CAPEDP-Attachment: Parenting Skills and Attachment in Infants: Reducing Mental Health Risks and Promoting Resilience A French Project to Decrease Disorganized Attachment

The Project CAPEDP (Compétences parentales et Attachement dans la Petite Enfance : Diminution des risques liés aux troubles de santé mentale et Promotion de la résilience (i.e., Parenting Skills and Attachment in Infants: Reducing Mental Health Risks and Promoting Resiliency) is being held in Paris since 2006. CAPEDP is a randomised research and action program to promote mental health of young infants, conducted by the de infant department of the Hospital Bichat, and the Research Laboratory of the EPS Maison-Blanche. It funded by grants from the French ministry of Health, trough national research grants (PHRC, 2005) and from a public prevention institute (INPES). The goal of the research project is to assess the effect of a preventive intervention in a group of young parents with psychosocial vulnerability. The general project is CAPEDP, A (for Attachment) CAPEDP being the ancillary study in a sub sample of CAPEDP, with closer and specific measures of child disorganization and attachment status and of parental disorganizing behaviour and mentalizing abilities.

The CAPEDP-Attachment research consists in the evaluation of the infants’ security and disorganisation attachment, as well as their parents’ disrupted behaviour and mentalization skills, in a sub population of the general project CAPEDP. For this we compare the effect of the preventive intervention at home in an intervention and a control group.

Preventive interventions to promote mental health: the context of the research

Developmental theories recognize that social and family environment have long-term effects on the psychological functioning of individus1-4. The development of good quality early relationships allows infants to explore their environment safely and contribute to the establishment of a broader range of social skills. Moreover, infants are particularly sensitive to precarious contexts that generate significant stress in their families. The psychological suffering of parents (especially depression), and social contexts at multiple vulnerabilities can have a deleterious impact on their development 5.6. Intervention programs targeted on high risk populations have been developed in North America and in other different contexts over the years 1960-707. In France, since 1945 there is a preventive “universal” system, via the Protection Maternelle et Infantile (PMI, i.e., Infant and Maternal Protection, a network of public free well baby clinics), that offers to all pregnant women the possibility to be assisted. However, if this system of PMI has showed major effects on the public health (especially by reducing infant mortality by 80% in 50 years, along with other systems), it is now limited in its resources to accomplish its mission of prevention and mental health, particularly to support the development of parenting in families with psychosocial vulnerability.

The purpose of the project CAPEDP, based on the experiences of other cultural backgrounds who have demonstrated their effectiveness, is to strengthen the French prevention system, by implementing a home visits program to promote mental health and good quality parenting in young mothers waiting for their first infant.

The characteristics of the action-research program

CAPEDP is a program that aims to evaluate the effect of a preventive early intervention.

Families are recruited in maternity wards starting at 6th month of pregnancy. The involvement of professionals starts at the 7th month and continues up to babies’ two years of age. 220 families were recruited in a 18 months period in 9 maternity hospitals of the Assistance Publique-Hôpitaux de Paris. This intervention group will be compared with a similar group of 220 families with care as usual (maternity, PMI, paediatrician, GPs…). 440 families have now been recruited. Both groups will be compared on

  • Pre-and post-natal maternal depression,
  • Sense of parental competence,
  • Level of Parental stress,
  • Infants’ psychological and psychomotor development,
  • Infants’ attachment,
  • Social and medico-social insertion.

Inclusion criteria were:

  • Age less than 26 years
  • Expecting their first infant,
  • Speak enough French to give an informed consent,
  • Have at least one psychosocial vulnerability among the three following:
    • Declare to be socially isolated
    • Reach the CMU or AME (i.e., medical assistance for low income families as MEDICARE),
    • Have an education level below to the baccalaureate (less than12 years of school).

This is not to say that socio economic risk factors are the main weight on mental health. However, if none of these criteria is in itself a determinant of mental health, we now know that the accumulation of “risk factors” creates vulnerabilities (“it is easier to raise a infant when you are in good health, surrounded and able to assure his needs”, or as Mandela puts it: It needs a village to raise a child).

