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1. Citation: Barlow, J., Bennett, C., Midgley, N., Larkin, S. K., & Wei, Y. (2015). Parent-infant Psychotherapy for improving parental and infant mental health: A systematic review. Campbell Systematic Reviews, 6, pp. 1-223.

Parent-infant; psychotherapy;parental and infant mental health; disability;


Parent-infant psychotherapy (PIP) is a dyadic intervention that works with parent
and infant together, with the aim of improving the parent-infant relationship and
promoting infant attachment and optimal infant development. PIP aims to achieve
this by targeting the mother’s view of her infant, which may be affected by her own
experiences, and linking them to her current relationship to her child, in order to
improve the parent-infant relationship directly.

1. To assess the effectiveness of PIP in improving parental and infant mental health
and the parent-infant relationship.
2. To identify the programme components that appear to be associated with more
effective outcomes and factors that modify intervention effectiveness (e.g.
programme duration, programme focus).

We searched the following electronic databases on 13 January 2014: Cochrane
Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), Ovid MEDLINE,
EMBASE, CINAHL, PsycINFO, BIOSIS Citation Index, Science Citation Index,
ERIC, and Sociological Abstracts. We also searched the metaRegister of Controlled
Trials, checked reference lists, and contacted study authors and other experts.

Two review authors assessed study eligibility independently. We included
randomised controlled trials (RCT) and quasi-randomised controlled trials (quasiRCT)
that compared a PIP programme directed at parents with infants aged 24
months or less at study entry, with a control condition (i.e. waiting-list, no treatment
or treatment-as-usual), and used at least one standardised measure of parental or
infant functioning. We also included studies that only used a second treatment

We adhered to the standard methodological procedures of The Cochrane
Collaboration. We standardised the treatment effect for each outcome in each study
by dividing the mean difference (MD) in post-intervention scores between the
intervention and control groups by the pooled standard deviation. We presented
standardised mean differences (SMDs) and 95% confidence intervals (CI) for
continuous data, and risk ratios (RR) for dichotomous data. We undertook metaanalysis
using a random-effects model.

We included eight studies comprising 846 randomised participants, of which four
studies involved comparisons of PIP with control groups only. Four studies involved
comparisons with another treatment group (i.e. another PIP, video-interaction
guidance, psychoeducation, counselling or cognitive behavioural therapy (CBT)),
two of these studies included a control group in addition to an alternative treatment
group. Samples included women with postpartum depression, anxious or insecure
attachment, maltreated, and prison populations. We assessed potential bias
(random sequence generation, allocation concealment, incomplete outcome data,
selective reporting, blinding of participants and personnel, blinding of outcome
assessment, and other bias). Four studies were at low risk of bias in four or more
domains. Four studies were at high risk of bias for allocation concealment, and no
study blinded participants or personnel to the intervention. Five studies did not
provide adequate information for assessment of risk of bias in at least one domain
(rated as unclear).
Six studies contributed data to the PIP versus control comparisons producing 19
meta-analyses of outcomes measured at post-intervention or follow-up, or both, for
the primary outcomes of parental depression (both dichotomous and continuous
data); measures of parent-child interaction (i.e. maternal sensitivity, child
involvement and parent engagement; infant attachment category (secure, avoidant,
disorganised, resistant); attachment change (insecure to secure, stable secure,
secure to insecure, stable insecure); infant behaviour and secondary outcomes (e.g.
infant cognitive development). The results favoured neither PIP nor control for
incidence of parental depression (RR 0.74, 95% CI 0.52 to 1.04, 3 studies, 278
participants, low quality evidence) or parent-reported levels of depression (SMD -
0.22, 95% CI -0.46 to 0.02, 4 studies, 356 participants, low quality evidence). There
were improvements favouring PIP in the proportion of infants securely attached at
post-intervention (RR 8.93, 95% CI 1.25 to 63.70, 2 studies, 168 participants, very
low quality evidence); a reduction in the number of infants with an avoidant
attachment style at post-intervention (RR 0.48, 95% CI 0.24 to 0.95, 2 studies, 168
participants, low quality evidence); fewer infants with disorganised attachment at
post-intervention (RR 0.32, 95% CI 0.17 to 0.58, 2 studies, 168 participants, low
9 The Campbell Collaboration |
quality evidence); and an increase in the proportion of infants moving from insecure
to secure attachment at post-intervention (RR 11.45, 95% CI 3.11 to 42.08, 2 studies,
168 participants, low quality evidence). There were no differences between PIP and
control in any of the meta-analyses for the remaining primary outcomes (i.e. adverse
effects), or secondary outcomes.

Four studies contributed data at post-intervention or follow-up to the PIP versus
alternative treatment analyses producing 15 meta-analyses measuring parent mental
health (depression); parent-infant interaction (maternal sensitivity); infant
attachment category (secure, avoidant, resistant, disorganised) and attachment
change (insecure to secure, stable secure, secure to insecure, stable insecure); infant
behaviour and infant cognitive development. None of the remaining meta-analyses
of PIP versus alternative treatment for primary outcomes (i.e. adverse effects), or
secondary outcomes showed differences in outcome or any adverse changes.
We used the Grades of Recommendation, Assessment, Development and Evaluation
Working Group (GRADE) approach to rate the overall quality of the evidence. For all
comparisons, we rated the evidence as low or very low quality for parental
depression and secure or disorganised infant attachment. Where we downgraded the
evidence, it was because there was risk of bias in the study design or execution of the
trial. The included studies also involved relatively few participants and wide CI
values (imprecision), and, in some cases, we detected clinical and statistical
heterogeneity (inconsistency). Lower quality evidence resulted in lower confidence
in the estimate of effect for those outcomes.

