Retroalimentación con vídeos para la sensibilidad de los padres y la seguridad del apego en niños menores de cinco años
Resumen
Antecedentes
Los niños que están firmemente apegados a por lo menos uno de los padres pueden ser consolados por ese padre cuando están angustiados y explorar el mundo con confianza, y utilizan a ese padre como una "base segura". Los estudios de investigación indican que un apego seguro permite que los niños funcionen mejor en todos los aspectos del desarrollo. Por lo tanto, la promoción de un apego seguro es un objetivo de muchas intervenciones tempranas. El apego está mediado por la sensibilidad de los padres a las señales de angustia del niño. Una forma de mejorar la sensibilidad de los padres es a través de la retroalimentación con vídeos, que consiste en mostrar a los padres breves momentos de su interacción con su hijo, para fortalecer su sensibilidad y la receptividad a las señales del niño.
Objetivos
Evaluar los efectos de la retroalimentación con vídeos sobre la sensibilidad de los padres y la seguridad del apego en niños menores de cinco años con riesgo de presentar resultados deficientes en cuanto al apego.
Métodos de búsqueda
En noviembre de 2018 se hicieron búsquedas en CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, otras nueve bases de datos y dos registros de ensayos. También se realizaron búsquedas manuales en las listas de referencias de los estudios incluidos, las revisiones sistemáticas relevantes y varios sitios web relevantes
Criterios de selección
Ensayos controlados aleatorizados (ECA) y cuasialeatorizados que evaluaron los efectos de la retroalimentación con vídeos versus ningún tratamiento, una intervención alternativa inactiva o el tratamiento habitual para la sensibilidad de los padres, el funcionamiento reflexivo de los padres, la seguridad del apego y los efectos adversos en niños desde el parto hasta los cuatro años y 11 meses de edad.
Obtención y análisis de los datos
Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane.
Resultados principales
Esta revisión incluye 22 estudios de siete países de Europa y dos países de Norteamérica, con un total de 1889 díadas o unidades familiares aleatorizadas de padres e hijos. Las intervenciones se dirigieron a los padres de niños menores de cinco años que experimentaban una amplia gama de dificultades (como sordera o prematuridad), o se enfrentaban a desafíos que los ponían en riesgo de problemas de apego (por ejemplo, depresión paterna). Casi todos los estudios informaron sobre alguna forma de financiamiento externo, ya sea de una organización de caridad (n = 7) o de una entidad pública, o de ambas (n = 18).
Se consideró que la mayoría de los estudios tuvieron un riesgo de sesgo bajo o incierto en la mayoría de los dominios, con la excepción del cegamiento de los participantes y el personal, donde se evaluó que todos los estudios tuvieron alto riesgo de sesgo de realización. Para los resultados en los que se utilizaron medidas de autoinforme, como el estrés y la ansiedad de los padres, todos los estudios se calificaron como alto riesgo de sesgo para el cegamiento de los evaluadores de resultados.
Sensibilidad de los padres. Un metanálisis de 20 estudios (1757 díadas padres‐hijo) informó evidencia de que la retroalimentación con vídeos mejoró la sensibilidad de los padres en comparación con un control o ninguna intervención desde la posintervención hasta el seguimiento a los seis meses (diferencia de medias estandarizada [DME] 0,34; intervalo de confianza [IC] del 95%: 0,20 a 0,49; evidencia de certeza moderada). La magnitud de la repercusión observada se compara de manera favorable con otras intervenciones similares.
Funcionamiento reflexivo de los padres. Ningún estudio informó sobre este resultado.
Seguridad del apego. Un metanálisis de dos estudios (166 díadas padres‐hijos) indicó que la retroalimentación con vídeos aumentó las probabilidades de un apego seguro, medido a través del Strange Situation Procedure posintervención (odds ratio 3,04; IC del 95%: 1,39 a 6,67; evidencia de muy baja certeza). Un segundo metanálisis de dos estudios (131 díadas padre‐hijo) que evaluó la seguridad del apego a través de una medida diferente (Attachment Q‐sort) no encontró efectos de la retroalimentación con vídeos en comparación con los grupos de comparación (DME 0,02; IC del 95%: ‐0,33 a 0,38; evidencia de muy baja certeza).
Eventos adversos. Ocho estudios (537 díadas padre‐hijo) proporcionaron datos en la posintervención o el seguimiento a corto plazo para un metanálisis sobre el estrés de los padres, y dos estudios (311 díadas padre‐hijo) proporcionaron datos de seguimiento a corto plazo para un metanálisis sobre la ansiedad de los padres. No hubo diferencias entre los grupos intervención y comparación para cualquiera de los resultados. Para el estrés de los padres, la DME entre la retroalimentación con vídeos y el control fue ‐0,09 (IC del 95%: ‐0,26 a 0,09; evidencia de baja certeza), mientras que para la ansiedad de los padres la DME fue ‐0,28 (IC del 95%: ‐0,87 a 0,31; evidencia de muy baja certeza).
Conducta infantil. Un metanálisis de dos estudios (119 díadas padre‐hijo) en el seguimiento a largo plazo no encontró evidencia de la efectividad de la retroalimentación con vídeos sobre la conducta infantil (DME 0,04; IC del 95%: ‐0,33 a 0,42; evidencia de muy baja certeza).
Un análisis moderador no encontró evidencia de efecto para las tres variables preespecificadas (tipo de intervención, número de sesiones de retroalimentación y cuidador participante) cuando se probaron de manera conjunta. Sin embargo, el género de los padres (ambos padres versus solo madres o solo padres) tiene un posible efecto de moderación negativa estadísticamente significativo, aunque solo con un α (alfa) = 0,1
Conclusiones de los autores
Existe evidencia de certeza moderada de que la retroalimentación con vídeos puede mejorar la sensibilidad en los padres de niños con riesgo de tener resultados deficientes en cuanto al apego debido a varias dificultades. En la actualidad solo existe evidencia escasa y de certeza muy baja con respecto al efecto de la retroalimentación con vídeos sobre la seguridad del apego, en comparación con el control: los resultados difirieron según el tipo de medida utilizada, y la duración del seguimiento fue limitada. No existe evidencia de que la retroalimentación con vídeos tenga una repercusión sobre el estrés o la ansiedad de los padres (evidencia de baja y muy baja certeza, respectivamente). Se necesita más evidencia con respecto a la repercusión a más largo plazo de la retroalimentación con vídeos sobre el apego y los resultados más distantes como la conducta de los niños (evidencia de muy baja certeza). Se necesitan estudios de investigación adicionales sobre la repercusión de la retroalimentación con vídeos sobre la sensibilidad paterna y el funcionamiento reflexivo de los padres, ya que ningún estudio midió estos resultados. Esta revisión está limitada por el hecho de que la mayoría de los padres incluidos eran madres.
PICO
Resumen en términos sencillos
Retroalimentación con vídeos para la sensibilidad de los padres y el apego en los niños
Antecedentes
Los niños que están firmemente apegados a al menos uno de los padres pueden ser consolados por ese padre cuando están angustiados, son más capaces de explorar el mundo con confianza y utilizan a ese padre como una "base segura". Los estudios de investigación indican que un apego seguro permite que los niños funcionen mejor en todos los aspectos del desarrollo. Por lo tanto, la promoción del apego seguro es un objetivo de muchos programas que tienen como objetivo apoyar a los niños y a las familias en los primeros años de vida del niño. La retroalimentación con vídeos consiste en mostrar a los padres breves momentos de interacción grabados en vídeo entre ellos y su hijo, con el fin de reforzar su sensibilidad a las señales del niño y mejorar el apego.
Pregunta de la revisión
Evaluar los efectos de la retroalimentación con vídeos sobre la sensibilidad de los padres y la seguridad del apego en niños menores de cinco años con riesgo de resultados deficientes, en comparación con ninguna intervención (ningún tratamiento), un tratamiento simulado (como una llamada telefónica) o el tratamiento habitual.
Estudios incluidos
Esta revisión incluyó 22 estudios en los que participaron 1889 pares de padres e hijos o unidades familiares aleatorizados. No todos se pudieron combinar en un metanálisis (un método estadístico para combinar los datos de varios estudios con el fin de establecer una conclusión única y más sólida). Se combinaron los datos de 20 estudios (con 1757 pares de padres e hijos) para examinar los efectos de la retroalimentación con vídeos sobre la sensibilidad de los padres. Se combinaron los datos de menos estudios para examinar la seguridad del apego, el estrés de los padres, la ansiedad de los padres y la conducta de los niños.
Los estudios incluidos se realizaron principalmente en Canadá, los Países Bajos, el Reino Unido y los EE.UU. Se realizaron estudios individuales en Italia, Alemania, Lituania, Noruega y Portugal.
Casi todos los estudios informaron sobre alguna forma de financiamiento externo, ya sea de una organización de caridad (n = 7) o de una entidad pública (n = 18).
Resultados
Los resultados muestran evidencia de una mejora en la sensibilidad de los padres después del uso de la retroalimentación con vídeos. Los resultados para la seguridad del apego fueron mixtos: un metanálisis mostró que el grupo de intervención tuvo más seguridad, mientras que el segundo metanálisis, que midió la fuerza del apego de una manera diferente, no mostró evidencia de una repercusión. No hubo evidencia de una repercusión sobre la ansiedad o el estrés de los padres. Ningún estudio midió el funcionamiento reflexivo de los padres. No hubo evidencia de repercusión sobre la conducta de los niños.
Certeza de los estudios
La certeza general de la evidencia (hasta qué punto se considera que los resultados son correctos o adecuados) se calificó como moderada para la sensibilidad de los padres y baja o muy baja para los otros resultados. Lo anterior significa que existe una certeza razonable en que la retroalimentación con vídeos mejora la sensibilidad de los padres a corto plazo, pero no hay mucha certeza acerca de su repercusión sobre los otros hallazgos.
Conclusiones de los autores
La retroalimentación con vídeos puede ser un método útil para mejorar la sensibilidad de los padres, pero actualmente hay poca o ninguna evidencia de que mejore la seguridad del apego de los niños, el estrés de los padres, la ansiedad de los padres o la conducta de los niños. Se necesitan más estudios de investigación acerca de los efectos de la retroalimentación con vídeos sobre otros resultados, incluido el funcionamiento reflexivo de los padres, y estudios en padres.
Conclusiones de los autores
Summary of findings
| Video feedback versus no intervention or inactive alternative intervention for parental sensitivity and attachment | ||||||
| Patient or population: parent‐child dyads (including foster or adoptive carers), where the child was aged between birth and four years 11 months (inclusive), and where problems had been identified that were impacting or might impact on the parent's sensitivity | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | Number of participants | Certainty of the evidence (GRADE) | Comments | |
| Risk with no intervention or inactive alternative intervention | Risk with video feedback | |||||
| Parental sensitivity Follow‐up: postintervention or short‐term follow‐up | ‐ | The mean parental sensitivity score in the intervention group was 0.34 standard deviations higher (0.20 higher to 0.49 higher) | ‐ | 1757 dyads (20 RCTs) | ⊕⊕⊕⊝ | Higher scores indicate a better outcome. Effect size of 0.33 standard deviations compares favourably to other similar interventions. |
| Parental reflective functioning | ‐ | ‐ | ‐ | ‐ | ‐ | No study reported this outcome. |
| Attachment security Measured by: Strange Situation Procedure (odds of being securely attached) Follow‐up: postintervention | Study population | OR 3.04 | 166 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a better outcome. | |
| 341 per 1000 | 612 per 1000 | |||||
| Attachment security Measured by: Attachment Q‐sort Follow‐up: postintervention | The mean attachment security score across control groups ranged from 0.33 to 0.37 (scores can range from + 1.00 to −1.00) | The mean attachment security score in the intervention group was0.02 standard deviations higher (0.33 lower to 0.38 higher) | ‐ | 131 dyads | ⊕⊝⊝⊝ | Effect size of 0.02 standard deviations indicates no evidence of effectiveness. |
| Adverse events: parental stress Follow‐up: postintervention or short term | ‐ | The mean parental stress score in the intervention group was 0.09 standard deviations lower (0.26 lower to 0.09 higher) | ‐ | 537 dyads (8 RCTs) | ⊕⊕⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.09 standard deviations indicates no evidence of effectiveness. |
| Adverse events: parental anxiety Follow‐up: short term | ‐ | The mean parental anxiety score in the intervention group was0.28 standard deviations lower (0.87 lower to 0.31 higher) | ‐ | 311 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.28 compares favourably to other similar interventions. |
| Child behaviour Follow‐up: long term | ‐ | The mean child behaviour score in the intervention group was 0.04 standard deviations higher (0.33 lower to 0.42 higher) | ‐ | 119 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.04 standard deviations indicates no evidence of effectiveness. |
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| aDowngraded one level due to inconsistency: moderate heterogeneity, which was not explained by our subgroup analysis. | ||||||
Antecedentes
Descripción de la afección
Apego
La relación de un niño con su cuidador principal es la primera, y posiblemente la más importante, relación que se forma después del parto. El cuidador principal es normalmente, pero no siempre, la madre o el padre biológicos del niño. Este vínculo emocional entre un niño y su cuidador principal se conoce como una relación de "apego selectivo". El apego es un sistema de conducta biológica que ha evolucionado con el tiempo. Su objetivo es brindar protección frente al peligro percibido y al miedo que conlleva (Bowlby 1969). Cuando un niño está angustiado, está programado para buscar y asegurar la proximidad y el contacto con el cuidador principal (Bowlby 1969). La conducta de apego puede ser activado por circunstancias internas del niño como la enfermedad, el hambre o el dolor; por la separación del cuidador principal, como cuando la madre abandona la habitación o desestimula la proximidad; o por eventos externos que causan angustia como los eventos atemorizantes o el rechazo de los demás (Bowlby 1969). Según la intensidad de la amenaza, la conducta de apego puede terminar con la aparición del cuidador con o el contacto físico con él. Cuanto más joven sea el niño, o más grave sea la amenaza, más probable es que solo la tranquilidad física y la contención le proporcionen consuelo. La relación de apego, por lo tanto, es dinámica, y el niño juega un papel activo (ver Shin 2008). Ha sido descrita por Zeanah y colegas como una relación recíproca del buscador (niño) y el proveedor (padre), cuyo propósito es consolar a los niños cuando están molestos, apoyar el desarrollo de la regulación emocional y ofrecer seguridad (Zeanah 1993).