A home based intervention by a trained and supervised psychologist

For all families participating in the study, the first contact is made by a CAPEDP assessment psychologist. These psychologists visit these women at their homes for the first time when they are still pregnant and then, after the child birth, at the 3rd, 6th, 9th, 12th, 18th and 24th months of the baby, in order to assess the intervention effects, by means of observation and a set of instruments. For families receiving the intervention, a psychologist, specifically trained on preventive home-interventions, makes then a contact to begin the home visits since the mothers’ 7th month of pregnancy. Visits take place approximately twice a month, but the frequency decreases from the twelfth month of the infant in order to empower the families’ competences.

The intervention is adapted to each family. A basic manual was developed in order to ensure uniformity of the worked themes: mother and baby’s health (psychomotor development, sleep, food), parenting skills (helping parents recognize the signs of the baby), mother-infant’s relationship (encourage interaction between the mother and her baby), identifying the needs of the infant (e.g. understand the crying of infants), assistance on the social environment (encouraging mothers to address themselves to the PMI to be guided in the care for their infant).

Two specificities: we do not wait for people to ask for help. We use a promotion of health oriented model:

1. The anticipation of demand. Once CAPEDP is a preventive intervention, the ethical issue underlying is whether such an intervention with families who have not made any specific needs is adequate. Two answers are proposed:

The first is provided by the scientific data suggesting that these are the people most in need of support but that benefit the less 8, because of their difficulty (physical or psychological) to access the traditional services. The home preventive intervention is now recognized as the most efficient model to meet their needs.

The second concerns the choice of the intervention models: CAPEDP is based on a model of health promotion, rather than a psychopathological model: develop skills, not treatment. Our experience shows that families have been able to emotionally invest in the research project, valorise the utility of having a professional that answers promptly to their daily defies and to whom they may ask for help in a more regular way when difficult situations arrive.

The risk was to generate a “pathologizing” model of these families. To undergo this risk we have decided for a non-medical model of intervention, as well as for a weekly supervision of the psychologists-interveners by “senior” professionals of infancy.

2. Home- based intervention. The culture of mental health intervention in France does not focus on families’ all day life strategies. This is true especially when it comes to preventive actions. Intervention in the living environment is based on the available resources and proposes solutions that are based on a context that parents can better understand. We hope that this type of format may help to question the traditional framework of psychological intervention and will generate a reflection on the role of mental health professionals.

Inclusions have begun in December 2006 and the end of the follow-up assessments is scheduled for May 2011. The first data will be available in 2010. Nevertheless, the first families’ feedback is quite positive, as well as the feelings of the home visitors of being of enormous help to the mothers in their relationships with the baby. However, we find that some of them, generally the most vulnerable-are difficult to reach, with all their difficulties in receiving a regular intervention (the visits are still maintained as much as possible). The purpose is for professionals to restore the confidence of these families to newborn and infancy professionals, and to help them to formalize, their needs.

Inclusion rate CAPDEP study: 440 women included in 18 months
Inclusion rate CAPDEP study: 440 women included in 18 months

CAPEDP-Attachment Research

Attachment describes the human infant’s tendency to seek comfort, support, nurturance and protection from a small number of caregivers. Based upon experiences of regular interactions with adult caregivers, infants learn gradually to seek comfort and protection not from just anyone but selectively from caregivers they have learned they can rely upon. Attachment is considered a vital component of social and emotional development in the early years, and individual differences in the quality of attachment relationships are believed to be important early indicators of infant mental health 9. The way a child learns to develop relationships is vital for her subsequent psychosocial relations, since the use of an attachment figure as a secure base allows her optimal development and her ability to explore the world. Many studies have shown that attachment quality influences the ability to manage situations of alarm or distress and the infants’ subsequent mental health. Literature also suggests that the mother’s attachment organisation may be transmitted to the infant, specifically through the mean of her auto-reflexive skills and by sensitive or disrupting behaviour.

Within this theoretical framework, CAPEDP-Attachment study has four principal aims:

1. There is not, at the present, a French cohort describing the infants’ attachment categories nor describing the security or insecurity transmission of attachment from mother to child. The research project CAPEDP-attachment is designed to create such a cohort, in a population with psychosocial vulnerability factors.

