Summary of the impact

Research into parent-child attachment carried out by Professor Pasco Fearon and colleagues at UCL has had a major impact on clinical services, policy and wider society through the development of: 1) novel assessment tools for measuring parent-child attachment, which are used in a variety of clinical services; 2) innovative prevention and intervention programmes deployed throughout the world; 3) dissemination of research evidence and best practice, through training and policy work in the UK and internationally.

Underpinning research

UCL's Research Department of Clinical, Educational and Health Psychology is home to one of the world's leading centres of excellence in the study of parent-child attachment and its importance for lifespan mental health. The work is led by three clinical academics (Professors Peter Fonagy, Mary Target and Pasco Fearon) who combine expertise in developmental psychology, clinical psychology and neuroscience.

The origins of this work can be traced back to research at UCL published in 1994 in which Fonagy and colleagues demonstrated for the first time that the security of the parent-child attachment bond at one year of age could be predicted from an interview with the parent regarding their own attachment history prior to the child's birth [1]. Most importantly from the point of view of intervention, the work that followed showed that a parent's capacity to make sense of their early experiences and relationships in terms of mental states (thoughts, feelings, beliefs, emotions), a capacity referred to as `reflective function', is a critical factor that shapes the quality of care they provide to their infant and the security of the evolving attachment relationship [2, 3]. A monograph detailing the theory was published in 2002, and has sold over 10,000 copies [4].

A key implication of this research was that insecure relationships may be perpetuated from one generation to the next. Using behaviour-genetic methods, the group showed that this process is indeed mediated by environmental processes, not via genetic transmission, and is linked to the quality of care [5]. Furthermore, the group made a critical contribution to the demonstration that these early differences in attachment security have long-term consequences for child development [6, 7]. Recently, the group has begun to shed light on the brain bases of attachment, particularly the critical role played by the mesolimbic dopamine system and the neuropeptide oxytocin [8].

The notion that patterns of relationship are laid down in early life, may be relatively stable over time, and may be passed from one generation to the next is an exceptionally important one when thinking about prevention strategies for breaking cycles of disadvantage. As we detail below, our group has been very active in bringing the theory, tools and interventions that have arisen from our research on attachment into the public domain in order to promote young children's health and wellbeing. Key to the success of these efforts has been our partnership with the Anna Freud Centre (AFC), where joint posts with UCL enable many of the group's clinical implementation and training programmes to be based. The UCL-AFC collaboration has created an effective platform for our findings to guide the training and skills of practitioners, to inform social and health policy and to impact directly on the welfare of vulnerable children and families. Key beneficiaries of our attachment research include teenage parents, parents raising infants in extreme poverty and parents with mental health problems. Our work has also directly impacted on the care of children who have been maltreated or are under threat of removal by the courts.

References to the research

Details of the impact

Attachment-based clinical interventions

We have translated our research findings into major new clinical programmes with direct impact on the lives of children and families. For example, our Parent-Infant Psychotherapy programme (PIP), developed at the AFC, supports parents in understanding and responding sensitively to their baby's needs, thereby promoting the development of secure attachments. This programme was initially set up in 2005-8, supported by Big Lottery funding (£206,000). In the period 2008-13, it has been delivered to 1,733 vulnerable mothers and infants in the UK including mothers with postnatal mental health problems in deprived London communities, mothers who are homeless and seeking asylum (funded by Rowntree), and mothers with severe psychiatric problems [a]. In 2008, the home office provided funding of £114,000 to extend the PIP programme to mothers in four UK Prisons [b]. The programme is recommended by the Department of Education as an evidence-based intervention for parents and infants under one year of age experiencing difficulties in the parent and baby relationship [c].

Based directly on our work, colleagues at Yale University developed the Minding the Baby (MTB) programme, which is designed to promote parental reflective functioning (RF) [d]. MTB supports the mother to develop her capacity to think about what is happening in her baby's mind, which helps her to respond sensitively, improving the quality of their relationship. Since 2008, MTB has supported 133 impoverished mothers in the US. In 2010 a training institute was created and 67 clinicians from the US and Europe have attended so far [e].

Recently we initiated a new partnership with the NSPCC to support the development and evaluation of Minding the Baby for highly vulnerable families in the UK. This five-year programme involves delivery of a comprehensive home visiting package to 320 high-risk families in three UK cities. By July 2013, 105 families had so far benefited from the programme. The Head of Strategy & Development at the NSPCC reports the impact of our work as follows:

"Fearon and Fonagy have made an important and distinctive contribution to national policy in the field of early years intervention and prevention... Their developmental approach has influenced the policy narrative around the importance of sensitive and critical periods for intervention across different stages of early childhood. They have advocated effectively for an attachment perspective and clearly articulated the importance of parental sensitivity as a key predictor of child outcomes of interest to policy makers. The impacts of this work can be very concretely seen in policy documents such as the NSPCC's highly influential report `All Babies Count' which received wide acclaim amongst policy makers... The Unit has also had a significant impact on practice. Fonagy and Fearon have delivered training in early child development and attachment to almost all of the NSPCC's workforce of social workers, psychologists and midwives delivering services to babies. Their work has also been highly influential on shaping NSPCC's strategy and pioneering programme of new services for babies and their families. All of the new services are influenced by a strong attachment perspective and several have integrated a very explicit focus on the role of maternal reflective function as a protective factor against abuse and neglect" [f].