Los niños cuyos cuidadores proporcionan cuidados sensibles y receptivos desarrollan relaciones de apego seguras con esos cuidadores. Los niños que experimentan una crianza insensible, impredecible o intrusiva desarrollan relaciones de apego inseguras, lo que los pone en riesgo de sufrir consecuencias adversas en varios aspectos de su desarrollo psicosocial, como una mayor dependencia de los maestros, una menor expresión afectiva positiva y una menor capacidad de resolución de problemas sociales, más frustración y menos persistencia, más respuestas negativas hacia los demás y una menor competencia social en general (Sroufe 2005). Además de ser clasificados como seguros o inseguros, los niños también pueden ser clasificados como desorganizados cuando hay evidencia de un conflicto entre querer acercarse y querer evitar al cuidador cuando se activa el sistema de apego (Main 1990a). El apego desorganizado ocurre cuando los niños tienen miedo de la persona que los cuida y han estado expuestos a una serie de interacciones anómalas y atípicas entre padres e hijos (Madigan 2006). El apego desorganizado se asocia con predictores de psicopatología posterior que incluyen la externalización de la conducta (Fearon 2010) y los trastornos de la personalidad (Steele 2010). Muchos estudios solo consideran patrones de apego seguros e inseguros al clasificar a los niños, ya que fueron los patrones de apego que se describieron por primera vez (Weinfield 2004). Estos estudios (realizados en la población general) encuentran de manera habitual que aproximadamente el 60% de los niños tienen un apego seguro, y en el resto (40%) el apego es inseguro (Moullin 2014). Para los niños con apego inseguro, el 25% aprende a evitar a sus padres cuando están angustiados (apego evasivo) y el 15% aprende a resistir a los padres, a menudo porque los padres responden de manera impredecible o amplifican su angustia (apego resistente; Moullin 2014). En los estudios en los que se ha incluido el apego desorganizado, alrededor del 40% de los niños desfavorecidos se clasifican como desorganizados (Weinfield 2004), y hasta el 80% de los niños maltratados reciben esta clasificación (Cyr 2010).
Aunque los niños suelen tener un vínculo particularmente fuerte con un cuidador principal, la mayoría tiene más de una relación de apego, a menudo con los padres, hermanos y abuelos, así como con las madres (véase, por ejemplo, Hallers‐Haalboom 2014). Como tal, los niños pueden estar firmemente apegados a uno de sus padres, pero tener un apego inseguro con el otro. La función de las experiencias de relaciones tempranas y el desarrollo de las habilidades de autorregulación del niño se han vinculado a la capacidad del niño para controlar las respuestas fisiológicas y conductuales como la ira (Gilliom 2002), la agresión (Alink 2009) y la ansiedad (Hannesdottir 2007).
Sensibilidad del cuidador
Un predictor clave del estado de apego del niño es el estado de apego del padre (Van Ijzendoorn 1995). La repercusión del estado de apego del padre sobre el apego del niño parece estar mediada por la sensibilidad de los padres a las señales del niño.
Ainsworth y colegas definieron la sensibilidad como la capacidad de una madre para atender y responder a su hijo de manera que se ajuste exactamente a sus necesidades (Ainsworth 1978). Los padres sensibles y receptivos hacen lo siguiente: notan las señales de un niño, interpretan estas señales correctamente y responden a las señales de manera oportuna y apropiada (Ainsworth 1974). El concepto de sensibilidad, por lo tanto, no se refiere a un conjunto específico de conductas maternas, sino a algo mucho más dinámico y relacional.
La sensibilidad de los padres se puede ver comprometida por varios factores. Incluyen influencias sociales como el aislamiento social (Belsky 2002; Kivijärvi 2004), o la violencia doméstica (Levendosky 2006); factores psicológicos como la depresión materna (NICHD Early Child Care Research Network 1999; Karl 1995; Murray 1997), o los trastornos de la personalidad (Laulik 2013); los antecedentes maternos de maltrato (Pereira 2012), el consumo de sustancias (Eiden 2014), una baja autoestima (Leerkes 2002; Shin 2008); o factores cognitivos como los preconceptos maternos sobre la crianza de los hijos (Kiang 2004; Leerkes 2010). Las características del niño también pueden tener una repercusión negativa en la sensibilidad de los padres, incluida la prematuridad del niño (Singer 1999); la presencia de una conducta infantil excesivamente negativa, como la angustia general (Leerkes 2002); y la propensión del niño a la ira (Ciciolla 2013) y la irritabilidad (Van den Boom 1991). Algunos estudios han examinado la participación del padre como mediador de la sensibilidad materna (véase, por ejemplo, Stolk 2008), mientras que otros han examinado el papel del padre como cuidador (véase, por ejemplo, Pelchat 2003). Los estudios de investigación comparativos sobre la sensibilidad relativa de madres y padres es escasa y, por lo tanto, los resultados no son concluyentes; algunos estudios informan que los padres son menos sensibles que las madres (véase Hallers‐Haalboom 2014; Heerman 1994; Lovas 2005), mientras que otros no han encontrado diferencias (Pelchat 2003).
Aunque se ha descubierto que la sensibilidad de los padres es un factor importante para predecir la seguridad del apego de los niños, una revisión sistemática de los antecedentes de la seguridad del apego indica que solo explica alrededor de un tercio de la varianza (De Wolff 1997). Los estudios de investigación también han destacado la importancia de la contingencia de rango medio (Beebe 2010), y el funcionamiento reflexivo materno (Slade 2005), o la mentalidad (Meins 2001). La contingencia de rango medio se refiere a la capacidad de los padres para regular con flexibilidad sus propios estados emocionales internos y su interacción con el niño, y se caracteriza por momentos de sincronía o sintonía, seguidos de ruptura y posterior reparación. Un estudio de Beebe 2010 encontró que la interacción que se produjo fuera de este rango medio, como resultado de la preocupación de los padres por la autorregulación (p.ej. padres deprimidos) o la regulación interactiva (p.ej. padres ansiosos), se asoció con un apego inseguro o desorganizado.
El funcionamiento reflexivo es un término que describe la capacidad de un padre de comprender la conducta de su hijo con respecto a sus estados mentales internos (Slade 2005). El funcionamiento altamente reflexivo se correlaciona con los rasgos positivos de la crianza materna, como la flexibilidad y la receptividad. El bajo funcionamiento reflexivo se puede ver junto con conductas maternas negativas como el abandono y la intrusión (Kelly 2005; Slade 2005). Del mismo modo, la mentalidad desprejuiciada, que se refiere a la capacidad de los padres de comprender el estado mental de un niño pequeño y de responder de manera adecuada, se ha asociado con la sensibilidad conductual y la sincronía interactiva (Meins 2001), y con una mejor predicción de la seguridad del apego del niño al año de edad que la sensibilidad materna (Lundy 2003; Meins 2001; Meins 2012).
Otros estudios han identificado la importancia de una serie de interacciones atípicas o anómalas entre padres e hijos caracterizadas como "conductas atemorizantes", que son las conductas de los padres que están atemorizados o que atemorizantes, o ambas cosas (Jacobvitz 1997; Main 1990b), o que son hostiles e indefensos (Lyons‐Ruth 2005). La conducta frustrada de ha descrito como sutil (p.ej. períodos de aturdimiento y la falta de receptividad) o más abierto (niños deliberadamente atemorizados; Lyons‐Ruth 2005), y se asocia fuertemente con el apego desorganizado (Madigan 2006).
Descripción de la intervención
La retroalimentación con vídeos es un término genérico que se refiere al uso de interacciones grabadas en vídeo del padre y del niño para promover la sensibilidad de los padres; tiene otros nombres, como la Guía de Interacción con Vídeos (Video Interaction Guidance [VIG, por sus siglas en inglés]), la Guía de Interacción (Interaction Guidance [IG, por sus siglas en inglés]), el Entrenamiento Domiciliario con Vídeos (Video Home Training [VHT, por sus siglas en inglés]) y la Intervención de Retroalimentación con Vídeos para Promover una Crianza Positiva (Video Feedback Intervention to Promote Positive Parenting [VIPP, por sus siglas en inglés]). Desarrollada por Harrie Biemans y colegas en los años ochenta, el vídeo de retroalimentación es una intervención de crianza basada en la relación que tiene como objetivo mejorar la sensibilidad materna a nivel conductual (Kennedy 2010). Los aspectos fundamentales de las intervenciones basadas en la retroalimentación con vídeos son los siguientes.
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Grabación en vídeo de la interacción entre padres e hijos durante el juego o los aspectos del cuidado diario.
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Edición de la grabación para seleccionar micromomentos de interacción que demuestren las iniciativas de contacto del niño y ejemplos de la respuesta sintonizada del padre a estas señales.
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El padre y el "guía" (la persona responsable de la terapia) revisan conjuntamente las grabaciones y el guía elogia al padre, no por la sintonía per se sino por participar en la evaluación de las interacciones que se observan.
El modelo de intervención se sustenta en dos conceptos básicos: la intersubjetividad y el aprendizaje mediado. La intersubjetividad, o "momentos de sintonía compartidos", es modelada por el terapeuta (o "guía") en su relación e interacciones con el padre, además de identificarlas en las grabaciones de vídeo de la interacción padre‐hijo. El aprendizaje mediado, o "andamiaje", se refiere a la función que desempeñan los adultos al ayudar a los niños a aprender a hacer cosas que de otro modo no podrían hacer solos. El aprendizaje mediado también es modelado por el guía en sus relaciones con el padre, ya que el guía ayuda al padre a describir lo que sucede en las escenas que ve, y lo que el padre y el hijo pueden pensar o sentir en el vídeo, y a identificar las consecuencias para el padre y el hijo (Kennedy 2011).
La retroalimentación con vídeos se puede proporcionar individualmente (p.ej. VIPP, VIG) o en grupo (p.ej. Círculo de Seguridad [Circle of Security, CS]), y se ha utilizado con madres primerizas (Klein Velderman 2006); familias difíciles de abordar (Kennedy 2010); padres de recién nacidos prematuros (Hoffenkamp 2015); padres con problemas de salud mental, incluida la depresión posparto (Vik 2006); padres de niños autistas (Poslawsky 2015), niños maltratados (Moss 2011) y niños adoptados (Juffer 1997); padres de niños con dermatitis atópica (Cassibba 2015); padres de minorías étnicas (Yagmur 2014); y padres con trastornos alimentarios (Stein 2006). Aunque la retroalimentación con vídeos se realiza normalmente en el entorno doméstico, también se ha utilizado en entornos clínicos, como los entornos hospitalarios con madres de recién nacidos prematuros (Hoffenkamp 2015) y los las residencias para tratamiento (Kennedy 2010). En la actualidad la utilizan en más de 15 países los profesionales que trabajan en una amplia gama de profesiones de ayuda (p.ej. trabajo social, educación y salud; Kennedy 2010).
De qué manera podría funcionar la intervención
En cuanto al modelo teórico subyacente, la mayoría de las formas de retroalimentación con vídeos se basan en el apego, en el sentido de que su objetivo es mejorar la sensibilidad materna y promover el desarrollo social y emocional óptimos del niño (Klein Velderman 2006a), con el objetivo a largo plazo de promover un mejor apego infantil (Juffer 2008). Sin embargo, los supuestos mecanismos por los cuales se logra todo lo anterior varían entre los diferentes modelos de retroalimentación con vídeos. Todas las intervenciones de retroalimentación con vídeos se centran principalmente en el nivel conductual y utilizan episodios de la interacción padre‐hijo grabados en vídeo. El guía proporciona una oportunidad para que el cuidador experimente interacciones sintonizadas con un adulto sensiblemente sintonizado (Kennedy 2011), y también para que se vea a sí mismo en interacción con su hijo y observe las respuestas positivas de éste. En conjunto, se ha planteado la hipótesis de que se producen una serie de cambios meta‐cognitivos a partir de la discrepancia entre sus propias creencias acerca de su capacidad para ser padres y lo que pueden ver en el vídeo, además de un aumento en los sentimientos de empoderamiento y autoeficacia, y de su capacidad para la autorreflexión (Kennedy 2011).
Algunos modelos de intervención de retroalimentación con vídeos incluyen componentes adicionales que pueden proporcionar un enfoque más explícito sobre aspectos de la representación. Por ejemplo, la Intervención de Retroalimentación con Vídeos para Promover una Crianza Positiva con Discusiones sobre el Nivel Representacional (Video Feedback Intervention to Promote Positive Parenting with Discussions on the Representational Level [VIPP‐R, por sus siglas en inglés; Juffer 2008]), implica que el terapeuta aborde las representaciones y el apego de la madre mediante discusiones que pueden, por ejemplo, centrarse explícitamente en las propias experiencias de separación de la madre en la primera infancia y en las vividas con su propio hijo (Klein Velderman 2006a).
Otros modelos incluyen la inclusión de la enseñanza sobre técnicas disciplinarias sensibles, como la Intervención de Retroalimentación con Vídeos para Promover una Crianza Positiva ‐ Disciplina Sensible (Video Feedback Intervention to Promote Positive Parenting ‐ Sensitive Discipline [VIPP‐SD, por sus siglas en inglés]). Existe evidencia que indica que la efectividad de la retroalimentación con vídeos puede variar con factores a nivel de los padres y de los hijos. Por ejemplo, Klein Velderman 2006 informó que entre las madres con apego inseguro, las clasificadas como "marginadas inseguras" (que idealizan a sus propios padres o minimizan la importancia de las relaciones de apego en sus propias vidas) se beneficiaron más de la retroalimentación con vídeos, mientras que las clasificadas como "preocupadas inseguras" se beneficiaron más cuando participaron en la retroalimentación con vídeos junto con discusiones adicionales sobre sus experiencias individuales de apego en la niñez.
Por qué es importante realizar esta revisión
La mejoría de la salud y el bienestar de los niños forma parte de un programa mundial. Si bien las necesidades básicas de los niños (p.ej. alimentación, saneamiento, atención de la salud) son fundamentales para la supervivencia y el desarrollo, también es importante vivir con un adulto que responda a sus necesidades (Jones 2003). UNICEF 2008 destaca que una relación amorosa, estable y estimulante con los cuidadores en los primeros meses y años de vida es fundamental para todos los aspectos del desarrollo del niño. Específicamente, la literatura empírica muestra que la sensibilidad materna es un predictor clave de la seguridad del apego infantil (De Wolff 1997), y que un apego seguro promueve un desarrollo infantil más óptimo (Sroufe 2005), mientras que un apego inseguro o desorganizado predice problemas de conducta posteriores (Fearon 2010) y psicopatología (Steele 2010). Los estudios de investigación indican que las intervenciones tempranas y específicas tienen el potencial para ser un medio eficaz para aumentar la sensibilidad de los padres (Bakermans‐Kranenburg 2003), y aunque se han realizado varias revisiones de la repercusión de la retroalimentación con vídeos sobre una serie de resultados que incluyen la sensibilidad materna (Balldin 2018; Fukkink 2008; Juffer 2018; NICE 2016; Van den Broek 2017), solo se han realizado dos metanálisis. Fukkink 2008 concluyó que la retroalimentación con vídeos era una forma efectiva de mejorar la conducta y las actitudes de los padres, así como el desarrollo infantil. Sin embargo, el informe no proporcionó las fechas de búsqueda para la revisión, que se presentó en junio de 2008, no buscó en una amplia gama de bases de datos y fue muy amplio en su alcance, ya que incluyó todos los usos de la retroalimentación con vídeos sin límites de edad para los niños (que variaron en cuanto a edad desde el parto hasta los siete años, con una edad promedio de 2,4 años [desviación estándar (DE) 2,7 años]). Más importante aún, los autores del estudio prestaron poca atención a la calidad de los estudios incluidos (es decir, no hubo evaluaciones del "riesgo de sesgo") e incluyeron estudios no aleatorizados. Juffer 2018 solo analizó los estudios que utilizaron un tipo de retroalimentación con vídeos conocida como Interacción con Vídeos para Promover la Crianza Positiva (Video Interaction to Promote Positive Parenting [VIPP, por sus siglas en inglés]) y encontró que la VIPP fue efectiva para mejorar la sensibilidad de los padres.
