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Assessing a change mechanism in a randomized home-visiting trial: Reducing disrupted maternal communication decreases infant disorganization

Published online by Cambridge University Press:  12 April 2017

Susana Tereno*
Université Paris Descartes Laboratoire de Psychologie et Processus de Santé
Sheri Madigan
Alberta Children's Hospital Research Institute University of Calgary
Karlen Lyons-Ruth
Harvard Medical School
Andre Plamondon
Université Laval, Québec City
Leslie Atkinson
Ryerson University
Nicole Guedeney
Institut Mutualiste Montsouris, Paris Université Paris Diderot
Tim Greacen
Etablissement Public de Santé Maison Blanche
Romain Dugravier
Université Paris Diderot Institut de Puériculture de Paris
Thomas Saias
Université du Québec, Montréal
Antoine Guedeney
Laboratoire de Psychologie et Processus de Santé Université Paris Diderot Hôpital Bichat-Claude Bernard, Paris INSERM CIE 801
Address correspondence and reprint requests to: Susana Tereno, Institut de Psychologie (Bureau 4094), Laboratoire de Psychologie et Processus de Santé (LPPS-EA4057), Université Paris Descartes, 71 Avenue Édouard Vaillant, 92 100 Boulogne-Billancourt, France; E-mail:


Although randomized interventions trials have been shown to reduce the incidence of disorganized attachment, no studies to date have identified the mechanisms of change responsible for such reductions. Maternal sensitivity has been assessed in various studies and shown to change with intervention, but in the only study to formally assess mediation, changes in maternal sensitivity did not mediate changes in infant security of attachment (Cicchetti, Rogosch, & Toth, 2006). Primary aims of the current randomized controlled intervention trial in a high-risk population were to fill gaps in the literature by assessing whether the intervention (a) reduced disorganization, (b) reduced disrupted maternal communication, and (c) whether reductions in disrupted maternal communication mediated changes in infant disorganization. The results indicated that, compared to controls (n = 52), both infant disorganization and disrupted maternal communication were significantly reduced in the intervention group (n = 65) that received regular home-visiting during pregnancy and the first year of life. Furthermore, reductions in disrupted maternal communication partially accounted for the observed reductions in infant disorganization compared to randomized controls. The results are discussed in relation to the societal cost effectiveness of early attachment-informed interventions for mothers and infants, as well as the importance of formally assessing underlying mechanisms of change in order to improve and appropriately target preventive interventions.

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The contributions of the first and second authors to this article were equal. The Compétences parentales et Attachement dans la Petite Enfance: Diminution des risques liés aux troubles de santé mentale et Promotion de la resilience—Attachment project (CAPEDP-A) was supported by research grants from the French Ministry of Health (Hospital Clinical Research Program PHRC AOM05036), the French National Institute for Health Promotion and Health Education (INPES), the French National Institute of Health and Medical Research (INSERM), and the French Public Health Research Institute (IReSP, PREV0702). The Pfizer Foundation funded CAPEDP-A Phase II. The CAPEDP general project was financed with a grant from the National Ministry of Health Hospital Clinical Research Program (PHRC AOM 05056) and INPES. The sponsor was the Clinical Research and Development Department of the Assistance publique–Hôpitaux de Paris. The funders had no role in the study design, data collection and analysis, the decision to publish, or the preparation of the current manuscript. Research support was provided to Sheri Madigan by the Alberta Children’s Hospital Foundation and the Canada Research Chairs program. We thank the CAPEDP study group, the 440 families who participated in the study, the assessment and coding teams, the members of the home-visiting team, and the research assistants, without whom this project would not have been possible. Special thanks to Jaqueline Wendland, Claire Lamas, Lauriane Vulliez-Coady, and Violaine Bekhechi for coding the AMBIANCE. We also thank Marinus H. van IJzendoorn for coding infant disorganization and for giving feedback on a draft of the manuscript.


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