. The level of antisocial behaviour and callous-unemotional traits were assessed. Cost predictors were calculated using generalised linear models.

RESULTS

Mean 12-months service costs were £5,368 (sd 5,769) per adolescent, with justice system and educational service costs being the main components. After adjusting for covariates, economic costs were predicted by attachment quality to fathers, with a difference of £2,655 per year between those with secure (£3,338) versus insecure attachment (£5,993); significant cost effects were not found for attachment quality to mothers. Higher levels of callous-unemotional traits, lower verbal IQ, higher levels of antisocial behaviour, and older age were also significant cost predictors.

CONCLUSIONS

Secure attachment to fathers is a predictor of reduced public cost in adolescents with severe antisocial behaviour. This novel finding for severely antisocial youth extends previous findings in less antisocial children and underscores the public health and policy benefits of good caregiving quality and the value of population-level dissemination of evidence-based interventions that improve caregiving quality.

Protocol for the effectiveness evaluation of an antenatal, universally offered, and remotely delivered parenting programme 'Baby Steps' on maternal outcomes: a Born in Bradford's Better Start (BiBBS) study

BACKGROUND

Poor perinatal mental health and maternal sensitivity towards a child in the early years can carry a long-term cost to individuals and to society, and result in negative child outcomes such as poor mental health and social emotional issues. Despite the recognition of early intervention and prevention, there is mixed evidence regarding antenatal parenting interventions that aim to enhance perinatal mental health and maternal sensitivity to prevent negative child outcomes. 'Baby Steps' is a relationship-based antenatal and postnatal parenting programme. The service evaluated in this study is delivered in a low-income and ethnically diverse community via Better Start Bradford. This study aims to assess whether the universally, and remotely delivered Baby Steps programme is effective in improving postnatal maternal sensitivity (primary outcome) and postnatal maternal mental health (secondary outcome) when compared to services as usual 6-10 weeks post-birth. It will also assess differences in birth outcomes, and differences in the prevalence of poor perinatal mental ill health through routine data. The feasibility of collecting cost and health related resource use data for a future economic evaluation will be explored.

METHODS

The study is a quasi-experimental evaluation in a single centre. All participants are drawn from Born in Bradford's Better Start (BiBBS) interventional family cohort study. Intervention participants will be matched to a demographically comparable control group using propensity score matching. The required minimum sample is n = 130 (ratio 1:1) to detect a medium effect (± 2.35, d = .50) on the primary outcome-maternal-child sensitivity, using the Mothers Object Relations Scale Short Form (MORS-SF). Secondary outcomes include the Patient Health Questionnaire (PHQ-8), Generalised Anxiety Disorder assessment 7 (GAD-7), identification of poor perinatal mental health through routine data, and birth outcomes (delivery method, gestation period, low birth weight). Service delivery costs and health resource use will be gathered from routine data.

DISCUSSION

This study will evaluate the effectiveness of Baby Steps for enhancing maternal-child sensitivity and maternal mental health when delivered universally and remotely. The findings regarding programme effectiveness, process, and costs will be relevant for researchers, service commissioners, and service staff.

TRIAL REGISTRATION

This study was prospectively registered with ISRCTN (22/04/2022, ISRCTN12196131).

Newborn behavioral observations system in rural Pakistan: A feasibility and acceptability study

The Newborn Behavioral Observations (NBO) system is a relationship-based tool that helps parents recognize their infant's competencies and learn their behavioral cues, with the goals of enhancing parental responsiveness and satisfaction in the infant-parent relationship. In our study, a pediatrician integrated the NBO into 44 pediatric health care visits of infants in rural Pakistan villages, under the remote guidance of two U.S.-based child psychiatrists. A clinician then gave the mothers a survey about their experience of the NBO and found that the mothers were highly satisfied, reporting greater appreciation of their infant's strengths, greater understanding of their infant's behavioral cues, stronger attachment to their infant, and greater self-confidence as a mother. In their consideration of these results, the authors explore cultural reasons for the mothers' responses and generate hypotheses to inform an outcome study of a similar intervention. This was a feasibility and acceptability study and was not randomized, had no control group, and did not use objective measures of outcome.

