Attachment and Biobehavioral Catch-up (ABC)

About This Program

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

For parents/caregivers of children ages: 0 – 2

Program Overview

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, warm 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

Logic Model

The program representative did not provide information about a Logic Model for Attachment and Biobehavioral Catch-up (ABC).

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 with delight, and non-frightening behaviors. These are used throughout the home visiting session while working with the parent.

Program Delivery

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 help the parents use new skills in the moment, and the parents are expected to observe and note the child's behavior and practice new skills them with between sessions.

Recommended Intensity:

Weekly one-hour sessions

Recommended Duration:

10 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 languages other than English:

German, Mandarin, Norwegian, Russian, Spanish, Swedish

For information on which materials are available in these languages, 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:

Audiovisual Needs:

  • 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

Manuals and Training

Prerequisite/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-day training and a year of supervision.

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Training is held at University of Delaware for individuals or small groups or training. On-site training is held for larger groups. Weekly supervision is conducted through videoconferencing.

Number of days/hours:

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

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 their 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 Zoom (HIPAA-compliant video conference software that the program provides). 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 an expert-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 quality 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

Child Welfare Outcome: Child/Family Well-Being

A systematic review, see citation following, has been conducted on the Attachment and Biobehavioral Catch-up (ABC), however, this article is not used for rating and therefore is not summarized:

  • Grube, W. A., & Liming, K. W. (2018). Attachment and Biobehavioral Catch‐up: A systematic review. Infant Mental Health Journal, 39(6), 656–673. https://doi.org/10.1002/imhj.21745

The CEBC reviews all of the articles that have been published in peer-reviewed journals as part of the rating process. When there are more than 10 published, peer-reviewed articles, the CEBC identifies the most relevant articles, with a focus on randomized controlled trials (RCTs) and controlled studies that have an impact on the rating. The 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., Ackerman, J., Bernier, A., & 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. https://doi.org/10.1111/j.1540-4560.2006.00486.x

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
  • 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 basic study design, measures, results, and notable limitations)
The purpose of the study was to test the effectiveness of Attachment and Biobehavioral Catch-up (ABC), to target relationship formation in young children in the foster care system. Participants were randomly assigned to receive either the ABC intervention or a control intervention. Measures utilized include the Parent’s Daily Report (PDR/IT). Results indicate that children in the experimental intervention group had lower cortisol values than children in the control intervention. Also, the experimental intervention parents reported fewer behavior problems. Limitations include small sample size, length of follow-up, and generalizability of findings due to ethnicity and age.

Length of controlled postintervention follow-up: 1 month.

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(3), 845–859. https://doi.org/10.1017/S0954579408000400

Type of Study: Randomized controlled trial
Number of Participants: 141

Population:

  • Age — 15-24 months
  • Race/Ethnicity — ABC: 81% African American, 17% White/Non-Hispanic, and 2% Hispanic; DEF: 66% African American, 29% White/Non-Hispanic, and 5% Hispanic; Comparison: 56% White/Non-Hispanic, 35% African American, 5% Hispanic, and 4% Asian American
  • Gender — ABC: 59% Female; DEF: 43% Female; Comparison: 44% Female
  • Status — Participant were children in foster care.

Location/Institution: University of Delaware

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the effectiveness of Attachment and Biobehavioral Catch-up (ABC) with regards to hypothalamus-pituitary-adrenal (HPA) functioning. Children were randomly assigned to receive the ABC intervention or to a comparison group which received the Developmental Education for Families (DEF) program which focuses on cognitive and language development. A comparison group of children who had never been in foster care was also included. Measures utilized include the Strange Situation and salivary cortisol which was used as the measure of stress level. Results indicate that children in the ABC intervention and comparison group showed lower initial values of cortisol than children in the treatment control group, considering arrival at lab as initial values. Groups did not differ significantly in change over time. Limitations include small sample size, lack of generalizability to other populations, and lack of follow-up.

Length of controlled 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. https://doi.org/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% Non-Hispanic/White, 7% Biracial, and 3% Hispanic
  • Gender — 50% Female
  • Status — Participants were children in foster care.

Location/Institution: Two mid-Atlantic states

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the effectiveness of Attachment and Biobehavioral Catch-up (ABC) on children’s attachment behaviors. Participants 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. Results indicate that children whose parents received the ABC intervention condition showed significantly less avoidance than children in the DEF group. Limitations include the small sample size, the brief timeframe, lack of standardized measures, and the reliance on parental report.

Length of controlled postintervention follow-up: 1 month.