2. To test the hypothesis that the CAPEDP home-intervention protocol helps to impede the transmission to the child of the mother’s insecure attachment style, and is associated with a lower frequency of maternal disrupting behaviour, as well as with better maternal auto-reflexive skills.

3. Our third goal is the French validation of a number of assessment tools and the setting of a French Attachment Laboratory.

For achieving this aims a sub-sample of 120 mother-infant dyads was selected from the intervention and control randomized groups of CAPEDP general (60 of each group). At their 12 months, infants’ attachment is assessed with the Strange Situation Paradigm 10 (ABCD) in our laboratory and later, at infants’ 18 months, the Attachment Waters’ Q sort 11 is used to assess attachment quality at home. The maternal disrupting behaviours are assessed by the AMBIANCE scale 12. Finally, the parental reflexive capacity is assessed by the Insightfulness Assessment interview 13.

A work in progress

Since January 2008, the team of CAPEDP-Attachment has progressively organised the following structures: A) Production of intervention documents and manuals for the CAPEDP general intervention team. B) Training of the CAPEDP general intervention team. C) Training of the CAPEDP-Attachment assessment team. D) Training of the CAPEDP-Attachment coding teams.

A) Production of intervention documents and manuals for the CAPEDP general intervention team.

  1. Production of the intervention pamphlet entitled “Infants’ Emotional Development”, directed to the mothers of the intervention group, to promote their sensibility for the infants’ attachment needs.
  2. Production of the “Intervention Manual CAPEDP-Attachment”. The manual details the preventive intervention methods, focusing on maternal sensitivity to the infants’ signals, and the use of video-feedback intervention at home.
  3. Production of the “Intervention Manual on Parental Authority”, for the 12th to 24th months’ period, to prevent parental behaviour disruption in the so-called opposition age.
  4. Organisation of an Attachment Documentation Centre available to the intervention and assessment psychologists (400 articles and documents in paper and digital format).

B) Training of the CAPEDP general intervention team.

Training and supervision of the intervention psychologists on the use of home video feedback for the promotion of maternal sensitivity, promotion of maternal mentalizing skills, prevention, detection and reduction of maternal atypical behaviour and infants’ disorganized attachment.

Two particular approaches characterise the attachment focus of the CAPEDP intervention. The first one is the use of the pamphlet entitled “Infants’ Emotional Development” by the intervention psychologists, which is an idea taken from VIPP, aiming to give knowledge to the parents on babies and infants’ emotional life. The French pamphlet was developed as part of this research and is based on the results of recent attachment longitudinal studies. Our aim is that the mothers work it with the psychologists and then read it and reread it when a problem of this area arrives or when they are in doubt. We have decided to introduce the pamphlet to the mother at baby’s 3 months taking into consideration the sensitive periods for the formation of the attachment relationship. In this line, the possibility to do this at baby’s 6 months seemed to us a bit late and doing it before 3 months seemed too early. Especially because first time mothers at babies’ 3 months are still involved in a phase of some relevant turbulence or looking for pragmatic ideas. We want to avoid the use of the pamphlet as a guide to parenting, rather that as an tool to help them to face the challenge of raising their first child 14. Other arguments in favour of its use at that age 14 are: a) parents are particularly open to suggestions for change in the first year of life of their infant, b) sometimes it’s only a bit after the baby is born that they realize that raising an infant creates problems that they can’t manage without special attention or extra help, c) reciprocal interactions of daily life are not yet rigid and we can help with a soft model.

The second one is the use of the video intervention based on the STEEP and VIPP programs. This type of approach is relatively recent in this kind of programs. The reasons for the increased use of this approach are associated with several factors (STEEP):
– Parents need a mirror of their own daily interactions with their child to change their behaviour;
– Video can be a starting point: we regard the current behaviour of the baby and not the retrospective narratives that are so often biased;
– Video offers opportunities to practice observational skills while watching the video together with the parent;
– It also offers opportunities to reinforce the behaviours that the sensitive parent shows, even when they are fluid.