Esta revisión sistemática de la mejor evidencia actual aborda las debilidades metodológicas de Fukkink 2008 y tiene un alcance más amplio que Juffer 2018. Será de interés para los elaboradores de políticas y los profesionales de todo el mundo.
Objetivos
Evaluar los efectos de la retroalimentación con vídeos sobre la sensibilidad de los padres y la seguridad del apego en niños menores de cinco años con riesgo de presentar resultados deficientes en cuanto al apego.
Métodos
Criterios de inclusión de estudios para esta revisión
Tipos de estudios
Se incluyeron ensayos controlados aleatorizados (ECA) y cuasialeatorizados (en los que la asignación a los brazos de estudio no es realmente aleatorizada; por ejemplo, la asignación se realiza mediante una forma de alternancia, como los días de la semana o la fecha de nacimiento). Se incluyeron ECA grupales y cruzados (cross‐over).
Se excluyeron los estudios en los que hubo un tratamiento alternativo sin un control. Los tratamientos control alternativos no son apropiados cuando se busca investigar la efectividad de una intervención, que fue el objetivo de esta revisión (lo que coincide con las recomendaciones del Grupo Cochrane de Problemas de Desarrollo, Psicosociales y de Aprendizaje (Cochrane Developmental, Pyschoscial and Learning Problems).
Tipos de participantes
Se incluyeron díadas padre‐hijo (incluidos los cuidadores de acogida o adoptivos) o unidades familiares, en las que el niño tenía una edad comprendida entre el parto y los cuatro años y 11 meses (inclusive), y en las que se habían identificado problemas que podrían afectar o que afectaban la sensibilidad del padre o de la madre (p.ej. lazos afectivos deficientes, depresión, trastornos alimentarios, maltrato) o el apego del niño (p.ej. problemas de conducta, temperamento desafiante, parto prematuro). La mayoría de los estudios examinaron díadas padre‐hijo.
Si los estudios incluyeron una proporción de participantes de más de cuatro años y 11 meses, se intentó obtener los datos sobre la muestra de hasta cuatro años y 11 meses; cuando no fue posible se utilizaron en el metanálisis los datos de resultados de niños fuera del grupo etario objetivo (p.ej. Moss 2011; Poslawsky 2015).
Se excluyeron los estudios en los que la intervención se utilizó con un grupo de población en el que ni los padres ni los niños tenían factores de riesgo para los problemas de apego.
Tipos de intervenciones
Se incluyeron las intervenciones de retroalimentación con vídeos realizadas en cualquier entorno, en las que el padre y el niño fueron filmados y luego se le proporcionó retroalimentación al padre, ya sea en forma individual o en grupos, con el objetivo de mejorar la sensibilidad de sus interacciones con el niño, el apego del niño o el funcionamiento reflexivo del padre.
Se incluyeron intervenciones que, además de la retroalimentación con vídeos, también proporcionaron un pequeño número de sesiones adicionales relacionadas con el objetivo principal de la intervención; por ejemplo, VIPP‐R o VIPP‐SD.
Se incluyeron los estudios en los que la intervención se comparó con ningún tratamiento, una intervención alternativa inactiva o el tratamiento habitual. Algunos ejemplos de tratamiento control incluyeron una secuencia de llamadas telefónicas con uno de los padres (Barone 2019; Kalinauskiene 2009; Negrão 2014; Van Zeijl 2006; Yagmur 2014); un número limitado de visitas domiciliarias con (1) grabaciones de vídeo entre el padre y el hijo sin retroalimentación (Benzies 2013; Koniak‐Griffin 1992; Moran 2005); (2) mediante un servicio de juego y desarrollo (Green 2010); (3) discusiones sobre la crianza (Poslawsky 2015); atención hospitalaria estándar (Hoffenkamp 2015) o atención habitual en unidades para niños sanos (Høivik 2015).
Se excluyeron los estudios que compararon la retroalimentación con vídeos con otras intervenciones, así como:
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intervenciones en las que se utilizó la retroalimentación por vídeo como parte de un conjunto más amplio de métodos de trabajo con la familia y en las que no fue posible diferenciar el efecto de la retroalimentación por vídeos, y
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programas que utilizaron modelos de cintas de vídeo o viñetas grabadas de padres e hijos (p.ej. Webster‐Stratton 2015).
Tipos de medida de resultado
Se excluyeron los estudios que no midieron la sensibilidad de los padres o que no lo hicieron de forma objetiva; por ejemplo, los estudios que se basaron en medidas de autoinforme, como la subescala Parent‐Child Dysfunctional Interaction (PCDI) del Parenting Stress Index (Abidin 1995).
Resultados primarios
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Sensibilidad de los padres, medida, por ejemplo, por la Ainsworth Sensitivity Scale (ASS; Ainsworth 1974), el Child‐Adult Relationship Experimental Index (CARE‐Index; Crittenden 2001), la Parental Sensitivity Assessment Scale (PSAS; Hoff 2004), la Coding Interactive Behaviour (CIB; Feldman 1998), las escalas Emotional Availability (EA) (Biringen 2000a), las Global Ratings Scales (GRS) de la interacción madre‐hijo (Murray 1996), el Maternal Behaviour Q‐sort (MBQS; Pederson 1999), o la Nursing Child Assessment Teaching Scale (NCATS; Sumner 1994).
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Funcionamiento reflexivo de los padres, medido, por ejemplo, por la Parent Development Interview (PDI; artículo no publicado, Aber 1985), o el PDI‐Revised (PDI‐R; artículo no publicado, Slade 2004).
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Seguridad del apego, medida, por ejemplo, por el Attachment Q‐sort (AQS; Waters 1985; Waters 1987), o el Strange Situation Procedure (SSP; Ainsworth 1978).
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Efectos adversos Se reconoce que un empeoramiento de cualquiera de las medidas de resultado primarias mencionadas anteriormente se consideraría un efecto adverso. Sin embargo, también se consideraron los efectos de la intervención sobre la ansiedad y el estrés de los padres, medidos, por ejemplo, por el Parenting Stress Index (PSI; Abidin 1995), o la Parenting Stress Scale (PSS; Berry 1995).
Resultados secundarios
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Salud mental infantil, medida por las evaluaciones conductuales de los trastornos emocionales, la hiperactividad y los trastornos de conducta.
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Desarrollo físico y socioemocional del niño, medido, por ejemplo, a través de las Bayley Scales of Infant and Toddler Development, Third Edition (Bayley‐III; Bayley 2006), o el Strengths and Difficulties Questionnaire (SDQ; Goodman 1997).
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Conducta infantil medida, por ejemplo, a través del Child Behaviour Assessment Instrument (CBAI; Samarakkody 2010).
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Costes, medidos por los costes directos declarados por los estudios.
Momento de evaluación de los resultados
Se recopilaron los datos de los resultados en los puntos temporales proporcionados dentro de los estudios incluidos y se agruparon como posintervención (inmediatamente después de la finalización de la intervención), a corto plazo (hasta seis meses), a medio plazo (hasta un año) y a largo plazo (más de un año).
Métodos de búsqueda para la identificación de los estudios
We ran the first database searches in August and September 2016 (Electronic searches) followed by searches of other resources in July 2017 (Searching other resources). In November 2018 we updated the searches, including bibliography screening, and ran further searches of other resources in July 2019. We did not apply any date or language restrictions to the electronic searches and had two papers translated into English (Bovenschen 2012; Kalinauskiene 2009).
Búsquedas electrónicas
We searched the electronic databases and trials registers listed below.
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Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11), in the Cochrane Library and which includes the Cochrane Developmental, Psychosocial and Learning Problems' Specialised Register (searched 10 November 2018)
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MEDLINE Ovid (1946 to November Week 1 2018)
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Embase Ovid (1974 to 2018 Week 44)
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CINAHL Plus EBSCOhos (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 November 2018)
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PsycINFO Ovid (1806 to 2018 Week 44)
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Sociological Abstracts ProQuest (1952 to 10 November 2018)
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Social Sciences Citation Index Web of Science (SSCI; 1970 to 10 November 2018)
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Social Services Abstracts ProQuest (1979 to 10 November 2018)
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Conference Proceedings Citation Index ‐ Social Science & Humanities Web of Science (CPCI‐SS&H; 1990 to 10 November 2018)
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LILACS (Latin American and Caribbean Health Science Information database; 1985 to current; lilacs.bvsalud.org/en; searched 10 November 2018).
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Cochrane Database of Systematic Reviews (CDSR; 2018; Issue 11), part of the Cochrane Library (searched 10 November 2018)
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Database of Abstracts of Reviews of Effects (DARE; 2015; Issue 2. Final issue), part of the Cochrane Library (searched 10 November 2018)
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Networked Digital Library of Theses and Dissertations (NDLTD; www.ndltd.org; searched 10 November 2018)
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WorldCat (limited to dissertations and theses; www.worldcat.org; searched 10 November 2018)
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Clinicaltrials.gov (Clinicaltrials.gov; searched 10 November 2018)
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World Health Organization International Clinical Trials Registry Platform (WHO ICTRP; www.who.int/ictrp/en; searched 10 November 2018)
Búsqueda de otros recursos
Two review authors (ES and LOH) screened the bibliographies of included studies (Barlow 2016; Barone 2019; Benzies 2013; Bovenschen 2012; Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Lam‐Cassettari 2015; Moran 2005; Moss 2011; Negrão 2014; Platje 2018; Poslawsky 2015; Seifer 1991; Stein 2006; Van Zeijl 2006; Yagmur 2014) and relevant reviews (Balldin 2018; Fukkink 2008; Juffer 2018; NICE 2015; Van den Broek 2017), to identify any additional relevant publications. They also searched the websites of the following relevant organisations and government departments: United Nations International Children's Emergency Fund (UNICEF) Global Evaluation Database (unicef.org/evaldatabase); National Society for the Prevention of Cruelty to Children (NSPCC) Impact and Evidence Hub (nspcc.org.uk/services‐and‐resources/impact‐evidence‐evaluation‐child‐protection); and the Association for Video Interaction Guidance UK (AVigUK; videointeractionguidance.net) (see Appendix 1). One review author (ES) visited the websites of research groups we knew to be conducting work in this area to screen their listed publications (see Appendix 1). Another review author (LOH) also used Google Scholar to search the internet for unpublished work (see Appendix 1).
Although originally planned (O'Hara 2016), we did not contact experts to enquire about other published work or unpublished work (Table 1).
Obtención y análisis de los datos
For this section, we only report those methods used in this review. Other methods that were not relevant to the available data, or that we could not use for other reasons, are summarised in Table 1. One of the review authors (JB) is an author of an included study (Barlow 2016). JB was not involved in data extraction or assessment of risk of bias; the review authors involved in this did not need to seek any further advice on either of these areas with regards to this particular study.
Selección de los estudios
At least two review authors (from ES, LOH and NH) independently screened titles and abstracts yielded by the searches against the inclusion criteria for the review (Criteria for considering studies for this review). The review authors retrieved the full‐text reports of all studies selected for potential inclusion, or those where there was some uncertainty, and assessed the reports for eligibility. Where review authors could not agree, they further discussed the papers with JB or GM. In one case, Mendelsohn 2005, we wrote to the study authors for the purposes of clarifying whether or not the study met our inclusion criteria (Table 2). We list excluded studies in the Characteristics of excluded studies tables, together with the reason for their exclusion. We report the flow of studies in a PRISMA diagram (Liberati 2009).
Extracción y manejo de los datos
Two review authors (from NH, LOH, ES) independently extracted data from each included study and recorded the following information on a pre‐piloted data extraction form.
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Participant characteristics (age, gender, ethnicity, location)
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Intervention characteristics (including delivery, duration, outcomes and measures, and within‐intervention variability)
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Comparison characteristics (including whether the study used an active or inactive comparison)
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Study characteristics (study design, sample size, length of follow‐up, attrition or dropout, handling of missing data, methods of analysis, dates of study, funding sources, conflicts of interest)
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Outcome data (relevant details on all primary and secondary outcome measures used, and summary data, including means, standard deviations (SDs), confidence intervals (CIs) and significance levels for continuous data and proportions for dichotomous data)
Review authors resolved disagreements through discussion. Where clarity was needed over whether an outcome in a study was relevant, the reviewer authors sought advice from JB.
Evaluación del riesgo de sesgo de los estudios incluidos
Two review authors (ES for all studies, with either LOH or NH) independently assessed the risk of bias of each included study using the Cochrane 'Risk of bias' tool (Higgins 2017). They assigned judgements of low, high or unclear risk of bias for each of the following domains, using the criteria set out in Appendix 2: sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting and other bias. Where review authors did not agree after discussion, they discussed further with another author (JB or NL). We recorded the judgements in 'Risk of bias' tables.
Medidas del efecto del tratamiento
We calculated unadjusted treatment effects using Review Manager 5 (RevMan 5) (Review Manager 2014).
Dichotomous outcome data
We calculated the odds ratio (OR) with 95% CI for dichotomous outcomes. For dichotomous outcomes that we included in the 'Summary of findings' tables, we expressed the results as absolute risks and used high and low observed risks among the control groups as reference points.
Continuous outcome data
For continuous outcomes, we calculated the mean difference (MD) if all included studies used the same measurement scale, or the standardised mean difference (SMD) if studies used different measurement scales, and 95% CIs. We calculated SMD using Hedge's g. In one instance, we converted an SMD from Cohen's d to Hedge's g.
Economics issues
We reviewed studies for data on the costs of programmes within the included studies.
Cuestiones relativas a la unidad de análisis
Studies with multiple treatment groups
In the primary analysis, we combined results across all eligible intervention groups and compared them with the combined results across all eligible control groups, and made single pair‐wise comparisons. Where studies compared more than one form of video interaction with a control group or groups, such that combining them prevented investigation of potential sources of heterogeneity, we analysed each video interaction group separately (against a common control group) but divided the sample size for common comparator groups proportionately across each comparison (Higgins 2011; Section 16.5.5). This simple approach allows the use of standard software and prevents inappropriate double counting of individuals. We applied this latter approach to three studies (Benzies 2013; Hoffenkamp 2015; Klein Velderman 2006).