Using a related model of intervention, we have worked with a team in Ethiopia to train mothers with malnourished infants in an attachment-based intervention, Play Therapy. It has been shown that malnutrition impacts negatively on the quality of the parent-child attachment relationship, and has serious physical, social and emotional consequences. This intervention aims to improve the mother's reflective function so that she can provide appropriate emotional stimulation to her child. The intervention helps mother and child re-engage and has been found to facilitate children's weight gain and faster discharge from hospital. Mothers are trained by local volunteers in the community. Since 2010, local youths have been trained and in turn have trained 191 mothers in the intervention. The results have been presented to the Ethiopian Health Minister, and Play Therapy is to be rolled out to wider populations in East Africa severely affected by drought [g].

Measurement tools

We have developed a range of specialised measurement instruments that are now widely used by clinicians to assess attachment and reflective function, including the Reflective Functioning (RF) scale, the Story Stem Assessment Profile (SSAP) and the Child Attachment Interview (CAI). Our courses in the administration and coding of these measures have been attended by more than 500 active clinicians aiming to use the instrument for their clinical assessments and court reports. We have also provided training to over 100 NSPCC practitioners (2012, 2013) and two County Councils (Portsmouth and Buckinghamshire in 2011, 2012 and 2013) involved in preventing child maltreatment. We have also run numerous clinical training courses in our attachment-based interventions that have been attended by more than 400 practitioners since 2008 [h].

These measures are now frequently used in child care proceedings by social workers needing to advise Child Protection Services and the Courts about the quality and safety of placements. The CAI is recognised as the best instrument available for evaluating the quality of the bond between child and parents or foster-parents. Examples of Boroughs which use the instrument include Southwark, Surrey and Fife [i]. The Clinical Lead for the Family Assessment and Safeguarding Service and the Infant Parent Perinatal Service (IPPS) at Oxford Health NHS Foundation Trust (which provides various services in Buckinghamshire, Wiltshire and Bath and North East Somerset, as well as in Oxfordshire) reports the following regarding the impact of our research on their services:

"It would be difficult to overstate the contribution the ground-breaking research conducted at UCL in attachment and in particular reflective function has had on our services... It has profoundly influenced the design of our clinical services... Crucially, the research and trainings provided have equipped us with effective measures that allow for accurate assessment in both Court and clinical cases and to measure outcomes following our treatment programmes" [j].

Influencing Policy

In part as a result of our work, the need to assess the quality of children's attachments and intervene to promote attachment in order to deliver best outcomes in the health and social care of young children is now broadly accepted in the UK. We have influenced policy through academic publishing of policy-relevant papers, talks at major national policy and practice conferences and direct engagement with policy-making. Our research contributed directly to Frank Field's government inquiry into Early Intervention and the Scottish Government's National Risk Framework to support the assessment of children and young people. We have also recently presented to the Secretary of State for Education, Michael Gove, and his Early Years Minister Liz Truss, to inform policy regarding infant attachment and its long-term consequences for children's life chances. We also advise the parliamentary Foundation Years Action Group [k], led by Frank Field and have been visited by a South Korean Assembly delegation who were seeking advice on how attachment interventions can be implemented to reduce aggression in schools [l]. In July 2013, Fonagy was appointed as chair of the NICE Guideline Development Group on attachment and the care of Looked After Children and adoptees, a group to which Fearon has also been appointed [m].

Sources to corroborate the impact

[a] Details of Parent-Infant Psychotherapy programme, including numbers treated, can be confirmed by the project's Clinical Administrator. Contact details provided.

[b] Anonymised feedback from mothers in prison who attended the course available on request.

[c] http://www.education.gov.uk/commissioning-toolkit/Programme/Detail/51

[d] Minding the Baby, details of programme: http://medicine.yale.edu/childstudy/mtb/index.aspx. See also http://mtb.yale.edu/clinicalmodel/theoreticalunderpinnings.aspx. This page explains how the programme is based on Fonagy's work, specifically ref. 3 above.

[e] Number of patients treated and clinicians trained can be corroborated by Project Director, Child Study Center, Yale University School of Medicine. Contact details provided.

[f] Supporting statement provided by Head of Strategy & Development, NSPCC. Copy available on request. NSPCC Report: `All Babies Count'. See p.36-7 in particular.
http://www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/all_babies_count_pdf_wdf85569.pdf

[g] Ethiopia intervention. Details on our website: http://www.annafreud.org/pages/emotional- stimulation-in-the-context-of-emergency-food-intervention-in-the-treatment-of-malnourished.html. Impacts can be corroborated by the Co-Director of Play Therapy Africa. Contact details provided.

[h] Information about our courses is available here:
http://annafreud.client.fatbeehive.com/shortcourses.php Corroboration of participant numbers can be obtained from the Anna Freud Centre (see [a])

[i] Examples of Boroughs who use the Child Attachment Interview:

• Southwark Child & Adolescent Mental Health Service for Looked After Children
  http://moderngov.southwark.gov.uk/documents/s12476/Appendix%201%20Southwark%20Carelink%20CAMHS%20for%20Children%20Looked%20After.pdf
• Fife Council — Therapeutic Service for Looked After Children
  www.fife.gov.uk/uploadfiles/Publications/c64_Item13SpringieldProject.doc

[j] Supporting statement from the Clinical Lead, FASS, IPPS Family Assessment and Safeguarding Service, and Infant and Parent Perinatal Service, Oxford. Available on request.

[k] Peter Fonagy advised Frank Field on: The Foundation Years: Preventing Poor Children Becoming Poor Adults. The report of the Independent Review on Poverty and Life Chances (2010). Frank Field. HM Government. Advisors on Parliamentary Foundation Years Action Group led by Frank Field http://www.fyag.org.uk/who_we_are.htm

[l] Emails from the delegation arranging the visit and outlining its purpose available on request.

[m] Email confirming Fonagy's position as Chair of the Guideline Development Group available on request.