Attachment and Biobehavioral Catch-up (ABC)

Scientific Rating:
1
Well-Supported by Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
High
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Attachment and Biobehavioral Catch-up (ABC) has been rated by the CEBC in the area of: Infant and Toddler Mental Health Programs (Birth to 3).

Target Population: Caregivers of infants 6 months to 2 years old who have experienced early adversity

For parents/caregivers of children ages: 0 – 2

Brief Description

ABC targets several key issues that have been identified as problematic among children who have experienced early maltreatment and/or disruptions in care. These young children often behave in ways that push caregivers away. The first intervention component helps caregivers to re-interpret children's behavioral signals so that they provide nurturance even when it is not elicited. Nurturance does not come naturally to many caregivers, but children who have experienced early adversity especially need nurturing care. Thus, the intervention helps caregivers provide nurturing care even if it does not come naturally. Second, many children who have experienced early adversity are dysregulated behaviorally and biologically. The second intervention component helps caregivers provide a responsive, predictable environment that enhances young children's behavioral and regulatory capabilities. The intervention helps caregivers follow their children’s lead with delight. The third intervention component helps caregivers decrease behaviors that could be overwhelming or frightening to a young child.

Program Goals:

The program goals of Attachment and Biobehavioral Catch-up (ABC) are:

  • Increase caregiver nurturance, sensitivity, and delight
  • Decrease caregiver frightening behaviors
  • Increase child attachment security and decrease disorganized attachment
  • Increase child behavioral and biological regulation

Essential Components

The essential components of Attachment and Biobehavioral Catch-up (ABC) include:

  • Targets three key issues:
    • Child behaves in ways that push caregiver away: The caregiver is helped to override tendencies to respond “in kind” and to provide nurturance regardless.
    • Child is dysregulated at behavioral and biological levels: Caregiver is helped to provide environment that helps child develop regulatory capabilities. This includes parent following child's lead and showing delight in child.
    • Caregiver is helped to decrease behaviors that may be frightening or overwhelming to the child.
  • While ABC is a manualized intervention that also incorporates video-feedback and homework, the most crucial aspect of the intervention is the parent coach’s use of “In the Moment” comments that target the caregiver behaviors of nurturance, following the lead, delight, and non-frightening behaviors. These are used throughout the home visiting session while working with the parent.

Parent/Caregiver Services

Attachment and Biobehavioral Catch-up (ABC) directly provides services to parents/caregivers and addresses the following:

  • Has child that pushes caregivers away or has difficulty being soothed; has child with behavioral and biological dysregulation; difficulty in providing parental nurturance, following the lead, or delighting; tendency to be frightening or overwhelming; and own history of care that may interfere with parenting
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: The child is involved in the home visits to show the parents new skills and the parents are expected to observe and note the child's behavior and practice new skills them with between sessions.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Foster/Kinship Care

Homework

Attachment and Biobehavioral Catch-up (ABC) includes a homework component:

Parents make observations over the week and record observations. For most weeks, daily activities are suggested.

Languages

Attachment and Biobehavioral Catch-up (ABC) has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

A/V:

  • Laptop computer
  • Video camera
  • Webcam for supervision

Personnel:

  • Clinician with excellent interpersonal skills

Space:

  • Must be conducted at caregivers’ homes; this can include shelters or other temporary living situations

Minimum Provider Qualifications

There is no educational level requirement for parent coaches. Potential parent coaches participate in a screening prior to training. If they pass the short screening, coaches attend a 2-3 day training and a year of supervision.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

Training at University of Delaware with Supervision through videoconferencing

Number of days/hours:

3 days training to become a Parent Coach then followed by 1 year supervision (1.5 hours weekly, including group supervision and individual supervision in In the Moment commenting) to become a Certified Parent Coach

Implementation Information

Since Attachment and Biobehavioral Catch-up (ABC) is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Attachment and Biobehavioral Catch-up (ABC) as listed below:

A half-hour screening is used to predict which potential coaches (i.e., home visitors) are likely to be most successful. This screening can be conducted remotely through video conferencing with potential coaches. After the screening, program staff informs the parent coach as to his or her suitability for training. This step is conducted before training.