Manejo de los datos faltantes
Where necessary, one review author (LOH or ES) contacted the authors of included studies requesting them to supply any unreported data such as missing outcome data (e.g. group means and SDs and details of number of dropouts). Details of which study authors we contacted and why are in the Characteristics of included studies tables and Table 2.
If we were not able to obtain unreported outcome data, we followed the recommendations in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 16.1) and did the following:
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Analysed the data available, as we assumed the data were missing at random.
Two studies had unreported outcome data on parental sensitivity that the study authors were unable to provide: Koniak‐Griffin 1992 reported a result for a scale with parental sensitivity as a subdomain, but did not report the subdomains; and Moran 2005 reported means but not SDs or standard errors (SE). We did not impute this unreported data, as we assumed the data were missing at random.
Evaluación de la heterogeneidad
We assessed clinical heterogeneity across included studies by examining the distribution of important participant factors (e.g. age) and intervention characteristics (e.g. style, setting, personnel, context of delivery) among studies. The details of this information are included in the Characteristics of included studies tables, and discussed in the Results section.
We assessed methodological heterogeneity across included studies by comparing the distribution of study factors (e.g. allocation concealment, blinding of outcome assessment, losses to follow‐up, treatment type, cointerventions). This information is contained in the Characteristics of included studies tables and 'Risk of bias' tables, and considered in the Discussion.
We described statistical heterogeneity by computing the I2 statistic (Higgins 2002), which describes approximately the proportion of variation in point estimates that is due to heterogeneity rather than sampling error. In addition, we used the Chi2 test (P < 0.10) of homogeneity to detect the strength of evidence that heterogeneity is genuine (Deeks 2017).
Evaluación de los sesgos de notificación
We drew a funnel plot (estimating differences in treatment effects against their standard error (SE)) when we identified 10 or more studies that provided data on an outcome; in this case, parental sensitivity. We assessed the funnel plot by visual inspection and also by Egger's regression test (Egger 1997). We redrew the funnel plot without an outlying study (Green 2010), to better assess the asymmetry.
We considered the reasons for any asymmetry. Asymmetry might be due to publication bias, but might also reflect a relationship between study size and effect size, such as when larger studies have lower compliance, and compliance is positively related to effect size. It may also be due to clinical variation between the studies (Sterne 2017, Section 10.4), for example the study population, reflecting true heterogeneity.
As a direct test for publication bias, we compared results extracted from published journal reports with results obtained from other sources for the two outcomes for which this was possible, parental sensitivity and parental stress. In these cases we obtained some outcome data directly from study authors that were not reported in the published papers (see Table 2).
Síntesis de los datos
Where interventions were similar in terms of (1) the age of the child(ren), (2) parent gender and (3) intensity, frequency and duration of video feedback, we synthesised results in a meta‐analysis.
We used both fixed‐effect and random‐effects models and compared the results to assess the impact of statistical heterogeneity. Except where the model was contraindicated (e.g. if there was funnel plot asymmetry), we present the results from the random‐effects model. When we report the results of the random‐effects model, we include an estimate of the between‐study variance (Tau2).
We calculated all overall effects using inverse variance methods.
Where some primary studies reported an outcome as a dichotomous measure and others used a continuous measure of the same construct (as in the case of attachment security), we performed two separate analyses rather than converting the OR to a SMD. This was because we could not assume that the underlying measure had a normal or logistic distribution, as the nature of the populations in the two relevant studies means that the distribution of attachment patterns is likely to be skewed (teenage mothers in Moran 2005 and families where children had been subjected to maltreatment in Moss 2011).
Where a trial reported two outcomes within a time period covered by the same meta‐analysis, we combined the data from the time point nearest the end of the intervention. Where possible, we tried to combine outcomes measured at similar time points in the follow‐up period.
'Summary of findings' table
We created a 'Summary of findings' table for the following comparison: video feedback versus no intervention or inactive alternative intervention.
We followed the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions (Schünemann 2017), and included the following six elements in these tables.
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A list of all outcomes
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A measure of the typical burden of these outcomes
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Absolute and relative magnitude of effect
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Numbers of participants and studies that address these outcomes
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A rating of the overall certainty of evidence for each outcome
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Additional comments
Two review authors (LOH, ES) independently assessed the certainty of the evidence, using the following five GRADE considerations (Schünemann 2017).
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Limitations in study design and implementation: for RCTs, for example, these included lack of allocation concealment, lack of blinding and large loss to follow‐up.
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Indirectness of evidence: for example, if findings were restricted to indirect comparisons between two interventions. RCTs that met the eligibility criteria but that addressed a restricted version of the main review questions in terms of population, intervention, comparator or outcomes are another example of this and would also have been downgraded.
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Unexplained heterogeneity or inconsistency of results: we looked for robust explanations for heterogeneity in studies that yielded widely differing estimates of effect.
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Imprecision of results: we downgraded the certainty of evidence for those studies that included few participants and few events and thus had wide CIs.
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Publication bias: we downgraded the certainty of evidence level if investigators failed to report studies or outcomes on the basis of results.
We downgraded the ratings (from high to very low), depending on the presence of the five factors.
We used GRADEpro GDT to prepare the 'Summary of findings' table, and specifically, to enable us to produce relative effects and absolute risks associated with the interventions (GRADEpro GDT). We used all primary outcomes and one secondary outcome of interest to populate the ‘Summary of findings’ table (primary outcomes: parental sensitivity at postintervention to six months; reflective functioning; attachment security measured by Strange Situation Procedure at postintervention; attachment security measured by Attachment Q‐sort at postintervention; parental stress measured at postintervention and short‐term follow‐up; and parental anxiety at short‐term follow‐up; secondary outcome: child behaviour measured at long‐term follow‐up). We also used Ryan 2016 to guide our judgements.
Análisis de subgrupos e investigación de la heterogeneidad
We investigated heterogeneity by conducting moderator analyses for the outcome of 'parental sensitivity'. To perform this analysis, we used a random‐effects meta‐analysis with a Sidik‐Jonkman estimator, which is robust for small numbers of studies and provides improved CI (Veroniki 2019). We considered the following factors, some of which we decided post hoc.
Prespecified factors
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Intervention dose: defined by number of video feedback sessions (zero to five versus six to 10 versus more than 10; grouping this factor in this way was a post hoc decision).
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Participating carer: all mothers versus all fathers versus mix of mothers and fathers (we made a post hoc decision to include studies with a mix of parental genders along side those who were all fathers or all mothers).
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Type of video feedback (VIPP versus non‐VIPP; grouping types of video feedback in this way was a post hoc decision).
Factors specified post hoc
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Age of child (children under one year old versus children aged one year or older; using age of child as a factor was a post hoc decision).
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Disability status of children (disability versus no disability; using disability status of the child was a post hoc decision).
In the first step, we assessed the moderators individually and reported their overall contribution to the reduction of heterogeneity (Q‐between). To assess whether moderation effects for study characteristics existed, we conducted a moderator analysis in which we included the three prespecified moderators (type of video feedback, duration of video feedback and participating carer) simultaneously, this accounts for potential correlations between moderators. Given the small number of studies, this analysis should be treated with caution, due to the relatively low power. Predicted values are reported alongside regression results. We did not impute missing data in line with the main analyses.
We conducted the moderator analyses in R version 3.6.1 (R 2018), using the metafor‐package 2.1.0 (Viechtbauer 2010); analysis syntax and data are available from the review authors on request.
Análisis de sensibilidad
We assessed the robustness of findings to decisions made in obtaining them by conducting the following sensitivity analyses (Deeks 2017).
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Reanalysis excluding studies at high or unclear risk of bias
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Reanalysis using different statistical approaches (comparing the use of a random‐effects model with a fixed‐effect model).
Results
Description of studies
Results of the search
Our initial electronic searches (August to September 2016 and July 2017) identified 6191 records (see Figure 1). We identified an additional 381 records from other sources. After the removal of duplicates, we screened the titles and abstracts of 4368 records. We obtained and scrutinised 81 full‐text reports for eligibility, 47 of which (37 studies) did not meet the inclusion criteria and were excluded from the review with reasons (see Characteristics of excluded studies), and 34 (19 studies) that did and were included in the review.
95 Study flow diagram
Our updated electronic searches (November 2018) identified 2887 records. We identified an additional 211 records through other sources in November 2018, and an additional two records in July 2019. After the removal of duplicates, we screened the titles and abstracts of 1662 records. During the title and abstract screening, we identified six ongoing studies, one of which we excluded, leaving five ongoing studies (Euser 2016; Firk 2015; ISRCTN92360616; NCT03052374; Schoemaker 2018), and one study awaiting classification (Mendelsohn 2008). We reviewed seven full‐text reports and added six reports pertaining to three new studies (Barone 2019; Platje 2018; Seifer 1991) and one report of a study identified during our initial search (Hodes 2017), to the review (see Figure 1).
Included studies
This review includes 22 studies (see Characteristics of included studies tables and Table 3), comprising a total of 41 reports and 1889 randomised parent‐child dyads or family units.
| Study | Aim | Content/delivery |
| Video‐feedback Intervention to promote Positive Parenting (VIPP; Juffer 2008) | ||
| To test the effect of a parent‐mediated intervention for children at high risk of autism spectrum disorder | Video Interaction for promoting Positive Parenting (iBASIS‐VIPP), a modification for the autism prodome of the VIPP infancy programme. The intervention consisted of 12 sessions (an additional 6 booster sessions compared with VIPP).The intervention uses video feedback "to help parents understand and adapt to their infants' individual communication style to promote optimal social and communicative development" (quote). The study authors describe that "The therapist uses excerpts of parent‐child interactions in a series of developmentally sequenced home‐sessions focusing on interpreting the infant's behaviour and recognising their intentions; enhancing sensitive responding; emotional attunement and patterns of verbal and non‐verbal interaction." (quote) | |
| To test if a video‐feedback intervention to promote positive parenting and sensitive discipline reduces child‐related parental stress in parents with mild learning disabilities in comparison with care as usual | A Video‐feedback Intervention for Positive Parenting and Learning Difficulties (VIPP‐LD) where the original protocol of VIPP‐SD (Juffer 2008) was adapted for mild intellectual disabilities. For VIPP‐LD, in each session, the parent is videoed interacting with their child. The coach and parent review the footage together, drawing attention to instances of sensitive responsiveness and sensitive discipline, and the coach helps the parent look at the child from the child's perspective. The adaptation included shortening of each session, shorter video recordings and more real‐life practice. The study authors describe how "Parents also received a personal scrapbook with skills taken from video recordings and quotes from the parents representing the theme of the session." (quote) | |
| To evaluate the effectiveness of a short‐term, interaction‐focused video‐feedback intervention implemented in families with mothers rated low in maternal responsiveness | A Video‐feedback Intervention to promote Positive Parenting (VIPP). The intervention was applied as per protocol with the main goal "to reinforce mothers' sensitive responsiveness to their infants' signals focusing on different aspects of mother‐infant interactions" (quote). Mothers were also "provided with information on attachment‐related issues by giving them brochures about sensitive parenting." (quote) | |
| To explore if a combination of attention to parental sensitivity and parental attachment representations might lead to firmer and more enduring changes in both parenting behaviour and children's attachment security | A Video‐feedback Intervention to promote Positive Parenting (VIPP). VIPP programs consisted of four home visits lasting 1.5 hours each, with 3‐4 weeks in between. Each session was focused around a specific theme. VIPP‐R included additional discussions on parental representations. | |
| To test the effectiveness of a video‐feedback intervention to promote positive parenting and sensitive discipline in a sample of poor Portuguese mothers and their 1‐4‐year old children | A sensitive discipline video‐feedback intervention to promote positive parenting (VIPP‐SD). The study authors state that "VIPP‐SD is a short term intervention programme that relies on video‐feedback technique to enhance parental sensitivity and positive discipline strategies. The intervention was applied through standardised protocols of six home visits...The VIPP‐SD working method is divided into three steps: (1) Sessions 1 and 2 main goals are building a relationship with the mother, focusing on child behaviour and emphasizing positive interactions in the video feedback; (2) Sessions 3 and 4 actively work on improving parenting behaviours by showing the mother when her parenting strategies work and to what other situations she could apply these strategies; and (3) Sessions 5 and 6 (booster) aim to review feedback and information from the previous sessions in order to strengthen intervention effectiveness." (quote) | |
| To evaluate a video‐feedback intervention aimed at improving parent‐child interaction for parents of children with a visual or visual and intellectual disability | A Video‐feedback Intervention to promote Positive Parenting adapted to parents of children with a visual or visual and intellectual disability (VIPP‐V). The study authors state that the intervention was based on VIPP, but "this new intervention [is] applicable for use in families with a young child with a visual or visual‐and‐intellectual disability. Particular attention was devoted to increasing (safe) exploration, joint attention, and parent’s abilities to recognize and understand the signals and emotions of their child" (quote). The intervention consists of 7 home visits (5 primary visits plus 2 booster sessions). | |
| To evaluate the early intervention programme, video‐feedback intervention to promote positive parenting adapted to autism, with primary caregivers and their child with autism spectrum disorder | VIPP adapted to autism (VIPP‐AUTI). The intervention comprised 5 home visits lasting 60‐90 minutes every 2 weeks. Sessions included: (1) "Attachment and Exploration" (quote); (2) "Speaking for the Child" (quote); (3) "Sensitivity Chain" (quote); (4) "Sharing Emotions" (quote); (5) "Booster session" (quote). | |
