Enhancing parental reflective functioning through early dyadic interventions: A systematic review and meta-analysis

Parental reflective functioning (PRF) is an important predictor of infant attachment, and interventions that target parent-infant/toddler dyads who are experiencing significant problems have the potential to improve PRF. A range of dyadic interventions have been developed over the past two decades, some of which explicitly target PRF as part of their theory of change, and some that do not explicitly target PRF, but that have measured it as an outcome. However, no meta-analytic review of the impact of these interventions has been carried out to date. The aim of this review was to evaluate the effectiveness of dyadic interventions targeting parents of infant and toddlers, in improving PRF and a number of secondary outcomes. A systematic review and meta-analysis was conducted in which key electronic databases were searched up to October 2018. Eligible studies were identified and data extracted. Data were synthesised using meta-analysis and expressed as both effect sizes and risk ratios. Six studies were identified providing a total of 521 participants. The results of six meta-analyses showed a nonsignificant moderate improvement in PRF in the intervention group (standardised mean difference [SMD]: -0.46; 95% confidence interval [CI] [-0.97, 0.04]) and a significant reduction in disorganised attachment (risk ratio: 0.50; 95% CI [0.27, 0.90]). There was no evidence for intervention effects on attachment security (odds ratio: 0.71; 95% CI [0.19, 2.64]), parent-infant interaction (SMD: -0.10; 95% CI [-0.46, 0.26]), parental depression (SMD: -1.55; 95% CI [-3.74, 0.64]) or parental global distress (SMD: -0.19, 95% CI [-3.04, 22.65]). There were insufficient data to conduct subgroup analysis (i.e. to compare the effectiveness of mentalisation-based treatment with non-mentalization-based treatment interventions). Relational early interventions may have important benefits in improving PRF and reducing the prevalence of attachment disorganisation. The implications for future research are discussed.