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. https://doi.org/10.1111/j.1467-8624.2011.01712.x

Type of Study: Randomized controlled trial
Number of Participants: 120 children and 113 parents

Population:

  • Age — Children: 1.7-21.4 months; Parents: 15.7-47.0 years
  • Race/Ethnicity — Children: 61% African American, 20% Biracial, 11% White/Hispanic, and 8% White/Non-Hispanic; Parents: 61% African American, 15% White/Hispanic, 15% White/Non-Hispanic, and 9% Biracial
  • Gender — Children: 58% Male and 42% Female; Parents: 98% Female and 2% Male
  • Status — Participants were parents that were referred by agencies working with child protective services.

Location/Institution: Large mid-Atlantic city

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the efficacy of Attachment and Biobehavioral Catch-up (ABC). Participants were randomly assigned to receive either the ABC intervention or a control intervention. Measures utilized include the Strange Situation. Results indicate that children in the ABC intervention 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 include the use of the Strange Situation exercise outside of the age groups for which it has been validated, did not examine possible effects of the comparison intervention, and length of follow-up.

Length of controlled 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. https://doi.org/10.1016/j.jadohealth.2012.05.005

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

Population:

  • Age — Children: 4-6 years (Mean=60.3 months); Parents: Not specified
  • Race/Ethnicity — Children: 43% African American, 36% European American, and 21% Hispanic, Asian American, or Biracial; Parents: 57% European American, 39% African American, and 3% Asian American
  • Gender — Children: 51% Male; Parents: 100% Female
  • Status — Participants were children in foster care when they were infants.

Location/Institution: Two mid-Atlantic states

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Dozier et al. (2009). The purpose of the study was to examine longer term effects of the Attachment and Biobehavioral Catch-up (ABC) intervention. Participants 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 utilized include the Dimensional Change Card Sort (DCCS), the Peabody Picture Vocabulary Test, 3rd ed. (PPVT-III), and the Brief Symptom Inventory. Results indicate that preschool-aged foster children who received the ABC intervention showed stronger cognitive flexibility and theory of mind skills, relative to foster children who received a control intervention. Foster children who 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 include 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 controlled 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(2), 95–103. https://doi.org/10.1002/imhj.21373

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

Population:

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

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

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the effectiveness of the Attachment and Biobehavioral Catch-up (ABC) intervention to promote sensitive care giving behavior among foster mothers. Participants were randomly assigned to ABC or the control Developmental Education for Families (DEF) intervention. Measures utilized include the use of study developed measures regarding material sensitivity. Results indicate 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, lack of standardized measures, and the limited nature of the assessment.

Length of controlled postintervention follow-up: Varied by age of child.

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. https://doi.org/10.1111/cdev.12418

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

Population:

  • Age — Children: Not specified; Adults: Mean=31.6 years
  • Race/Ethnicity — Children: Not specified; Adults: 74% African American, 16% White/Non-Hispanic, 6% Hispanic, and 4% Biracial
  • Gender — Children: 58% Male and 42% Female; Adults: 100% 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 basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the neurobiology of maternal sensitivity to children’s emotions among mothers involved with Child Protective Services (CPS) and low-risk comparison mothers. Participants were randomly assigned to the Attachment and Biobehavioral Catch-up (ABC) intervention or the control, Developmental Education for Families (DEF) intervention. Measures utilized include Electroencephalogram (EEG) activity. Results indicate that CPS-referred ABC mothers and low-risk comparison mothers showed a larger enhancement of event-related potential (ERP) responses for emotional faces relative to neutral faces than CPS-referred control mothers. Additionally, the magnitude of ERP responses to emotional faces was associated with observed maternal sensitivity. Limitations include the small sample size, variations in the families’ maltreatment experiences, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Bernard, K., Lee, A. H., & Dozier, M. (2017). Effects of the ABC intervention on foster children's receptive vocabulary: Follow-up results from a randomized clinical trial. Child Maltreatment, 22(2), 174-179. https://doi.org/10.1177/1077559517691126

Type of Study: Randomized controlled trial
Number of Participants: 52 parent/child dyads

Population:

  • Age — Children: 2.85-3.87 years; Adults: 19.0-58.6 years
  • Race/Ethnicity — Children: 29 African American, 15 Caucasian, 4 Biracial, 3 Hispanic, and 1 Asian American; Adults: 24 African American, 23 Caucasian, 3 Hispanic, and 2 Biracial
  • Gender — Children: 56% Female and 44% Male; Adults: 94% Female
  • Status — Participants were children and parents referred by caseworkers at foster care agencies and were involved in the child welfare system.