Formal Support for Implementation

There is formal support available for implementation of Attachment and Biobehavioral Catch-up (ABC) as listed below:

Supervision is conducted for one year via video conferencing using Skype or Adobe Connect. Parent coach trainees have 2 supervision meetings per week, General Clinical Supervision and “In the Moment Commenting” Supervision:

  • General Clinical supervision is 1-hour per week group supervision conducted in groups of 2 or 3, with a PhD-level supervisor. Supervision includes video review each week.
  • “In the Moment Commenting” supervision is a 30 minute session per week conducted by staff members at the University of Delaware. A 5-minute segment from the parent coach’s case is assigned to the parent coach and staff member for coding prior to the supervision session. The supervision is directed at enhancing coding reliability (so that parent coaches will learn to identify triggers for comments and components of comments) and at enhancing comment quality and frequency.

After a year of supervision, parent coaches' adherence and fidelity are evaluated for certification. If they pass, coaches are certified for 2 years, after which time adherence and fidelity are reevaluated.

Fidelity Measures

There are fidelity measures for Attachment and Biobehavioral Catch-up (ABC) as listed below:

Parent coaches are reviewed for both their adherence and their fidelity to the model. Parent coaches are measured on their adherence to manual content and general clinical issues. For treatment adherence, there is a short list of specific issues from each session that are to be covered from manual content. For treatment fidelity, a parent coach’s frequency and level of “In the Moment” commenting is monitored and tracked each week in addition to a qualitative review.

Implementation Guides or Manuals

There are implementation guides or manuals for Attachment and Biobehavioral Catch-up (ABC) as listed below:

Two manuals have been developed for ABC implementation:

  • The first manual includes the content of the intervention, describing in detail what material should be covered in each of the 10 sessions. Content is provided with example language that parent coaches may use with the parent. The manual also includes lists of materials needed for each session as well as a summary of the critical adherence items for each session.
  • The second manual details procedures and rules for coding “In the Moment” commenting. The manual is designed to help coaches better understand the targets for commenting as well as how to code selected segments on their own sessions.

Implementation materials are supplemental to the intensive supervision provided across a year of training.

Research on How to Implement the Program

Research has not been conducted on how to implement Attachment and Biobehavioral Catch-up (ABC).

Relevant Published, Peer-Reviewed Research

This program is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The program must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. The article(s) below that reports outcomes from an RCT showing a sustained effect of at least 1 year has an asterisk (*) at the beginning of its entry. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

Show relevant research...

When more than 10 research articles have been published in peer-reviewed journals, the CEBC reviews all of the articles as part of the rating process and identifies the 10 most relevant articles, with a focus on randomized controlled trials (RCTs) and controlled studies that have an impact on the rating. The 10 articles chosen for Attachment and Biobehavioral Catch-up (ABC) are summarized below:

Dozier, M., Peloso, E., Lindhiem, O., Gordon, M. K., Manni, M., Sepulveda, S., ... & Levine, S. (2006). Developing evidence-based interventions for foster children: An example of a randomized clinical trial with infants and toddlers. Journal of Social Issues, 62(4), 767-785.

Type of Study: Randomized controlled trial
Number of Participants: 60, plus 104 comparison children not in foster care.

Population:

  • Age — 3.6-39.4 months at postintervention
  • Race/Ethnicity — 63% African American, 32% White, and 5% biracial
  • Gender — 51% Female
  • Status — Participants were children in foster care.

Location/Institution: Mid-Atlantic, U.S.