| To test the video‐feedback intervention to promote positive parenting and sensitive discipline in "a large sample of families screened for their children's relatively high scores on externalizing behaviour." (quote) | The study applied VIPP‐SD, aimed at parental sensitivity and sensitive parental discipline. The first four intervention sessions each had their own themes, (1) "exploration versus attachment" (quote); (2) "centered around speaking for the child" (quote); (3) "the intervener stressed the importance of adequate and prompt responses to the child’s signals" (quote); (4) "the importance of sharing—both positive and negative—emotions (sensitivity) and promoting empathy for the child" (quote); (5 & 6) "aimed at consolidating intervention effects by integrating—in video feed‐back and discussion—all tips and feedback given in the previous sessions" (quote). | |
| "To test the effectiveness of the video feedback intervention to promote positive parenting and sensitive discipline adapted to the specific child‐rearing context of Turkish families (VIPP‐TM) in the Netherlands" (quote), including second‐generation Turkish immigrant families with toddlers at risk for the development of externalising problems | "The VIPP‐TM program is a culturally sensitive adaptation of the VIPP‐SD program for Turkish minority families in the Netherlands, but follows the general procedures of the original program...The VIPP‐SD program is described in a detailed protocol and consists of six home visits. The first four visits each have their own themes regarding sensitivity and discipline, and the last two sessions are booster sessions in which the themes from previous sessions are reviewed once more." (quote) | |
| Video Interaction Guidance (VIG) | ||
| "To assess the potential of video interaction guidance to increase sensitivity in parents of preterm infants." (quote) | The study authors report that "VIG is a strengths‐based form of video feedback in which parents are invited to jointly observe and reflect on their own successful interactions with their baby...The core aspects of the model involve three home visits comprising (a) video recording the parent‐infant interaction during play or other aspects of care giving, (b) editing of the recording to select micro‐moments of interaction that demonstrate the infant's contact initiatives and the parents attuned response to these signals and (c) joint reviewing of the recordings with the parent." (quote) | |
| To evaluate the effectiveness of hospital‐based video interaction guidance in parents with moderately and very preterm babies | "Video recordings of parent‐infant interactions and the feedback from a VIG professional provide an opportunity for parents to observe, analyse and discuss the infant's behaviour and contact initiatives" (quote). In this study "VIG consisted of three sessions during the first week after birth" (quote), and included "(1) video‐recording parent‐infant interaction; (2) editing the video recordings; (3) reviewing the edited recordings with parents." (quote) | |
| To examine "the effect of a family‐focused psychosocial video intervention program on parent‐child communication in the context of childhood hearing loss" (quote) | Parents completed three sessions: "(a) a goal setting session; (b) three filming sessions of parent–child interaction in the family home, and (c) three shared review sessions in which three short video clips (demonstrating attuned responses linked to the family’s goal) were played so families could microanalyze and discuss." (quote) | |
| Video feedback of Infant‐Parent Interaction (VIPI) | ||
| To investigate "in a heterogenic community sample of families with interactional problems, whether VIPI would be more effective than standard care (TAU) received in the community" (quote) | VIPI involves at least 6 consultation sessions over a maximum period of 3 months focusing on (1) "Initiative of the infants to contact caregivers and initiate pauses in the dyadic exchange" (quote); (2) "Responses of caregivers" (quote); (3) "Following the child" (quote); (4) "Naming" (quote); (5) "Step‐by‐step guidance" (quote); (6) "Directing attention towards social interaction and exploration" (quote). In this study, "families in the VIPI group received eight video feedback sessions, with the last two sessions tailored to meet the individual family needs regarding any of the six topics in the manual" (quote). | |
| Video self‐modelling with feedback | ||
| To explore if fathers of late, preterm children who received video self‐modelling with feedback intervention would have better father‐child interaction skills when the child was 8 months old than fathers who received information only | Self‐modelling "involves the father's active participation that increases his cognitive awareness of specific behaviours such as infant cues and how to stimulate development" (quote). The intervention involved video recording a father‐infant play interaction and providing positive feedback and suggestions to enhance the interaction and language development. | |
| Video feedback (non‐specified or other) | ||
| To assess "the effectiveness of an attachment‐based short term intervention using video‐feedback" (quote) | Up to 10 sessions of home‐based video feedback | |
| To test a parent‐child communication‐focused intervention in children with core autism | A parent‐mediated communication‐focused intervention: "The intervention consisted of one‐to‐one clinic sessions between therapist and parent with the child present. The aim of the intervention was first to increase parental sensitivity and responsiveness to child communication and reduce mistimed parental responses by working with the parent and using video‐feedback methods to address parent‐child interaction... incremental development of the child's communication was helped by the promotion of a range of strategies such as action routines, familiar repetitive language and pauses...After an initial orientation meeting, families attended biweekly 2 hour clinic sessions for 6 months followed by booster sessions for 6 months (total 18). Between sessions families were also asked to do 30 mins of daily home practice." (quote) | |
| To evaluate "the effects of video tape instruction and feedback (video‐therapy) on mothering behaviours" (quote) | The intervention group received two home visits. Participants were "video taped during structured mother‐infant teaching episodes in their homes at 1 and 2 months postpartum" (quote). Participants "reviewed the video tapes with feedback from a professionally trained nurse who emphasised positive aspects of maternal behaviour" (quote) | |
| To evaluate "the effectiveness of a brief intervention program designed to support adolescent mothers' sensitivity to their infants attachment signals" (quote) | A brief intervention programme (eight home visits) designed to support the mother's sensitivity to her child. The home visits (lasting approximately one hour) were "designed to provide mutually beneficial play interactions and the mother's enjoyment of her infant" (quote). The four goals of the programme included "to affirm parenting strengths already present in the mother...increase the mother's awareness of how her behaviour influenced her child's behaviour...look for ways to augment the mother's awareness of her infant's signals and for ways to establish positive experiences for both the mother and infant" (quote). | |
| To evaluate the "efficacy of a short‐term attachment‐based intervention for changing risk outcomes for children of maltreating families" (quote) | The intervention consisted of "8 weekly home visits directed at the caregiver–child dyad and focused on improving caregiver sensitivity" (quote). The study authors describe that "All intervention sessions were primarily focused on reinforcing parental sensitive behavior by means of personalized parent–child interaction, video feedback, and discussion of attachment/emotion regulation‐related themes" (quote). | |
| To examine the effects of easy‐to‐use interaction coaching techniques on interaction style and developmental status of a population of mothers and their young children with developmental disabilities | "Interaction coaching" (quote; 10‐month programme). "Sessions lasted six minutes and parents were asked to play with their children as they would during a short break at home...After the initial taping session the video record was viewed by the mother and an interaction coach. Suggestions were then provided by the therapist for the mother to employ during interaction with her child...Another 6 minute interaction was then recorded that was reviewed by the intervener and could be used during the next week’s session. The procedure was repeated for a maximum of 6 sessions." (quote) | |
| To test "whether video‐feedback treatment especially targeting mother‐child interaction would be superior to counselling in improving mother‐child interaction, especially mealtime conflict and infant weight and autonomy" (quote) | "Thirteen 1‐hour treatment sessions were offered in the mothers’ homes beginning when the infants were between 4 and 6 months old and completed by the time the infants were 12 months old. The intervention group received video‐feedback interactional treatment that was a modification of that developed by [Juffer et al]" (quote). Treatment consisted of three stages: "The first concentrated on the infant’s perspective, focusing on his or her signals...The second stage included the mother’s perspective...Third, as treatment progressed, the videotapes were used to help the mother identify and address potential triggers of mealtime conflict" (quote). | |
IBASIS‐VIPP: Intervention within the British Autsim Study of Infant Siblings ‐ Video‐feedback Interaction to promote Positive Parenting; Mins: Minutes; TAU: Treatment as usual; VIG: Video Interaction Guidance; VIPI: Video‐feedback of Infant‐Parent Interaction; VIPP: Video‐feedback Interaction to promote Positive Parenting; VIPP‐AUTI: Video‐feedback Interaction to promote Positive Parenting ‐ Autism;VIPP‐LD: Video‐feedback Interaction to promote Positive Parenting ‐ Learning Difficulties; VIPP‐R: Video‐feedback Interaction to promote Positive Parenting ‐ Representational level; VIPP‐SD: Video‐feedback Interaction to promote Positive Parenting ‐ Sensitive Discipline; VIPP‐TM: Video‐feedback Interaction to promote Positive Parenting ‐ Turkish Minorities; VIPP‐V: Video‐feedback Interaction to promote Positive Parenting ‐ Visual or visual and intellectual disability.
Location
Seven studies were conducted in the Netherlands (Hodes 2017; Hoffenkamp 2015; Klein Velderman 2006; Platje 2018; Poslawsky 2015; Van Zeijl 2006; Yagmur 2014), five in the UK (Barlow 2016; Green 2010; Green 2015; Lam‐Cassettari 2015; Stein 2006), three in Canada (Benzies 2013; Moran 2005; Moss 2011), and two in the USA (Koniak‐Griffin 1992; Seifer 1991). One study apiece was conducted in Germany (Bovenschen 2012), Italy (Barone 2019), Lithuania (Kalinauskiene 2009), Norway (Høivik 2015), and Portugal (Negrão 2014).
Design
All but two studies were RCTs (Bovenschen 2012; Seifer 1991). Bovenschen 2012 was originally designed as an RCT but some mothers only agreed to take part if they could participate in the intervention, thereby undermining the randomisation. Seifer 1991 was a quasi‐RCT, with participants allocated based on the day of the week they attended a linked treatment programme.
Two of the 22 included RCTs employed a three‐arm design (Benzies 2013; Klein Velderman 2006). Klein Velderman 2006 allocated parents to either a video‐feedback group, a video‐feedback and discussion group, or a control group. In Benzies 2013, one group was allocated two visits with a video‐feedback intervention, the second group was allocated four visits with a video‐feedback intervention and the final group was allocated to a control condition.
The other studies employed a two‐arm design with parents allocated either to a video‐feedback intervention or control group (see Table 3).
Sample size
The number of dyads randomised in each trial ranged from 14 (Lam‐Cassettari 2015), to 237 (Van Zeijl 2006).
Recruitment
Two studies recruited participants from an inpatient hospital setting (Barlow 2016; Hoffenkamp 2015). The other 20 studies recruited participants from a community setting, including primary care, and hospital outpatient clinics.
Participants
The majority of studies (n = 14) randomised only mother‐child dyads. Seven studies randomised male as well as female caregiver and child dyads (Barlow 2016; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Moss 2011; Platje 2018; Poslawsky 2015). Only one study randomised father‐child dyads (Benzies 2013).
The average age of carers, when reported, ranged from 17.16 years (Koniak‐Griffin 1992), to 42.6 years (Barone 2019).
Twelve studies had a mean age of participant children that was under one year at baseline (Barlow 2016; Benzies 2013; Bovenschen 2012; Green 2015; Hoffenkamp 2015; Høivik 2015; Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Moran 2005; Seifer 1991; Stein 2006); the remaining 10 studies had a mean age of participant children that was over one year at baseline (Barone 2019; Green 2010; Hodes 2017; Lam‐Cassettari 2015; Moss 2011; Negrão 2014; Platje 2018; Poslawsky 2015; Van Zeijl 2006; Yagmur 2014). Many studies specified in their inclusion criteria that they were either recruiting babies (children aged under one year) or children (children aged one year or over); however, in some studies, their inclusion criteria included children both under and over one year of age.
Participants were recruited for a range of reasons including: child behaviour problems; parental diagnosis of an eating disorder; adverse family circumstances; parental depression; sensitivity problems; insecure attachment; parental intellectual disability; teenage or single parenthood (or both); migration status; preterm baby; adopted child; deaf children; parents who were being monitored by social services for child maltreatment; parents of children with a visual or visual and intellectual disability; and autistic children or children considered at risk of autism.
It is difficult to summarise the ethnicities of participants as different studies categorised this variable in different ways. Six studies did not report ethnicity (Bovenschen 2012; Hodes 2017; Hoffenkamp 2015; Klein Velderman 2006; Moss 2011; Poslawsky 2015). In 12 studies the majority of participants appeared to be from white European backgrounds (see Characteristics of included studies tables). One study recruited internationally adopted children (Barone 2019), and in one study the majority of participants were from African American or Hispanic backgrounds (Koniak‐Griffin 1992). Two studies used ethnicity as part of their inclusion or exclusion criteria (Negrão 2014; Yagmur 2014).
Type of video‐feedback intervention
Table 3 provides an overview of type of video‐feedback interventions that the included studies evaluated, organised by type. In summary:
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10 studies implemented Video‐feedback Intervention to promote Positive Parenting (VIPP) or a variation of VIPP (VIPP with a representational component (VIPP‐R), VIPP and sensitive discipline (VIPP‐SD), VIPP adapted to autism (VIPP‐AUTI), VIPP adapted for Turkish mothers (VIPP‐TM), VIPP‐visual (VIPP‐V), VIPP adapted for fostered or adopted children (VIPP‐FC/A)): (Barone 2019; Green 2015; Hodes 2017; Kalinauskiene 2009; Klein Velderman 2006; Negrão 2014; Platje 2018; Poslawsky 2015; Van Zeijl 2006; Yagmur 2014);
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Three studies included Video Interaction Guidance (VIG; Barlow 2016; Hoffenkamp 2015; Lam‐Cassettari 2015);
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One study implemented Video‐feedback of Infant‐Parent Interaction (VIPI; Høivik 2015);
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One study implemented video self‐modelling with feedback (Benzies 2013); and
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Six studies implemented a non‐specified type of video feedback or another type not named above (Bovenschen 2012; Green 2010; Koniak‐Griffin 1992; Moran 2005; Moss 2011; Seifer 1991; Stein 2006).
Treatment intensity
Six studies had between one and five sessions of video feedback (Barlow 2016; Benzies 2013; Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Poslawsky 2015); 12 studies had six to 10 sessions of video feedback (Barone 2019; Bovenschen 2012; Hoffenkamp 2015; Høivik 2015; Lam‐Cassettari 2015; Moran 2005; Moss 2011; Negrão 2014; Platje 2018; Seifer 1991; Van Zeijl 2006; Yagmur 2014); and four studies offered more than 10 sessions of video feedback (Green 2010; Green 2015; Hodes 2017; Stein 2006).
Monitoring of treatment fidelity
Two studies reported a quantitative measure of treatment fidelity (Green 2010; Green 2015). Ten studies reported having a process in place to monitor treatment fidelity, although they did not report a quantitative measure of treatment fidelity (Hodes 2017; Hoffenkamp 2015; Høivik 2015; Moran 2005; Moss 2011; Platje 2018; Poslawsky 2015; Stein 2006; Van Zeijl 2006; Yagmur 2014). The 10 remaining studies did not report any monitoring of treatment fidelity.
Comparisons
Eleven studies used either usual care (such as routine visits from community health staff or play support programmes) or no additional intervention for their control group (Barlow 2016; Bovenschen 2012; Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Klein Velderman 2006; Lam‐Cassettari 2015; Moss 2011; Platje 2018). The other 11 studies used some sort of inactive alternative treatment, such as telephone calls or videoing the parent‐child dyads, without providing any feedback.
Outcomes and outcome measures
Parental sensitivity
All studies measured parental sensitivity or used a measure that could act as a proxy.
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Seven studies (Barone 2019; Høivik 2015; Klein Velderman 2006; Lam‐Cassettari 2015; Negrão 2014; Poslawsky 2015; Yagmur 2014), used the Emotional Availability Scale (Biringen 2000b; Biringen 2008).
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Three studies (Bovenschen 2012, Kalinauskiene 2009; Klein Velderman 2006), used the Ainsworth Rating Scale (Ainsworth 1974; Ainsworth 1978), and one (Stein 2006), used an adapted version of this scale.
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Two studies (Moran 2005; Moss 2011), used the Maternal Behaviour Q‐sort (Pederson 1999; Pederson 1995).