Although the findings of the current review suggest that PIP is a promising model in
terms of improving infant attachment security in high-risk families, there were no
significant differences compared with no treatment or treatment-as-usual for other
parent-based or relationship-based outcomes, and no evidence that PIP is more
effective than other methods of working with parents and infants. Further rigorous
research is needed to establish the impact of PIP on potentially important mediating
factors such as parental mental health, reflective functioning, and parent-infant

Plain Language Summary:

Campbell Plain Language Summary 2016:

Plain Language Summary from Systematic planned out, orderly, regular Review go over, check (page 10):

Parent-infant psychotherapy (PIP) is intended to address problems in the parent-infant
relationship, and problems such as excessive too much, more than needed crying and sleeping/eating
difficulties. problems, trouble A parent-infant psychotherapist works directly with the parent and
infant baby in the home or clinic, to identify unconscious patterns of relating and
behaving, and influences from the past that are impeding the parent-infant
relationship. Parents may be referred to this service (e.g. by a general practitioner in
the UK) or may self refer to privately run services. The intervention care is delivered to
individual person, you, man, woman, one dyads but can also be delivered to small groups of parents and infants.

Review go over, check question
This review go over, check examined whether PIP is effective works well, good, strong in improving the parent-infant
relationship, or other aspects of parent or infant baby functioning, and to identify the
programme components that appear to be associated with more effective works well, good, strong outcomes
and factors that modify change intervention care effectiveness (e.g. programme duration,
programme focus).

Study characteristics
We searched electronic databases and identified randomised controlled trials (RCTs,
where participants are randomly allocated to one of two or more treatment action, medicine, therapy groups)
and one cluster randomised trial (where prisons rather than participants were used
as the unit of randomisation), in which participants had been allocated to a receive
PIP versus a control manage, have power over, take care of group, and which reported results using at least one standard
measure of outcome (i.e. an instrument tool, device which has been tested to ensure that it
reliably measures the outcome under investigation).

Evidence is current to 13 January 2014.

We identified eight studies with 846 randomised participants comparing either PIP
with a no-treatment control manage, have power over, take care of group (four studies) or comparing PIP with other types
of treatment action, medicine, therapy (four studies).

Key results
The studies comparing PIP with a no-treatment control manage, have power over, take care of group contributed data to 19
meta-analyses of the primary outcomes of parental mental health (depression),
parent-infant interaction outcomes of maternal sensitivity (i.e. the extent to which
the caregiver responds in a timely and attuned manner), child involvement and
parent positive engagement, and infant baby outcomes of infant baby attachment category (the
infant's ability skill, are able, can to seek and maintain take care of, keep, keep up closeness to primary caregiver - infant
attachment is classified as follows: 'secure' infant baby attachment is a positive outcome,
which indicates that the infant baby is able to be comforted when distressed and is able to
use the parent as a secure base from which to explore the environment. all the things around you in your daily life, at home and at work, world around you, your home Infants who
are insecurely attached are either 'avoidant' (i.e. appear not to need comforting when
they are distressed and attempt try, effort to manage control, direct, be in charge of, take care of, watch the distress themselves); or 'resistant'
(i.e. unable to be comforted when distressed and alternate take turns, one and then the other, rotate between resistance and
anger). Children who are defined as ‘disorganised’ are unable to produce a coherent
strategy in the face of distress and produce behaviour that is a mixture of approach
and avoidance to the caregiver); and the secondary outcomes of infant baby behaviour
and infant baby cognitive development (i.e. intellectual development, including thinking,
problem solving and communicating).

In our analyses, parents who received PIP were more likely to have an infant baby who
was securely emotionally attached to the parent after the intervention; this a
favourable outcome but there is very low quality evidence to support it.
The studies comparing PIP with another model of treatment action, medicine, therapy contributed data to 15
meta-analysis assessments of primary outcomes, including parental mental health,
parent-infant interaction (maternal sensitivity); infant baby attachment and infant
behaviour, or secondary infant baby outcomes such as infant baby cognitive development.
None of these comparisons showed differences that favoured either PIP or the
alternative option, another choice, other, different way, another option, different, another way intervention. care

None of the comparisons of PIP with either a control manage, have power over, take care of or comparison treatment action, medicine, therapy group
showed adverse bad, dangerous, hurtful, harmful changes for any outcome.

We conclude end, finish, judge, deem, that although PIP appears to be a promising method of improving
infant baby attachment security, there is no evidence about its benefits in terms of other
outcomes, and no evidence to show that it is more effective works well, good, strong than other types of
treatment action, medicine, therapy for parents and infants. Further research is needed.

Quality of the evidence
The included studies were unclear about important quality criteria, had limitations
in terms of their design or methods, or we judged that there was risk chance of bias in the
trial. This lower quality evidence gives us less confidence in the observed effects.

Full-Text Availability Options:

Available in Campbell Library
Plain Language Summary available in Campbell Library

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Record Updated:2017-03-10

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