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Children and caregivers were randomly assigned to receive either the Attachment and Biobehavioral Catch-up (ABC) intervention or a control intervention, Developmental Education for Families (DEF), which focused on cognitive and language development. Salivary cortisol was used as a measure of stress level in children and infants. Parents also reported on problem behaviors using the pre-school or infant/toddler Parent's Daily Report (PDR/IT). Post-intervention cortisol levels were significantly lower for the ABC group than for the DEF group. The levels for children in the ABC group also did not differ from those of the normally developing group at the follow-up. Parents in the ABC group reported few problem behaviors for toddlers than for infants, but the ABC and DEF groups did not differ from each other on this measure.

Length of postintervention follow-up: 1 month.

Bernard, K., Simons, R., & Dozier, M. (2015). Effects of an attachment‐based intervention on child protective services–referred mothers' event‐related potentials to children's emotions. Child Development, 86(6), 1673-1684. doi:10.1111/cdev.12418

Type of Study: Randomized controlled trial
Number of Participants: 70 parent and youth dyads

Population:

  • Age — Adults:Mean=31.6 years, Children:Not Specified
  • Race/Ethnicity — Adults: 74% African American, 16% White/non-Hispanic,6% Hispanic, and 4% Biracial; Children: Not specified
  • Gender — Adults: 100% Female, Children: 58% Male and 42% Female
  • Status — Participants were children and parents identified as at risk for neglect in a diversion from foster care program.

Location/Institution: Mid-Atlantic, U.S.

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses a subsample from the Lind et al. (2014) study. This study examined the neurobiology of maternal sensitivity to children’s emotions among mothers involved with Child Protective Services (CPS) and low-risk comparison mothers. CPS-referred mothers were randomized into the Attachment and Biobehavioral Catch-up (ABC) intervention or the control, Developmental Education for Families (DEF) intervention.Mothers’ event-related potentials (ERPs) were measured while they categorized images of children with crying, laughing, and neutral expressions.The primary measure was the EEG activity. Results indicate that that CPS-referred mothers who received the ABC intervention showed enhanced psychophysiological processing of emotional infant faces relative to mothers who received a control intervention. Limitations include the small sample size, variations in the families’ maltreatment experiences, and lack of follow-up.

Length of postintervention follow-up: None.

Dozier, M., Peloso, E., Lewis, E., Laurenceau, J., & Levine, S. (2008). Effects of an attachment based intervention on the cortisol production of infants and toddlers in foster care. Development and Psychopathology, 20, 845-859.

Type of Study: Randomized controlled trial
Number of Participants: 93, plus 48 children not in foster care

Population:

  • Age — 15-24 months
  • Race/Ethnicity — ABC: 38% African American, 8% White, and 1% Hispanic; DEF: 31% African American, 14% White, and 2% Hispanic
  • Gender — 59% female in the ABC group, 43% female in the DEF group and 44% in the comparison group of children who had not been in foster care
  • Status — Participant were children in foster care.

Location/Institution: University of Delaware

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Children and foster parents were randomly assigned to receive with the Attachment and Biobehavioral Catch-up (ABC) intervention or to a comparison group which received the Developmental Education for Families (DEF) program which focuses on cognitive and language development. Stress was measured before and after exposure to the Strange Situation, a structured observational session which is designed to assess attachment level in young children. Salivary cortisol was used as the measure of stress level. Initial cortisol levels were higher for the DEF group than the ABC group, suggested a higher initial stress level. The initial cortisol levels of the ABC group did not differ from those of a comparison group of children from the general population. Measures of cortisol taken at subsequent points did not show any increase in cortisol levels in response to the Strange Situation for either treatment group, which is consistent with current research suggesting that children may experience a period of reduced cortisol response to stress. The authors suggest that collecting saliva samples prior to arrival at the laboratory might have produced a more accurate assessment of baseline levels of cortisol.

Length of postintervention follow-up: None.