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Six other studies used the following scales:
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Barlow 2016 used the CARE‐Index (Crittenden 2001);
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Benzies 2013 used the Parent Child Interaction Teach Scale (Sumner 1994);
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Green 2015 used the Manchester Assessment of Caregiver‐Infant Interaction (Wan 2017);
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Hoffenkamp 2015 used an adapted measure based on a coding scale from NICHD Early Child Care Research Network 2005;
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Koniak‐Griffin 1992 used the Nursing Child Assessment Teaching Scale (Barnard 1978);
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Platje 2018 used an adapted version of the National Institute of Child Health and Human Development Scales (Egeland and Heister 1993); and
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Van Zeijl 2006 used measures for parental sensitivity that were taken from Egeland 1990.
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Three studies relied on proxy measures (Green 2010; Hodes 2017; Seifer 1991).
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Green 2010 used the proportion of parental communications with the child that were synchronous based on observation.
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Hodes 2017 assessed harmonious parent‐child interaction (measured using the three‐bag procedure; NIHCD Early Child Care Research Network 2003).
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Seifer 1991 used an observer to measure maternal responsive behaviour, but the report does not specify the type of scale used to code observations.
Fourteen studies measured parental sensitivity immediately postintervention (Barone 2019; Bovenschen 2012; Green 2015; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Kalinauskiene 2009; Koniak‐Griffin 1992; Lam‐Cassettari 2015; Moran 2005; Moss 2011Platje 2018; Poslawsky 2015; Seifer 1991), and 17 measured it in the short term (Barlow 2016; Barone 2019; Benzies 2013; Bovenschen 2012; Green 2010; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Klein Velderman 2006; Koniak‐Griffin 1992; Lam‐Cassettari 2015; Negrão 2014; Platje 2018; Poslawsky 2015; Stein 2006; Van Zeijl 2006; Yagmur 2014). None of the studies measured it in the medium term, and just three studies measured it in the long term (Kalinauskiene 2009; Klein Velderman 2006; Moss 2011).
Parental reflective functioning
No study measured this outcome.
Attachment security
Four studies measured child attachment security (Kalinauskiene 2009; Klein Velderman 2006; Moran 2005; Moss 2011), and all but one study, Klein Velderman 2006, measured this outcome postintervention. Klein Velderman 2006 assessed attachment security in both the short and long term.
Three studies, Klein Velderman 2006, Moran 2005 and Moss 2011, used the Strange Situation Procedure (Ainsworth 1978) to measure attachment security, and two studies, Kalinauskiene 2009 and Klein Velderman 2006, used the Attachment Q‐sort (Waters 1985; Waters 1987).
Adverse effects
Parental stress
Eight studies measured parental stress (Barlow 2016; Benzies 2013; Hodes 2017; Kalinauskiene 2009; Klein Velderman 2006; Negrão 2014; Platje 2018; Poslawsky 2015). Four studies measured the outcome postintervention (Hodes 2017; Kalinauskiene 2009; Platje 2018; Poslawsky 2015). Six studies measured this outcome in the short term (Barlow 2016; Benzies 2013; Klein Velderman 2006; Negrão 2014; Platje 2018; Poslawsky 2015). One study measured this outcome at an unspecified follow‐up time point (Hodes 2017).
Two studies, Barlow 2016 and Benzies 2013, used a version of the Parenting Stress Index (full or short form; Abidin 1995; Terry 1991). Three studies, Kalinauskiene 2009, Negrão 2014 and Poslawsky 2015, used the Parenting Daily Hassles or Daily Hassles Questionnaire (Crnic and Greenberg 1990; Kanner 1981). One study, Klein Velderman 2006, used the Support and Stress Questionnaire (Van den Boom 1988). Two studies, Platje 2018 and Hodes 2017, used the Nijmeegse Ouderlijke Stress Index ‐ Dutch version of the Parenting Stress Index (Abidin 1983; De Brock 1992).
Parental anxiety
Only two studies measured parental anxiety. Barlow 2016 measured parental anxiety in the short term using the Hospital Anxiety and Depresssion Scale (Zigmond 1983); and Hoffenkamp 2015 measured parental anxiety in the short and medium term using the State‐Trait Anxiety Inventory (Spielberger 1983).
Child mental health
One study, Green 2010, measured child mental health in the long term, using the Development and Well‐being Assessment (Goodman 2011).
Child physical and socioemotional development
Seifer 1991 measured child psychomotor development at postintervention using the Uzgiris and Hunt Ordinal Scales of Development (Uzgiris 1975); all seven subscales were measured individually.
Five studies measured aspects of children's socioemotional development (Green 2010; Green 2015; Høivik 2015; Poslawsky 2015; Seifer 1991). Høivik 2015 measured this immediately postintervention and in the medium term using the Ages and Stages Questionnaire (Squires 2002). Poslawsky 2015 measured it at both postintervention and in the short term using the Early Social Communication Scales (Mundy 2003). Green 2010 assessed this in the short term using the Vineland Adaptive Behaviour Scales (VABS; Sparrow 2005), and in the long term using the Strengths and Difficulties Questionnaire (Goodman 1997). Green 2015 used the VABS to measure this outcome in the short and long term (Sparrow 2005). Seifer 1991 measured child mental development using the Bayley Scales of Infant Development at postintervention (Bayley 1969).
Child behaviour
Five studies measured child behaviour at different time points, using various versions of the Child Behaviour Checklist (CBCL; Achenbach 1992; Achenbach 2000). Moss 2011 and Barone 2019 measured children's behaviour postintervention; and Van Zeijl 2006 and Barone 2019 did so in the short term. Two studies measured it in the long term (Kalinauskiene 2009; Klein Velderman 2006).
Three studies reported externalising behaviour, which is a domain of child behaviour (Barone 2019; Moss 2011; Van Zeijl 2006), using the CBCL (Achenbach 2000). Two studies reported it at postintervention (Barone 2019; Moss 2011), and two reported it at short‐term follow‐up (Barone 2019; Van Zeijl 2006). No study measured it at long‐term follow‐up.
Costs
None of the studies reported data on costs.
Funding sources
These are listed in the Characteristics of included studies tables. Almost all studies reported some sort of external funding, from a charitable organisation (n = 7) and/or public body (n = 18). No studies reported commercial funding.
Excluded studies
We formally excluded 37 completed studies, consisting of 47 reports, and one ongoing study, details of which can be found in the Characteristics of excluded studies tables.
We excluded completed studies for the following reasons: intervention had no video‐feedback component (4 studies); intervention contained multiple sessions of non‐video‐feedback intervention activities (14 studies); used video feedback as part of a multicomponent intervention (6 studies); study did not measure parental sensitivity, child attachment or reflective functioning outcomes (4 studies); study was not an RCT or quasi RCT (4 studies); caregivers did not match this review's inclusion criteria (3 studies); study was a comparison between two active interventions rather than an intervention and inactive alternative intervention (2 studies).
We excluded one ongoing study because it does not measure parental sensitivity, child attachment or reflective functioning outcomes.
Ongoing studies
We identified five ongoing studies, described in further detail here: Characteristics of ongoing studies. All five studies are RCTs. Three of the studies include parent‐child dyads (Firk 2015; ISRCTN92360616; NCT03052374), one study includes parents and twins (Euser 2016), and one includes foster parents and foster children (Schoemaker 2018). Two studies are being conducted in the Netherlands (Euser 2016; Schoemaker 2018), one study in Germany (Firk 2015), one in Ireland (ISRCTN92360616), and one in Canada (NCT03397719).
Three of the studies include a component of video feedback (Firk 2015; ISRCTN92360616; NCT03052374), and two include an adaptation of VIPP (Positve Parenting and Sensitive Discipline in twin families (VIPP‐twin; Euser 2016); Positive Parenting for Foster Care (VIPP‐FC; Schoemaker 2018)). Three studies used standard care as their control intervention (Firk 2015; ISRCTN92360616; NCT03052374), and two studies used phone calls as their control intervention (Euser 2016; Schoemaker 2018).
Of these studies, two were funded through public sector funding sources (Euser 2016; Firk 2015); two were funded through charitable sources (ISRCTN92360616; Schoemaker 2018), and one did not declare a source of funding (NCT03052374).
Studies awaiting classification
There was one report that we could not obtain in full (Mendelsohn 2008), despite a request to the first author (Smith 2018i [pers comm]). This is listed under Characteristics of studies awaiting classification.
Risk of bias in included studies
We present the 'Risk of bias' tables for each included study beneath the Characteristics of included studies tables. Figure 2 summarises the 'Risk of bias' assessments across all outcomes, and Figure 3 summarises these assessments across all included studies.
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
Allocation
Random sequence generation
We assessed the risk of selection bias from randomisation to be low in 16 studies (Barlow 2016; Barone 2019; Benzies 2013; Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Lam‐Cassettari 2015; Moss 2011; Negrão 2014; Platje 2018; Poslawsky 2015; Stein 2006; Van Zeijl 2006; Yagmur 2014). We assessed two studies as having a high risk of selection bias from poor randomisation (Bovenschen 2012; Seifer 1991); for instance due to randomisation based on the day of the week. Four studies stated that participants were randomised, but did not state how this was carried out (Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Moran 2005), so we assessed them as at unclear risk of bias.
Allocation concealment
We assessed the risk of selection bias to be low in six included studies across allocation concealment (Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Poslawsky 2015; Stein 2006). We assessed 13 studies as having an unclear risk of allocation bias, as they did not give sufficient information on how allocation took place (Barlow 2016; Barone 2019; Benzies 2013; Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Lam‐Cassettari 2015; Moran 2005; Moss 2011Negrão 2014; Platje 2018; Van Zeijl 2006; Yagmur 2014). We rated three studies at high risk of selection bias: Bovenschen 2012, as the study authors stated that some participants only agreed to take part if they were allocated to a specific arm of the study; Høivik 2015 due to the use of consecutive randomisation; and Seifer 1991 as allocation was based on presentation on a certain day of the week.
Blinding
Given the nature of the intervention, we judged it impossible to truly blind any of the participants, so we rated all studies at high risk of performance bias. Two studies did attempt to address this issue by giving participants limited information about the purpose of the study (Benzies 2013; Moran 2005); however, in our judgement, this was not sufficient to blind participants.
We judged detection bias relating to outcomes that were relevant to this review only. We rated each outcome separately. The results are presented below.
Primary outcomes
Parental sensitivity
All 22 included studies measured this outcome or proxy domain. All except two studies, Moran 2005 and Van Zeijl 2006, were able to adequately blind the outcome assessor(s), so we rated them at low risk of detection bias. As Moran 2005 and Van Zeijl 2006 did not describe the blinding in sufficient detail, we rated them as having an unclear risk of detection bias.
Parental reflective functioning
None of the included studies measured this outcome.
Attachment security
Four studies measured this outcome (Kalinauskiene 2009; Klein Velderman 2006; Moran 2005; Moss 2011). We rated one study, Moran 2005 at unclear risk of detection bias, and the other three studies at low risk of detection bias, as they blinded assessors.
Adverse effects
We examined parental stress and parental anxiety. Eight studies reported parental stress (Barlow 2016; Benzies 2013; Hodes 2017; Kalinauskiene 2009; Klein Velderman 2006; Negrão 2014; Platje 2018; Poslawsky 2015). All of these studies used self‐report scales, so we rated all at high risk of detection bias.
Two studies reported parental anxiety (Barlow 2016; Hoffenkamp 2015). Again, both of these studies used self‐report scales, so we rated them at high risk of detection bias.
Secondary outcomes
Child mental health
A single study measured child mental health (Green 2010). They used the Development and Well‐Being Assessment (DAWBA), which uses a parental assessment of their children. Consequently, we rated it at high risk of detection bias.
Child physical and socioemotional development
Four studies measured children's socioemotional development (Green 2010; Høivik 2015; Poslawsky 2015; Seifer 1991). Green 2010 and Høivik 2015 used scales based on parental assessments of their children, so we rated these studies at high risk of detection bias. Poslawsky 2015 and Seifer 1991 used blinded raters so we rated these studies at low risk of detection bias.
Child behaviour
Five studies measured child behaviour (Barone 2019; Kalinauskiene 2009; Klein Velderman 2006; Moss 2011; Van Zeijl 2006). All of these studies used scales based on parental ratings of their child's behaviour, so we rated all as being at high risk of detection bias.
Incomplete outcome data
Of the 22 included studies, we assessed 14 as being at low risk of attrition bias, due to either appropriate methods of imputation by the study authors, very low or no attrition, or attrition that was balanced across all arms of the study (Barlow 2016; Barone 2019; Benzies 2013; Green 2010; Green 2015; Hoffenkamp 2015; Kalinauskiene 2009; Klein Velderman 2006; Lam‐Cassettari 2015; Moran 2005; Negrão 2014; Poslawsky 2015; Stein 2006; Van Zeijl 2006); four as unclear risk of attrition bias because there was unclear reporting of number of, or reason for, dropouts (Bovenschen 2012; Hodes 2017; Koniak‐Griffin 1992; Seifer 1991); and four as high risk of attrition bias due to unequal attrition across arms that could have been for reasons related to the intervention (Høivik 2015; Moss 2011; Platje 2018; Yagmur 2014).
Selective reporting
The majority of studies did not have protocols, making it difficult to judge whether there was reporting bias. We judged 16 studies as having an unclear risk of reporting bias because they appeared to report all outcomes in their Methods section but did not have a protocol available (Barlow 2016; Barone 2019; Benzies 2013; Bovenschen 2012; Høivik 2015; Kalinauskiene 2009; Klein Velderman 2006; Koniak‐Griffin 1992; Lam‐Cassettari 2015; Moran 2005; Moss 2011; Negrão 2014; Poslawsky 2015; Seifer 1991; Van Zeijl 2006; Yagmur 2014). We rated six studies at low risk of reporting bias because they reported all prespecified outcomes from their published protocols (Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Platje 2018; Stein 2006).
For parental sensitivity, we compared published results with unpublished results, to test for publication bias in the three studies where this was possible (Barone 2019; Hoffenkamp 2015; Klein Velderman 2006). There was no evidence of a difference between the two groups of studies.
For parental stress, we compared published results with unpublished results, to test for publication bias in two studies (Klein Velderman 2006; Negrão 2014). We found no difference; neither group showed evidence of a difference between intervention and control groups.
Other potential sources of bias
We rated Moran 2005 at high risk of other bias as they did not report the maternal sensitivity outcome data completely (data were missing SDs or SEs).
Effects of interventions
We summarise the results of our meta‐analyses below. We also report the results from single studies that we did not combine in a meta‐analysis because: not enough studies reported that outcome; data were missing and we were unable to obtain them from the study authors; the outcome was measured at a different time point to other studies reporting that outcome, or the study measured the outcome at multiple similar time points, meaning that we selected a single time point for the meta‐analysis. In addition, we present the results of a moderator analysis for the outcome parental sensitivity; we decided post hoc to undertake this analysis (see Differences between protocol and review).