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

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Bick & Dozier (2013). The purpose of the study was to examine whether a parenting intervention administered in infancy improved preschool receptive language skills in children involved with the child welfare system. Participants were randomly assigned into the Attachment and Biobehavioral Catch-up (ABC) intervention or the control, Developmental Education for Families (DEF) intervention. Measures utilized include the Peabody Picture Vocabulary Test, 3rd ed. (PPVT-III). Results indicate that infants who received the ABC intervention scored significantly higher on a test of receptive vocabulary at age 36 months than infants who received a control intervention. Limitations include the small sample size, attrition due to children changing placements, and assessments of ABC intervention fidelity were not included.

Length of controlled postintervention follow-up: 3 years.

Yarger, H. A., Bernard, K., Caron, E. B., Wallin, A., & Dozier, M. (2020). Enhancing parenting quality for young children adopted internationally: Results of a randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 49(3), 378–390. https://doi.org/10.1080/15374416.2018.1547972

Type of Study: Randomized controlled trial
Number of Participants: 120

Population:

  • Age — Children: 6.8-48.4 months (Mean=21.9 months); Primary caregivers: 26.2-51.1 years (Mean=39.7 years)
  • Race/Ethnicity — Children: ABC: 68% Asian American, 15% White, 10% African American, 5% Biracial, and 2% Other; DEF: 57% Asian American, 25% White, and 18% African American; Primary caregivers: ABC: 98% White and 2% Asian American, DEF: 92% White, 5% Asian American, 2% Af
  • Gender — Children: 53% Female; Primary caregivers: 94% Female
  • Status — Participants were internationally adopted children and their adoptive parents.

Location/Institution: Mid-Atlantic region

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess whether parents randomized to receive Attachment and Biobehavioral Catch-up (ABC) demonstrated significant improvements in parenting quality when compared to parents receiving a control intervention. Participants were randomly assigned to receive either ABC or a control intervention (Developmental Education for Families [DEF]). Measures utilized include the use of study developed measures and a questionnaire about the child’s adoption history. Results indicate that parents who received ABC showed better parenting quality at postintervention than parents who received a control intervention, and these effects persisted at a 2-year follow-up. Limitations include low generalizability due to parent gender, heterogeneity of children’s preadoption history, lack of standardized measures, and small effect sizes.

Length of controlled postintervention follow-up: Varied based upon outcome.

Zajac, L., Raby, K. L., & Dozier, M. (2020). Sustained effects on attachment security in middle childhood: results from a randomized clinical trial of the Attachment and Biobehavioral Catch-up (ABC) intervention. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 61(4), 417–424. https://doi.org/10.1111/jcpp.13146

Type of Study: Randomized controlled trial
Number of Participants: 100

Population:

  • Age — Children: ABC: Mean=9.45 years, DEF: Mean=9.46 years; Parents: ABC: Mean=38.71 years; DEF: Mean=37.14 years
  • Race/Ethnicity — Children: 80% Non-Hispanic or Latino, 66% African-American, 20% Hispanic or Latino, 19% Biracial, and 15% Caucasian; Parents: Not specified
  • Gender — Children: 52% Male; Parents: 97% Female
  • Status — Participants were Child Protective Services (CPS)-referred children. 

Location/Institution: A large mid-Atlantic city

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Bernard et al. (2012). The purpose of the study was to examine whether receiving the Attachment and Biobehavioral Catch-Up (ABC) intervention during infancy led to improvements in perceived attachment security in middle childhood. Participants were randomly assigned to ABC or Developmental Education for Families (DEF). Measures utilized include the Kerns Security Scale. Results indicate that children whose parents received ABC reported higher levels of attachment security on the Kerns Security Scale at age nine than children whose parents had received the control intervention. Limitations include not looking at potential mediators of ABC’s effect and not considering child-specific factors.

Length of controlled postintervention follow-up: Varied

Additional 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 (pp. 178-194). Guilford.

Lewis, E., Dozier, M., Knights, M., & Maier, M. (2008). Intervening with foster infants' foster parents: Attachment and Biobehavioral Catch-up. In R. E. Lee & J. Whiting (Eds.), Foster care therapist handbook: Relational approaches to the children and their families (Ch. 12). Child Welfare League of America.

Contact Information

Mary Dozier, PhD
Agency/Affiliation: University of Delaware
Email:
Phone: (302) 831-8801
Caroline Roben, PhD
Title: Director of ABC Dissemination
Email:
Phone: (302) 319-1229

Date Research Evidence Last Reviewed by CEBC: April 2021

Date Program Content Last Reviewed by Program Staff: March 2020

Date Program Originally Loaded onto CEBC: June 2008