Dozier, M., Lindhiem, O., Lewis, E., Bick, J., Bernard, K., & Peloso, E. (2009). Effects of a foster parent training program on young children's attachment behaviors: Preliminary evidence from a randomized clinical trial. Child and Adolescent Social Work Journal, 26(4), 321-332. doi:10.1007/s10560-009-0165-1

Type of Study: Randomized controlled trial
Number of Participants: 46

Population:

  • Age — 3.6-39.4 months
  • Race/Ethnicity — 63% African American, 26% White, 3% Hispanic, and 7% biracial
  • Gender — 50% Female
  • Status — Participants were infants in foster care.

Location/Institution: Two mid-Atlantic states

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Children and foster parents were randomly assigned to receive the Attachment and Biobehavioral Catch-up (ABC) intervention or to a comparison group which received the Developmental Education for Families (DEF) program which focuses on cognitive and language development. Parents kept diaries of attachment-related behavior (e.g., help-seeking behaviors) by their children, their own behavioral response and infants’ response to foster parents’ behavior for a period of 3 days. Diaries were coded for proximity seeking, contact maintenance and successful calming to yield a score for secure. Also coded were avoidant behaviors including child anger, and inability to be soothed. Children in the ABC intervention condition had lower levels of avoidance than children in the DEF group. The two groups did not differ on security scores. Limitations include the small sample size, the brief timeframe, and the reliance on parental report.

Length of postintervention follow-up: 1 month.

Sprang, G. (2009). The efficacy of a relational treatment for maltreated children and their families. Child and Adolescent Mental Health, 14, 81-88.

Type of Study: Randomized controlled trial
Number of Participants: 53

Population:

  • Age — Adults: Mean=39.7 years, Children: Mean=42.5 months
  • Race/Ethnicity — Adults: 47 White and 6 African American, Children: Not specified
  • Gender — Adults: 45 Females and 8 Males, Children: 26 Females and 27 Males
  • Status — Participants were adult caregivers caring for children with attachment-related problems.

Location/Institution: Not specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study assessed the effects of participation in the Attachment and Biobehavioral Catch-up (ABC) intervention on child abuse potential, parenting stress, and child behavior in maltreated children and their foster parents. Foster parent-child dyads were randomly assigned to either ABC or a wait-list control group. Measures utilized were the Child Abuse Potential Inventory (CAPI), the Child Behavior Checklist (CBCL), and the Parenting Stress Index–Short Form (PSI/SF). Results indicated that ABC participants had significantly lower scores on total child abuse potential, parenting stress, and child internalizing and externalizing behavior than control subjects. Engagement in treatment was a significant predictor of positive change in reported child behavior. Limitations include the small sample size and lack of follow-up.

Length of postintervention follow-up: None.

Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E., Lindhiem, O., & Carlson, E. (2012). Enhancing attachment organization among maltreated infants: Results of a randomized clinical trial. Child Development, 83(2), 623-636.

Type of Study: Randomized controlled trial
Number of Participants: 120 children and 113 parents (7 parents had 2 children enrolled in the study)

Population:

  • Age — Children: 1.7-21.4 months, Parents: 15.7-47.0 years
  • Race/Ethnicity — Child: 61% African American, 20% Biracial, 11% White/Hispanic, and 8% White/non-Hispanic. Parent: 61% African American, 15% White/Hispanic, 15% White/non-Hispanic, and 9% Biracial
  • Gender — Children: 58% Male and 42% Female, Parent: 98% Female and 2% Male
  • Status — Participants were parents that were referred by agencies working with child protective services. All parents were enrolled in the city’s program that was intended to divert children from foster care because of identified needs and⁄ or concerns that children were at risk.

Location/Institution: Large mid-Atlantic city

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined the efficacy of Attachment and Biobehavioral Catch-up (ABC). Parents were randomly assigned to receive either the ABC intervention or a control intervention. Attachment quality was assessed using the Strange Situation exercise at baseline and approximately one month after completing the intervention sessions. Children in the ABC group showed significantly lower rates of disorganized attachment (32%) and higher rates of secure attachment (52%) relative to the control intervention (57% and 33%, respectively). Limitations included the use of the Strange Situation exercise outside of the age groups for which it has been validated.