We have organised results for the main comparison under headings corresponding to the primary and secondary outcomes outlined in the Types of outcome measures section.
Numbers given are the total number of participants randomised. Where it has been possible to calculate an effect size, we have reported this with 95% CI. Where the calculated effect size had a P value less than 0.05, we have stated whether or not the result favours the intervention group.
summary of findings Table for the main comparison summarises the main results of our meta‐analyses.
Video feedback versus no intervention or inactive alternative intervention
Primary outcomes
Parental sensitivity
Using a random‐effects model, we conducted a meta‐analysis of data from 20 studies (1757 parent‐child dyads) that measured the effects of video‐feedback on parental sensitivity from postintervention to six months' follow‐up (Barlow 2016; Barone 2019; Benzies 2013; Bovenschen 2012; Green 2010; Green 2015; Hodes 2017; Hoffenkamp 2015; Høivik 2015; Kalinauskiene 2009; Klein Velderman 2006; Lam‐Cassettari 2015; Moss 2011; Negrão 2014; Platje 2018; Poslawsky 2015; Seifer 1991; Stein 2006; Van Zeijl 2006; Yagmur 2014). We have presented data for mothers and fathers from Hoffenkamp 2015 separately as this is how the data were provided to us by the study authors. We have presented data for Benzies 2013 and Klein Velderman 2006 with two treatment groups, as these were three‐armed studies where both treatment groups in the study met our inclusion criteria. Details of how we managed unit of analysis issues are described in Unit of analysis issues.
The results suggest evidence favouring video feedback compared with the control group (SMD 0.34, 95% CI 0.20 to 0.49, Analysis 1.1). There was evidence of moderate heterogeneity, meaning that the observed variation is likely to be due to statistical heterogeneity (Tau2 = 0.07; Chi2 = 49.21, df = 22 (P = 0.0008); I2 = 55%). The GRADE certainty rating for this meta‐analysis was moderate; we downgraded due to inconsistency (moderate heterogeneity that was not explained by the subgroup analyses).
We drew a funnel plot (estimating differences in treatment effects against their SE) for the outcome 'parental sensitivity' as this was the only outcome with 10 or more studies that provided data. Figure 4 shows no major asymmetry for this comparison when all studies were included. We ran Egger's regression test for assessing funnel plot asymmetry; there was no evidence for funnel plot asymmetry (P = 0.281). However, when we removed Green 2010, Egger's regression test provided evidence for funnel plot asymmetry (P value = 0.022). The appearance of the funnel plot suggests that the asymmetry might be due to small study effects.
Funnel plot of comparison: 1. Primary outcomes, outcome: 1.1 parental sensitivity (postintervention ‐ 6 months)
Single study results (follow‐up only)
It should be noted that we included postintervention data from all of the following studies in the meta‐analysis for parental sensitivity, except Koniak‐Griffin 1992 and Moran 2005. The following data represent results for later follow‐up time points from these studies, and the single study results are all for later time periods.
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Barone 2019 measured maternal sensitivity at six months' follow‐up. The six‐month results were not reported in the study, but the study authors provided us with unpublished means, number of participants (n) and SDs (intervention group: mean = 25.88, SD = 2.8, n = 42; control group: mean = 22.13, SD = 4.13, n = 37). We used these to calculate an SMD of 1.07 (95% CI 0.59 to 1.54), suggesting evidence of a difference between groups.
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Bovenschen 2012 reported no evidence of an effect of the intervention at three months' follow‐up. The study authors provided the following unpublished data to us: intervention group: mean = 2.91, SD = 1.89, n = 17; control group: mean = 2.36, SD = 1.36, n = 19). A P value is not reported for this comparison; we used the data reported to calculate an SMD of 0.33 (95% CI −0.33 to 0.99), suggesting no evidence of a difference between groups.
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Green 2010 reported the impact on maternal sensitivity 5.75 years after the end of the trial. At 5.75 years there was not strong evidence of a difference between the groups (video‐feedback group: mean = 44.4%, SD = 16.1%, n = 59; comparator group: mean = 43.1%, SD = 15.7%, n = 62; log OR of parent synchrony in video‐feedback group versus comparator group: 0.02 (bootstrap 95% CI −0.30 to 0.36)).
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Hodes 2017 reported the impact on maternal sensitivity at three months' follow‐up. At three months' follow‐up there was not strong evidence of a difference between the groups (video‐feedback group: mean = 4.80, SD = 0.63, n = 43; comparator group: mean = 4.84, SD = 0.71, n = 42; repeated measures analysis of variance (ANOVA): F (2, 166) = 0.49, P = 0.61).
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Hoffenkamp 2015 reported medium‐term (six months) outcomes for fathers and mothers. At six months' follow‐up there was no evidence of a difference between the two groups (mothers: MD = 0.29, SD = 0.22, P = 0.19; fathers: MD = 0.12, SD = 0.23, P = 0.60). We did not include six‐month follow‐up outcomes in the meta‐analysis as this would have meant two time points from a single trial in the same meta‐analysis.
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Koniak‐Griffin 1992 measured maternal sensitivity as part of the NCATS (Nursing Child Assessment Teaching Scale) assessment. We were unable to obtain a breakdown of the data from the study authors, and so could not include them in the meta‐analysis.
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Lam‐Cassettari 2015 reported results at three months' follow‐up, but by this time participants in the waiting‐list control group had received the intervention, so the comparison does not fit with the review question.
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Moran 2005 measured maternal sensitivity at postintervention and at 12 months' follow‐up and reported that, "none of the t‐tests comparing the Intervention and Comparison group means at each age were significant". The data were not reported and the study author was unable to provide them when requested.
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Platje 2018 reported parental sensitivity at three months' follow‐up. The study authors found no strong evidence of a difference between groups with regards to parental sensitivity at three months postintervention (video‐feedback group: mean = 16.39, SD = 1.96, n = 37; comparator group: mean = 16.42, SD = 2.33, n = 40). Repeated measures ANOVA showed no evidence of an interaction between time and condition (Time × Condition interaction F (1, 75) = 0.13, P = 0.715).
Parental reflective functioning
None of our included studies measured or reported data on this outcome.
Attachment security
As described in Measures of treatment effect, we combined data from studies that measured OR separately to those that measured means.
Two studies (Moran 2005; Moss 2011; 166 parent‐child dyads) measured this outcome using the Strange Situation Procedure (Ainsworth 1974), at postintervention. The pooled analysis of these studies using OR under a random‐effects assumption resulted in evidence favouring the intervention (OR 3.04, 95% CI 1.39 to 6.67, Analysis 1.2). We did not assess heterogeneity due to the small number of studies included in this meta‐analysis. We rated the certainty of this evidence as very low using GRADE, due to risk of bias (we rated most domains in the 'Risk of bias' assessment at high or uncertain risk of bias), imprecision (low number of participants, leading to wide CI) and publication bias (few studies in this review reported this outcome).
Two other studies (Kalinauskiene 2009; Klein Velderman 2006; 131 parent‐child dyads) measured this outcome using the Attachment Q‐sort, with scores ranging from +1.00 for the perfectly secure child to −1.00 for the most insecure child (Waters 1985; Waters 1987). The time points of the data combined were quite different (one study reported data at postintervention and the other study at 12 months postintervention). The pooled analysis of these studies using SMD under a random‐effects assumption found no evidence of a difference between intervention and control groups (SMD 0.02, 95% CI −0.33 to 0.38, Analysis 1.3). We did not assess heterogeneity due to the small number of studies included in this meta‐analysis. We rated the certainty of this evidence as very low using GRADE: we downgraded one level for risk of bias (we rated most domains in the 'Risk of bias' assessment at high or uncertain risk of bias); one level due to imprecision (low number of participants, leading to wide CI); and one level due to publication bias (few studies in this review report this outcome).
Single study results
One study, Klein Velderman 2006, did not report data in a way that we could use in the meta‐analysis. The study found that there was no evidence that attachment security was different between the intervention and control group in the short term (VIPP group compared to control group: d = 0.33, P = 0.11 (one‐tailed), n = 55; VIPP‐R group compared to control group: d = 0.12, P = 0.33 (one‐tailed), n = 53).
Adverse effects
Parental stress
We pooled data from eight studies (537 parent‐child dyads) reporting data at postintervention or short‐term follow‐up (Barlow 2016; Benzies 2013; Hodes 2017; Kalinauskiene 2009; Klein Velderman 2006; Negrão 2014; Platje 2018; Poslawsky 2015). A random‐effects meta‐analysis did not show any strong evidence of a difference between intervention and control groups (SMD −0.09, 95% CI −0.26 to 0.09, Analysis 1.4). Heterogeneity was low (Tau2 = 0.00; Chi2 = 6.36, df = 8 (P = 0.61); I2 = 0%). We rated the certainty of this evidence as low using GRADE. We downgraded one level for risk of bias (we rated most domains in the 'Risk of bias' assessment at high or uncertain risk of bias) and one level due to imprecision (low number of participants, leading to wide CI).
Single study results: three studies reported the impact of video feedback on parental stress in ways that we could not include in the meta‐analysis (Hodes 2017; Platje 2018; Poslawsky 2015).
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Hodes 2017 measured the impact of video‐feedback at an unspecified follow‐up time point, reporting no evidence of a difference between intervention and control groups on a repeated measures multivariate ANOVA (MANOVA) (video‐feedback group: mean = 70.4, SD = 24.87, n= 43; comparator group: mean = 72.14, SD = 24.75, n = 42; F (1.57, 130, 6) = 4.39, P = 0.02). We did not include these data in the meta‐analysis as we used data provided by the same study at postintervention.
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Platje 2018 reported the impact on parents' stress levels at postintervention and six months' follow‐up. The postintervention data are included in the meta‐analysis. The study found no evidence of a difference between intervention and control groups at six months' follow‐up using a repeated measures ANOVA (video‐feedback group: mean = 2.36, SD = 0.94, n = 37; control group: mean = 2.58, SD = 0.90, n = 40; F (1, 75) = 3.52, P = 0.07, η2 = 0.05).
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Poslawsky 2015 measured parental stress at three months, but did not report it and were not able to provide the data when requested.
Parental anxiety
We combined data from two studies (311 parent‐child dyads), measured at short‐term follow‐up, using a random‐effects model (Barlow 2016; Hoffenkamp 2015). Data for mothers and fathers in Hoffenkamp 2015 are included separately, as this is how the data were provided to us. The meta‐analysis found no strong evidence of a difference between the intervention group and the control group (SMD −0.28, 95% −0.87 to 0.31, Analysis 1.5). We did not assess heterogeneity due to the small number of studies included in this meta‐analysis. We rated the evidence as very low certainty using GRADE. We downgraded one level due to imprecision (low number of participants, leading to wide CI), one level due to publication bias (few studies in this review reported this outcome) and one level due to inconsistency (high heterogeneity).
Secondary outcomes
Child mental health
Only one study, Green 2010, measured the rate of child mental illness at long‐term follow‐up, and found no strong evidence of a difference between intervention and control group (log odds of depression in video‐feedback group (n = 50) versus comparator group (n = 44): 0.07 (bootstrap CI −0.85 to 1.03); log odds of conduct/oppositional disorder in video‐feedback group (n = 50) versus comparator group (n = 44): −0.13 (bootstrap CI −1.08 to 0.72); log odds of hyperkinesis in video‐feedback group (n = 50) versus comparator group (n = 44): 0.11 (bootstrap CI −0.70 to 0.93); log odds of anxiety/OCD in video‐feedback group (n = 50) versus comparator group (n = 46): 0.51 (bootstrap CI −0.33 to 1.51).
Child physical and socioemotional development
Four studies measured elements of child socioemotional development in ways that were too clinically different for meta‐analysis to be appropriate (Green 2010; Høivik 2015; Poslawsky 2015; Seifer 1991).
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Green 2010 found no strong evidence of a difference between intervention and control groups with regards to prosocial behaviour (log odds of prosocial behavior in video‐feedback group (n = 59) versus control group (n = 62): 0.73 (bootstrap 95% CI −0.08 to 1.64) or peer problems (log odds of peer problems in video‐feedback group (n = 59) versus control group (n = 61): 0.64 (bootstrap 95% CI −0.21 to 1.62)).
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Høivik 2015 reported no strong evidence of a difference postintervention between intervention and control groups with regards to their score on the socioemotional element of the Ages and Stages Questionnaire (video‐feedback group: mean = 26.21, SD = 19.61, n = 37; comparator group: mean = 25.74, SD = 17.02, n = 27; P = 0.17). At six months postintervention there was evidence that the intervention group had fewer concerns regarding their child's socioemotional development than the control group (video‐feedback group: mean = 20.44, SD = 13.45, n = 22; comparator group: mean = 25, SD = 16.53, n = 27; P = 0.02).
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Poslawsky 2015, after controlling for school attendance, reported evidence that the video‐feedback group (n = 38) had better scores than the comparator group (n = 34) on measures of initiating joint attention (f = 2.35, df = 8, P = 0.03, ƞ2 = i) but not reciprocating joint attention.
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Seifer 1991 measured child mental development (measured by Bayley Scales of Infant Development) and child psychomotor development (measured by the Uzgiris and Hunt Ordinal Scales of Development ‐ the study authors report measuring all seven subscales individually) at postintervention. However, they did not report these data did not respond to our request for the data (Smith 2019b [pers comm]).
Child behaviour
We pooled data from two studies (119 parent‐child dyads) looking at child behaviour in the long term (Kalinauskiene 2009; Klein Velderman 2006). A random‐effects meta‐analysis found no strong evidence of a difference between intervention and control groups (SMD 0.04, 95% CI −0.33 to 0.42, Analysis 1.6). We did not assess heterogeneity due to the small number of studies included in this meta‐analysis. The GRADE certainty rating was very low: we downgraded one level for risk of bias (we rated most domains in the 'Risk of bias' assessment at high or uncertain risk of bias); one level due to imprecision (low number of participants, leading to wide CI) and one level due to publication bias (few studies in this review reported this outcome).
Single study results
Three studies measured aspects of child behaviour that we could not include in a meta‐analysis: one study reported the data at a different time point to other studies reporting this outcome (Barone 2019); and the other studies reported elements of child behaviour at two very different time points (Moss 2011; Van Zeijl 2006).