By using the video the parent is his own model of intervention (STEEP and VIPP). This is an opportunity to focus on the baby’s signals and expressions, while stimulating the mother’s observation skills and her empathy with her child. It also enables positive reinforcement moments of sensitive behaviour that the parent evidences on the video. The Videoscopy strategy is as more successful as it occurs within a supportive relationship that continually recognizes the individuals and the family’s strengths recognizing the broader context to which they belong.

The strategies of video feedback as been shown to be very effective (STEEP) since it:
– Provides a focus on the Parent – Child relationship
– Emphasises the expertise of the parents
– Provides a permanent memory (e.g., coming back to the subject, a witness, a gift);
– Offers new perspectives;
– Facilitate the parent to puts himself at the place of the baby;
– Helps parents to watch the baby as a third person.
– Increases attention on the real baby;
– Examines better the interactional dimension of maternal perception, signals reading and her interpretation and response to them;
– Shows the difference between what we think and our automatic responses, as well as what we can do to regain control.

In conclusion, we can say that auto-videoscopy is an opportunity for parents to get a little bit out of the relationship with their baby and to reflect on what they are learning together. This intervention method allows the professionals to use a new and powerful strategy to strengthen their efforts in the support and promotion of stronger parent-infant’s relationships (STEEP).

C) CAPEDP-Attachment coding team.

  1. Establishment of a French Attachment Laboratory: two rooms with two remote cameras managed with a remote control device.
  2. We pay the mothers 50 euros for participating in the assessment.
  3. Formation on attachment theory and research, disorganized attachment and Attachment Clinical Approaches.
  4. Training and supervision on the Strange Situation Paradigm administration, and the Insightfulness Assessment Interview.
  5. Attachment Journal Club for monthly presentation/discussion on the domain of attachment.

D) CAPEDP-Attachment coding team.

  1. Training on the Strange Situation (ABC) in 2005 with Fabienne Becker-Stoll & Karin Grossman of the University of Regensburg, Germany.
  2. Training on the Strange Situation (Disorganization) in 2005 with Elizabeth Carlson, University of Minnesota, USA.
  3. Training on the Insightfulness Assessment, in 2006 and 2007 with Nina Koren-Karin & David Oppenheim of the University of Haifa, Israel. A French translation of the English manual was done after the training period.
  4. Training on the Waters Q-Sort, in March 2008, and November 2008 with Manuela Verissimo, from the Institute of Applied Psychology (ISPA) of Lisbon, Portugal. A French translation of the English manual was done after the training period and the French Q sort was validated.
  5. Training on the AMBIANCE scale, in April 2008 with Karlen Lyons-Ruth and Elisabeth Bronfman, of the University of Harvard, USA. A French translation of the English manual was done after the training period.

Some reliability tests are still being done by certain coders.

CAPEDP-Attachment invitations and SS and IA assessments have begun in July 2008 and are scheduled until November 2009. There are currently 35 mother-infants’ dyads assessed at infants’ 12 months. Verbatim Transcripts of Insightfulness Assessment interviews have started in parallel with the data assessment, since July 2008. The SE / AMBIANCE / IA coding teams began their work in February 2009 and are scheduled until December 2009.


CAPEDP hopes to offer new perspectives on preventive mental health, as well as the opportunity to develop specific training on the work involving projects of early mental health promotion. CAPEDP-Attachment, by clarifying our understanding of the mechanisms implied in the secure attachment strategies, aims to contribute in a significant way to refine parent-infant’s early preventive intervention in contexts of psychosocial vulnerability.


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CAPEDP-Attachment: Parenting Skills and Attachment in Infants: Reducing Mental Health Risks and Promoting Resilience A French Project to Decrease Disorganized Attachment


Tereno, Susana *,
Guedeney, Nicole **,
Guedeney, Antoine *,
Dugravier, Roman *,
Saias, Thomas ***,
Greacen, Tim ***,
Tubach, Florence *
* Centre Hospitalier Universitaire BichatClaude Bernard, APHP, Paris, France
** Institut Mutualiste Montsouris, Paris, France
*** EPS Maison Blanche, Paris, France

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