Antisocial Behavior and Attitudes Towards Antisocial Behavior after a Five-Year Municipal Youth and Family Master Plan in Pomona, California, USA

Within an integrated conceptual framework made up of social cognitive theory, theory of fundamental causes, and the risk and protective factor approach, we assess reported antisocial behavior and favorable attitudes toward antisocial behavior among youths and parents in a high-school sample after the implementation of a Youth and Family Master Plan in Pomona, California, USA from 2005 to 2009. We perform z tests for same students (8th grade 2005 and 12th grade 2009), same grade (8th,10th, and 12th grade), inter-grade, same year, and overall, 2005 to 2009 comparisons for Pomona, Los Angeles, and US national samples. It was hypothesized that after five years of implementation, Pomona Youth and Family Master Plan (PYFMP) activities will reduce antisocial behavior and favorable parental and youth attitudes toward antisocial behavior. Within a p-value of 05, z-test results show a decline in youth antisocial behavior among youths in the Pomona sample. Patterns in youth antisocial behavior were not consistent with youth favorable attitudes toward antisocial behavior but were consistent with perceived parental favorable attitudes toward antisocial behavior. Though youth favorable attitudes toward antisocial behavior were generally rising within the Pomona data, when compared to the rates of change in Los Angeles and US, Pomona rates of change were lower. Intra and inter jurisdictional patterns above could be attributed to the community multicomponent interventions of the PYFMP. They also align with assumptions and explanations offered in the integrated conceptual framework, which suggest a mediating role for environmental factors.

Adverse childhood experiences are important but not the only risk to child development: Revisiting a full risk/resilience matrix

Much research has sought to distinguish key interacting factors affecting children as they develop which influence later outcomes. Some factors, notably adverse childhood experiences (ACEs), pose serious risks for later health or mental health problems for the children or predispose them for involvement in offending behaviours. However, other experiences, alongside ACEs, also pose risks and yet others offer protection. A matrix showing interacting influences from the mother's pregnancy onwards was published earlier; a revised matrix has been developed, showing a fresh picture of cumulative risk and protective factors.

A good investment: longer-term cost savings of sensitive parenting in childhood

BACKGROUND

Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested.

METHODS

Design: Longitudinal study with follow-up from 2012 to 2016.

SETTING

UK multicentre study cohort (London, South-East England).

PARTICIPANTS

174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years).

MEASURES

The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction.

RESULTS

Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security.

CONCLUSIONS

This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. Savings are likely to increase as individuals grow older since early parenting quality predicts health, behavioural and occupational outcomes in adulthood. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

A Systematic Review of Representational and Behavioral Measures of Parent-Child Attachment Available for Middle Childhood

A variety of parent-child attachment measures, representing a range of conceptual approaches, have been adapted for use in middle childhood. A recent surge in studies using the new methods makes a comprehensive review of these measures timely. This systematic review of 67 studies covers representational and behavioral measures of parent-child attachment used with children 9-12 years old. This paper aims to evaluate parent-child attachment measurements with an emphasis on understanding their theoretical bases in addition to considering the available validity evidence. Findings identify several independently well-validated representational measures, and they highlight a continued need to investigate direct comparisons of the measures, as very little research has considered how the measures relate to each other, both conceptually and empirically. Behavioral measures of attachment in middle childhood, which are relatively new, are identified as potentially important in developing a better understanding of attachment measurement in this age group.

Effect of a parenting intervention on decreasing adolescents' behavioral problems via reduction in attachment insecurity: A longitudinal, multicenter, randomized controlled trial

INTRODUCTION

Secure attachment in adolescence, related to caregiving quality, is a robust predictor of positive behavioral adjustment in early adulthood and beyond. Nevertheless, few attempts have been made to develop treatments to promote parent-adolescent attachment security.

METHODS

Using a longitudinal, multicenter, randomized controlled trial design, two questionnaire-based studies were run in Italy (Study 1: n = 100 mothers of adolescents, 60% boys, M_age = 14.89, SD = 1.58; Study 2: n = 40 mothers and 40 adolescents, 60% boys, M_age = 14.90, SD = 1.91) to test the effectiveness of an attachment-based parenting intervention (i.e., Connect) in reducing adolescents' behavioral problems and attachment insecurity 2 weeks post-intervention (t2) and at a 4-month follow-up (t3). It was further investigated whether a decrease in avoidant and anxious attachment at t2 would account for changes in externalizing and internalizing problems, respectively, at t3. All adolescents belonged to two-parent intact families.