Length of postintervention follow-up: 1 month.

Lewis-Morrarty, E., Dozier, M., Bernard, K., Terracciano, S. M., & Moore, S. V. (2012). Cognitive flexibility and theory of mind outcomes among foster children: Preschool follow-up results of a randomized clinical trial. Journal of Adolescent Health, 51(2), S17-S22.

Type of Study: Randomized controlled trial
Number of Participants: 61

Population:

  • Age — 4-6 years (mean = 60.3 months)
  • Race/Ethnicity — 42.6% African American, 36.1% European American, and 21.3% Hispanic, Asian American, or biracial
  • Gender — 50.8% Male
  • Status — Participants were children in foster care when they were infants.

Location/Institution: Two mid-Atlantic states

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses a sub-sample from Dozier, M., Lindhiem, O., Lewis, E., Bick, J., Bernard, K., & Peloso, E. (2009). This study examined longer term effects of the Attachment and Biobehavioral Catch-up (ABC) intervention. Infants in foster care were randomly assigned to receive the ABC intervention or a control intervention, and were compared to children who had never been in foster care. Measures included the Dimensional Change Card Sort (DCCS), the Peabody Picture Vocabulary Test, third edition (PPVT-III), and the Brief Symptom Inventory. Results showed that preschool-aged foster children who had received the ABC intervention showed stronger cognitive flexibility and theory of mind skills, relative to foster children who had received a control intervention. Foster children who had received the ABC intervention showed capabilities in these areas that were not significantly different from a comparison group of children who were never in foster care. Limitations included the small sample size and the inequality of the three groups on several demographic variables. In addition, there is some concern about whether the measures used at the 2-year follow-up were appropriate to show sustained effect, due to differences between the baseline and follow-up measures.

Length of postintervention follow-up: Approximately 2 years.

Bick, J., & Dozier, M. (2013). The effectiveness of an attachment-based intervention in promoting foster mothers’ sensitivity toward foster infants. Infant Mental Health Journal, 34, 95-103.

Type of Study: Randomized controlled trial
Number of Participants: 96 foster mother-infant dyads

Population:

  • Age — Adults: 24-74 years, Children: 22 months or younger
  • Race/Ethnicity — Adults: 46% White, 43% African American, 7% Hispanic, and 4% Biracial; Children: 59% African American, 28% White, 6% Hispanic, 6% Biracial, and 1% Asian
  • Gender — Adults: 100% Female, Children: 48% Female
  • Status — Participants were foster mothers and infants in foster care.

Location/Institution: Mid-Atlantic, U.S.

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The current study examined the effectiveness of the Attachment and Biobehavioral Catch-up (ABC) intervention to promote sensitive care giving behavior among foster mothers. Foster mothers and infants were randomly assigned to ABC or the control Developmental Education for Families (DEF) intervention, resulting in 44 foster mothers who received ABC and 52 foster mothers who received the control intervention. Measures included a rating of maternal sensitivity during an observed play interaction. Results of indicated that foster mothers who were assigned to ABC showed greater improvements in their sensitivity from pre-intervention to postintervention assessment time points when compared with foster mothers who were assigned to the control intervention. Limitations include the small sample size and the limited nature of the assessment.

Length of postintervention follow-up: Varied by child age – 12 months or longer in some cases.

*Lind, T., Bernard, K., Ross, E., & Dozier, M. (2014). Intervention effects on negative affect of CPS-referred children: Results of a randomized clinical trial. Child Abuse & Neglect, 38(9), 1459–1467.

Type of Study: Randomized controlled trial with post-test only assessment
Number of Participants: Children: 117, Caregivers: 112

Population:

  • Age — Children: 3.4-25.8 months. Parents: Mean=28.2 years
  • Race/Ethnicity — Children: 62% African American, 16% Biracial, 14% Hispanic, and 9% White; Parents: 63% African American, 18% Hispanic, 14% White, and 4% Biracial
  • Gender — Children: 47% Female. Parents: 97% Female
  • Status — Participants were children and caregivers reported to Child Protective Services (CPS) due to unsubstantiated allegations of maltreatment.

