Maternal sensitivity plays a central role in shaping children’s development across a number of domains, and may be disrupted by depression. The current meta-analysis quantified the magnitude of the association between depression and maternal sensitivity, defined broadly as timely, contingent, and appropriate responding to infants’ cues, from birth to 12 months. Across k = 48 studies and n = 4,934 mother–infant dyads, the aggregate effect size between depression and maternal sensitivity was r = −.16, p < .0001, indicating that mothers with higher depression levels were less sensitive than mothers with lower depression levels. Studies that compared a depressed group with a nondepressed/control group had larger effect sizes (r = −.35, p < .0001) than studies that examined depression within a single sample of either unselected cases or clinical-only cases (r = −.11, p < .001), suggesting that clinical levels of depression may pose a particular threat to sensitive parenting. Clinical implications (e.g. screening, prevention) are discussed.

Children experiencing parental maltreatment face dual harm due to frequent stressful interactions with their family¹ and lack of access to the stress-reducing benefits of high-quality parental care.² Thus, exposure to parental maltreatment can disrupt normative developmental processes and is a major risk factor for psychological and physical health problems.^1,3 Chronic activation of physiological stress systems, such as the hypothalamic-pituitary-adrenal (HPA) axis, is considered one of the mediating mechanisms for the unfolding of some of these disease processes.⁴ Indeed, there is accumulating evidence that HPA axis functioning is altered in children experiencing adverse care.^5-9 Disrupted patterns of HPA activity are associated with numerous behavioral and emotional problems in children, including both internalizing and externalizing symptoms.^10-13

The hypothalamus–pituitary–adrenal axis is particularly sensitive to conditions of maltreatment. In particular, neglected children have shown a flatter slope with lower wake-up values relative to nonneglected children. An intervention, the Attachment and Biobehavioral Catch-Up (ABC), was developed to enhance biological and behavioral regulation in young children at risk for neglect. The effectiveness of the intervention was assessed in a randomized clinical trial for children with involvement with Child Protective Services. Following the intervention, children receiving the ABC intervention (n= 49) showed more typical cortisol production, with higher wake-up cortisol values and a steeper diurnal slope, than children receiving the control intervention (n= 51). These results suggest that the ABC intervention is effective in enhancing biological regulation.

Attachment theory and research are drawn upon in many applied settings, including family courts, but misunderstandings are widespread and sometimes result in misapplications. The aim of this consensus statement is, therefore, to enhance understanding, counter misinformation, and steer family-court utilisation of attachment theory in a supportive, evidence-based direction, especially with regard to child protection and child custody decision-making. The article is divided into two parts. In the first, we address problems related to the use of attachment theory and research in family courts, and discuss reasons for these problems. To this end, we examine family court applications of attachment theory in the current context of the best-interest-of-the-child standard, discuss misunderstandings regarding attachment theory, and identify factors that have hindered accurate implementation. In the second part, we provide recommendations for the application of attachment theory and research. To this end, we set out three attachment principles: the child’s need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of attachment relationships. We also discuss the suitability of assessments of attachment quality and caregiving behaviour to inform family court decision-making. We conclude that assessments of caregiver behaviour should take center stage. Although there is dissensus among us regarding the use of assessments of attachment quality to inform child custody and child-protection decisions, such assessments are currently most suitable for targeting and directing supportive interventions. Finally, we provide directions to guide future interdisciplinary research collaboration.

Understanding mechanisms and active ingredients of intervention is critical to training clinicians, particularly when interventions are transported from laboratories to communities. One promising active ingredient of parenting programs is clinicians’ in vivo feedback regarding parent–child interactions. The present study examined whether a form of in vivo feedback, in the moment commenting, predicted treatment retention and parent behavior change when the Attachment and Biobehavioral Catch-up (ABC) intervention was implemented in a community setting. Observational data were collected from 78 parent–child dyads (96% mothers; M age = 29 years; 81% minority; infants’ M age = 12 months; 90% minority) across 640 sessions conducted by 9 clinicians (100% female, M age = 39; 67% minority) in Hawaii. Parental behavior was assessed with a semistructured play task before and after intervention. Clinicians’ in-the-moment feedback to parents was assessed from intervention session videos. Clinicians’ frequency and quality of in-the-moment feedback predicted change in parental intrusiveness and sensitivity at posttreatment. Frequency of in-the-moment feedback also predicted likelihood of retention. Hierarchical linear modeling demonstrated strong support for these associations at the between-clinician level, and limited additional support at the within-clinician (i.e., between-case) level. Thus, a hypothesized active ingredient of treatment, in-the-moment feedback, predicted community-based ABC outcomes. The results complement lab-based evidence to suggest that in vivo feedback may be a mechanism of change in parenting interventions. Helping clinicians to provide frequent, high-quality in vivo feedback may improve parenting program outcomes in community settings.