RESULTS

Mothers who completed Connect reported significantly fewer adolescent behavioral problems and lower adolescent attachment insecurity, compared to mothers in the waitlist group, at both t2 and t3 (Study 1). These findings were confirmed in a second subsample (Study 2), considering both mothers' and adolescents' reports. Controlling for pre-intervention behavioral problems, reductions in internalizing and externalizing problems were observed in both studies at t3 via a decrease in anxious and avoidant attachment, respectively, at t2.

CONCLUSIONS

The findings point to the malleability of attachment security in adolescence and highlight the importance of targeting parenting quality to promote adolescent behavioral adjustment.

Promoting mother-infant relationships and underlying neural correlates: Results from a randomized controlled trial of a home-visiting program for adolescent mothers in Brazil

Poverty and teenage pregnancy are common in low-and-middle-income countries and can impede the development of healthy parent-child relationships. This study aimed to test whether a home-visiting intervention could improve early attachment relationships between adolescent mothers and their infants living in poverty in Brazil. Analyses were conducted on secondary outcomes from a randomized controlled trial (NCT0280718) testing the efficacy of a home-visiting program, Primeiros Laços, on adolescent mothers' health and parenting skills and their infants' development. Pregnant youth were randomized to intervention (n = 40) or care-as-usual (CAU, n = 40) from the first trimester of pregnancy until infants were aged 24 months. Mother-infant attachment was coded during a mother-infant interaction when the infants were aged 12 months. Electrophysiological correlates of social processing (mean amplitude of the Nc component) were measured while infants viewed facial images of the mother and a stranger at age 6 months. Infants in the intervention group were more securely attached and more involved with their mothers than those receiving CAU at 12 months. Smaller Nc amplitudes to the mother's face at 6 months were associated with better social behavior at 12 months. Our findings indicate that the Primeiros Laços Program is effective in enhancing the development of mother-infant attachment.

Exploring Attachment and Internal Representations in Looked-After Children

BACKGROUND

This article explores the Story Stem Assessment Profile (SSAP), a narrative-based measure, for the assessment of internal representations in children between the ages of 4 and 11 years old.

METHODS

The findings draw upon two samples of children comprising of a sample of looked-after children at Five Rivers Child Care (FR) (n = 42) and a community-based population (n = 42). The FR group identified were suggested to have a higher level of need, as defined by scores obtained from the Strengths and Difficulties Questionnaire (SDQ) and Relationship Problems Questionnaire (RPQ).

RESULTS

Using the SSAP, the findings indicate the instrument's discriminant validity with strong differences being displayed between the two populations. Consistently children in the FR sample displayed more disorganized, avoidant and negative representations, whilst at the same time having significantly fewer representations characteristic of 'secure' attachment.

CONCLUSION

The SSAP is successful in differentiating between 'low' and 'high' cohorts of children aged 4-11 years. The study provides strong support for the measure as a way of capturing internal and attachment representations, with further research to explore possible changes in these representations at follow-up being promising and intriguing. Continued research efforts at FR will allow for improved clinical formulations, increased understanding and therefore positive outcomes relating to the children in their care.

Commentary: Money can't buy you love, but lack of love costs families and society plenty - a comment on Bachmann et al. (2019)

The target paper on the costs of (lack of) love underscores the ongoing need for early preventive interventions that support parents, both mothers and fathers, aiming to provide for their children. With effective targeting of such interventions, the emergence of children's antisocial behavioral problems may be greatly lessened. In addition to the economic costs to family and society of caring for children with moderate or severe antisocial behavior problems is substantial, the costs in terms of diminished health and well-being may persist across the lifespan. Recent research on attachment and physical health adds to the evidence base pointing to the substantial economic burdens, falling to families, schools, and health services, when insecurity or disorganization of attachment typifies early parent-child relationships. Further research ought to give consideration to potentially moderating or compensatory relationships that otherwise vulnerable youth may develop to supportive peers, siblings or teachers.