Location/Institution: Mid-Atlantic, U.S.

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study investigated the effectiveness of the Attachment and Biobehavioral Catch-up (ABC) intervention in a randomized clinical trial for young children who had been reported to Child Protective Services (CPS). Parent-child dyads received either the ABC intervention or a control intervention. Measures included videotape coding using the Revised Manual for Scoring Mother Variables in the Tool-Use Task. Results indicated that CPS-referred children in the ABC intervention group showed lower rates of negative affect expression during a series of challenging tasks than children in the control intervention at follow-up. ABC children showed less anger towards their parents and less anger in general than children in the control intervention group. Limitations include lack of information on maltreatment history and other risk factors, and the large number of families who declined to participate in the study.

Length of postintervention follow-up: Varied – 1.0 month-27.2 months (Mean=12.5 months, Standard Deviation=6.6 months).

*Bernard, K., Hostinar, C., & Dozier, M. (2014). Intervention effects on diurnal cortisol rhythms of CPS-referred infants persist into early childhood: Preschool follow-up results of a randomized clinical trial. JAMA-Pediatrics, 169(2), 112–119.doi:10.1001/jamapediatrics.2014.2369

Type of Study: Randomized controlled trial with post-test only assessment
Number of Participants: 115

Population:

  • Age — 46.5-69.6 months of age at the time of the preschool follow-up of cortisol regulation (Mean=50.73 months)
  • Race/Ethnicity — 65.2% African American, 15.7% bi-racial, 10.4% Hispanic, and 8.7% White
  • Gender — 43.5% Female
  • Status — Participants were children involved with Child Protective Services following allegations of neglect.

Location/Institution: Mid-Atlantic, U.S.

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study is a follow-up of the sample from Lind et al. (2014) study. This study examined differences in diurnal cortisol production between children receiving the Attachment and Biobehavioral Catch-up (ABC) intervention and children in the control group persisted at a preschool follow-up. Parents and infants were randomly assigned to ABC or the control Developmental Education for Families (DEF) intervention. The primary measure was the saliva cortisol level. Analyses revealed significant differences in cortisol production at the preschool follow-up, such that children in the ABC intervention group exhibited a typical pattern with higher morning levels and a steep decline across the day, while the control group showed a flatter cortisol rhythm with blunted morning levels. Limitations include the attrition between the intervention and follow-up timepoint, and a lack of information on potential mediators that may have occurred between the intervention and follow-up.

Length of postintervention follow-up: 3 years.

References

Dozier, M., Dozier, D., & Manni, M. (2002).  Recognizing the special needs of infants' and toddlers' foster parents: Development of a relational intervention. Zero to Three Bulletin, 22, 7-13.

Dozier, M., Lindhiem, O., & Ackerman, J. (2005). Attachment and biobehavioral catch-up. In L. Berlin, Y. Ziv, L. Amaya-Jackson, & M. T. Greenberg (Eds.), Enhancing early attachments. New York: Guilford (pp. 178-194).

Lewis, E., Dozier, M., Knights, M., & Maier, M. (In press). Intervening with foster infants' foster parents: Attachment and biobehavioral catch-up. In R. E. Lee & J. Whiting (Eds.), Handbook of relational therapy for foster children and their families. Washington, DC: Child Welfare League of America.

Contact Information

Name: Mary Dozier, PhD
Agency/Affiliation: University of Delaware
Email:
Phone: (302) 831-8801
Fax: (302) 831-3645

Date Research Evidence Last Reviewed by CEBC: August 2016

Date Program Content Last Reviewed by Program Staff: April 2016

Date Program Originally Loaded onto CEBC: June 2008