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Barone 2019 measured child behaviour at postintervention and six months' follow‐up. They reported results for externalising behaviour in their published report. The study authors reported that there was no evidence of an effect of the intervention at either time point for any of the outcomes measured, although they did not report a P value. The data reported at postintervention were as follows: video‐feedback group: mean = 16.6, SD = 9.5, n = 44; control group: mean = 14.2, SD = 10.4, n = 39. We used these data to calculate an SMD of 0.24 (95% CI −0.19 to 0.67). The data they reported at six months' follow‐up were as follows: video‐feedback group: mean = 16.1, SD = 10.9, n = 44; control group: mean = 12.7, SD = 10.6, n = 39. We used these data to calculate an SMD of 0.31 (95% CI −0.12 to 0.75). There is no evidence of an effect at either time point.
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Moss 2011 reported no strong evidence of a difference between intervention and control groups at postintervention for internalising behaviour (video‐feedback group: mean = 54.43, SD = 7.44, n = 35; comparator group: mean = 55.56, SD =11.45, n = 32) or externalising behaviour (video‐feedback group: mean = 57.85, SD = 9.84, n = 35; comparator group: mean = 57.54, SD = 12.61, n = 32). P values were not reported by the review authors. We used the data reported to calculate an SMD for internalising behaviour of −0.12 (95% CI −0.60 to 0.36), showing no evidence of a difference between groups. For externalising behaviour, we calculated an SMD of 0.03 (95% CI −0.45 to 0.51), again showing no evidence of a difference between groups.
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Van Zeijl 2006 reported no strong evidence of a difference between intervention and control groups for externalising behaviour at long‐term follow‐up (video‐feedback group: mean = 21.55, SD = 9.08, n = 83; comparator group: mean = 21.36, SD 8.62, n = 74). P values were not reported. We used the data reported to calculate an SMD of 0.02 (95% CI −0.29 to 0.33), demonstrating no evidence of a difference between groups.
Moderator analysis for parental sensitivity
Moderator analysis
Appendix 3 reports the overall effects by individual moderator. Three studies contained in this moderator analysis have two separate intervention groups (Benzies 2013; Hoffenkamp 2015; Klein Velderman 2006), meaning that for this part of the analysis, k (number of studies) = 23 studies, rather than 20 studies. Adding these as individual studies potentially biases the test statistic, as these intervention groups are not statistically independent. The usual solution to this problem is to conduct a multilevel meta‐analysis; however, the small number of related studies makes this unviable.
Notably, all subgroups except 'more than 10 sessions of video feedback' and studies with ‘only fathers’ and 'both parents' show evidence of an overall treatment effect, measured as SMDs (d). Substantively, the disability subgroup had the largest effect size (d = 0.49**, 95% CI 0.16 to 0.82). This suggests that some moderator effects may exist for some study characteristics when considered individually. For all moderators, heterogeneity is I2 greater than 50%, with evidence of residual heterogeneity (QE).
Figure 5 reports the results from the meta‐regression with all three prespecified moderators for k = 23 studies. There is no evidence that jointly the type of intervention, intervention duration, or gender of the participating carer reduce heterogeneity (Qbetween (F(df1moderators = 7, df2studies = 17) = 1.008, P = 0.4429; R2< 0.01%)), and substantial between‐study heterogeneity still exists (QE (df = 17) = 39.77, P = 0.014; though I2 = 55.6%, see Appendix 4). In addition, none of the three moderators in the meta‐regression are statistically significant (at α (alpha) = 0.05). Parent gender (both parents versus only mothers or only fathers) potentially has a statistically significant negative moderation effect, though only at α = 0.1. This suggests that, when we consider the three prespecified moderators simultaneously rather than as individual subgroups, no moderation effect exists for any specific study characteristics. In other words, we are not able to say that any particular characteristic accounts for the between‐study heterogeneity when controlling for other characteristics. Figure 5 reports the predicted study effect sizes controlling for the moderator variables. As the grey‐shaded polygons indicate, no consistent and strong moderation can be observed.
Observed versus predicted intervention effects following moderator analysis
Sensitivity analyses
Reanalysis excluding studies at high or unclear risk of bias
Only two meta‐analyses included data from more than two studies (Analysis 2.1; Analysis 1.4). For these analyses, we explored the effects of excluding studies at a high risk of bias.
Parental sensitivity
For Analysis 2.1, we first considered the effect of excluding four studies classed at high risk of attrition bias (Høivik 2015; Moss 2011; Platje 2018; Yagmur 2014). This had no effect on the results, which continued to show evidence of a difference between groups (16 studies, 1414 dyads; SMD 0.35, 95% CI 0.17 to 0.53). When we removed the two studies at high risk of selection bias (Bovenschen 2012; Seifer 1991), the analysis continued to show evidence of a difference between groups (14 studies, 1338 dyads; SMD 0.32, 95% CI 0.13 to 0.51). When we further removed the two remaining studies at unclear risk of selection bias (Kalinauskiene 2009; Klein Velderman 2006), the analysis still also showed evidence of a difference between groups (12 studies, 1203 dyads; SMD 0.27, 95% CI 0.06 to 0.48).
Adverse effects: parental stress
For Analysis 1.4, we considered the effect of excluding the two studies at high or unclear risk of attrition bias (Hodes 2017; Platje 2018). This had no effect on the analysis, which continued to show no difference between groups (6 studies, 375 dyads; SMD −0.07, 95% CI −0.28 to 0.14). This remained the case when we additionally excluded the two studies (Kalinauskiene 2009; Klein Velderman 2006) at unclear risk of selection bias (4 studies, 240 dyads; SMD −0.09, 95% −0.35 to 0.17).
Reanalysis using different statistical approaches
In the preceding sections, we have presented the results from meta‐analyses conducted using a random‐effects model. We repeated all analyses using a fixed‐effect model. There was no difference in overall outcomes for any of the meta‐analyses other than Analysis 1.5. Under a random‐effects assumption, there was no strong evidence of a difference in parental anxiety between intervention and control groups (311 dyads; SMD −0.28, 95% CI −0.87 to 0.31, Analysis 1.5). Under a fixed‐effect assumption, there was evidence of a reduction in parental anxiety in the short term in the intervention group compared to the comparison group (311 dyads; SMD −0.25, 95% −0.47 to −0.02). The two studies pooled in this meta‐analysis, Barlow 2016 and Hoffenkamp 2015, are clinically very similar: both studies are with parents of preterm children, using three sessions of VIG. This might explain why the fixed‐effect model produces some evidence of an effect; however, given the very high heterogeneity (82%), we chose to present the results of the random‐effects model.
Discusión
Resumen de los resultados principales
Veintidós estudios que reclutaron 1889 díadas padre‐hijo o unidades familiares cumplieron los criterios de inclusión para esta revisión. Los padres que participaron en los estudios presentaban varios problemas que podrían impedir su capacidad de responder de una manera sensible a las señales y necesidades de sus hijos y que, por lo tanto, también podrían socavar la capacidad de sus hijos para formar relaciones de apego seguras. La evidencia indica que la retroalimentación con vídeos puede ayudar a promover la sensibilidad de los padres (evidencia de certeza moderada). Un tamaño del efecto de 0,34 significa que si 10 000 padres recibieran una intervención de retroalimentación con vídeos, alrededor de 1100 de ellos se beneficiarían (Magnusson 2014). Además, aunque el sistema estándar de calificación de tales tamaños de efecto indica que este hallazgo es pequeño (Higgins 2017), es altamente favorable en comparación con el de otras intervenciones de crianza como los programas de visitas domiciliarias, que muestran evidencia de un tamaño del efecto general mucho más pequeño (véase, por ejemplo, Michalopoulos 2019).
En la actualidad solo existe evidencia escasa y de certeza muy baja con respecto al efecto de la retroalimentación con vídeos sobre la seguridad del apego, en comparación con el control: los resultados difirieron según el tipo de medida utilizada, y la duración del seguimiento fue limitada. No existe evidencia de una repercusión adversa sobre el estrés (evidencia de baja certeza) o la ansiedad de los padres (evidencia de muy baja certeza). Ningún estudio midió el funcionamiento reflexivo de los padres.
Tampoco hubo evidencia de un efecto moderador para las tres variables preespecificadas (tipo de intervención, número de sesiones de retroalimentación y cuidador participante) cuando se probaron de manera conjunta, aunque el sexo de los padres (ambos padres versus solo las madres o solo los padres) posiblemente tiene un efecto de moderación negativo estadísticamente significativo.
Compleción y aplicabilidad general de las pruebas
Se planificó evaluar la efectividad de la retroalimentación con vídeos para mejorar la sensibilidad de los padres y promover la seguridad del apego en niños menores de cinco años. En cuanto a la completitud, aunque algunos ECA no proporcionaron datos en una forma en la que fuera posible incorporarlos a un metanálisis (p.ej. Koniak‐Griffin 1992; Moran 2005), y los intentos de obtener dichos datos de los autores del estudio no siempre fueron exitosos, existe confianza en que se ha identificado toda la evidencia publicada disponible.
En cuanto a la aplicabilidad, se identificaron estudios dirigidos a padres y niños que presentan una serie de dificultades o problemas que los ponen en riesgo de una crianza deficiente (p.ej. depresión paterna; problemas de sensibilidad; discapacidad intelectual; apego inseguro; padres adolescentes primerizos o inmigrantes; recién nacidos prematuros; niños con autismo). Los estudios se realizaron en una variedad de países y con grupos étnicos muy diferentes, en uno de tres entornos: el domicilio, la comunidad, como un centro familiar, y los entornos de hospitalización, como los hospitales. También se incluyó una amplia variedad de intervenciones de retroalimentación con vídeos. La mayoría de los estudios incluyeron díadas madre‐hijo o díadas cuidador primario‐niño en las que el cuidador primario era la madre, mientras que en pocos estudios más del 10% de los participantes eran padres. Hubo algunos metanálisis (p.ej. para la conducta de los niños o la ansiedad de los padres) que contienen estudios principalmente con niños menores de un año de edad, lo que potencialmente limita su generalizabilidad.
Sin embargo, aunque los resultados de estos estudios no deberían, como tal, extenderse a los padres, para los que se necesitan más estudios de investigación, los hallazgos de la presente revisión con respecto a la sensibilidad de los padres parecen ser ampliamente aplicables y serán útiles para los elaboradores de políticas y para los profesionales sanitarios en varios contextos.
Calidad de la evidencia
Mediante los criterios GRADE la certeza general del conjunto de evidencia se calificó entre moderada y muy baja (véase Resumen de los hallazgos, tabla 1). La calidad no se disminuyó en más de un nivel para cualquiera de los resultados en los cinco dominios.
Limitaciones en el diseño y la implementación del estudio
La certeza de dos resultados se redujo debido a las limitaciones en el diseño y la realización del estudio (seguridad del apego en la posintervención y estrés de los padres en la posintervención o el seguimiento a corto plazo), y para un resultado (conducta infantil) debido al riesgo de sesgo.
Falta de direccionalidad de la evidencia
La certeza para cualquiera de los resultados no se disminuyó debido a la falta de direccionalidad de la evidencia.
Heterogeneidad inexplicable o inconsistencia de los resultados
La certeza se redujo en dos niveles para dos resultados debido a la heterogeneidad: la sensibilidad de los padres en la posintervención o el seguimiento a corto plazo debido a la heterogeneidad moderada no explicada, y la ansiedad de los padres en el seguimiento a corto plazo debido a la alta heterogeneidad.
Imprecisión de los resultados
Excepto la sensibilidad de los padres en la posintervención o el seguimiento a corto plazo, la certeza de todos los resultados se redujo debido a imprecisión (intervalos de confianza amplios).
Sesgo de publicación
Excepto la sensibilidad de los padres en la posintervención o el seguimiento a corto plazo y el estrés de los padres en la posintervención o el seguimiento a corto plazo, la certeza de todos los resultados se redujo debido al sesgo de publicación (la mayoría de los estudios en esta revisión no informaron estos resultados).
Sesgos potenciales en el proceso de revisión
El proceso de búsqueda y selección de la literatura se ajustó estrictamente a los criterios Cochrane, como se definió en la sección Métodos. Se realizaron búsquedas sistemáticas en un gran número de bases de datos de gran relevancia, incluidos los registros de ensayos, para identificar ensayos completos y en curso. Dos autores de la revisión seleccionaron de forma independiente los estudios potencialmente elegibles para su inclusión, extrajeron los datos, evaluaron el riesgo de sesgo de los estudios incluidos y calificaron la certeza de la evidencia. Por lo tanto, cualquier sesgo de los revisores fue muy limitado.
Para un pequeño número de estudios (Hodes 2017; Moss 2011; Poslawsky 2015), se utilizaron datos de resultados que incluyeron a niños de cinco años o más, ya que los autores del estudio no respondieron a la solicitud de información sobre los datos de resultados de los niños que estaban fuera del rango de edad, o no pudieron proporcionarlos. Se consideró que el número de niños de cinco años o más de esos estudios probablemente era muy pequeño, y los efectos beneficiosos de incluir los datos de los resultados superaron cualquier resultado negativo.
En cuanto a los conflictos de interés, se debe señalar que uno de los autores de la revisión (JB) fue el autor principal de uno de los estudios incluidos (Barlow 2016). Sin embargo, JB no participó en la selección, la extracción de los datos, la evaluación del riesgo de sesgo o las calificaciones GRADE para este estudio.
No se especificó previamente qué punto temporal se utilizaría si hubiera dos puntos temporales que se pudieran combinar en el mismo metanálisis. Se eligió el punto temporal más cercano al final de la intervención para mantener la consistencia; sin embargo, en varios de estos estudios hubo una disminución del efecto con el tiempo, por lo que es posible que se haya encontrado un resultado diferente si se hubieran elegido puntos temporales posteriores.
Se supuso que la falta de datos era aleatoria, pero puede haber sido una suposición incorrecta. El desgaste inexplicable fue bastante alto en algunos estudios, lo que también puede haber afectado la validez de algunos resultados.
Acuerdos y desacuerdos con otros estudios o revisiones
Se han realizado carias revisiones sobre los diferentes tipos de retroalimentación con vídeos. Cuando se publicó el protocolo para esta revisión (O'Hara 2016) solo se había realizado una revisión cuantitativa de la efectividad de la retroalimentación con vídeos: Fukkink 2008. Dicha revisión concluyó que la retroalimentación con vídeos fue efectiva para mejorar una variedad de resultados cuando se utilizó con padres de niños de hasta siete años de edad. Sin embargo, también tuvo varias limitaciones; la más importante fue probablemente que se incluyeron estudios no controlados y no se calificó la calidad de los estudios incluidos.
Desde la publicación de el protocolo de la presente revisión (O'Hara 2016) se han identificado otras revisiones sistemáticas sobre este tema. Balldin 2018 realizó una revisión sistemática de los ECA y los ensayos cuasialeatorizados de retroalimentación con vídeos; dicha revisión se centró en la descripción de los componentes de los programas de retroalimentación con vídeos y los resultados de los estudios individuales. Sin embargo, los autores no realizaron un metanálisis de los resultados y sus métodos afirman que solo buscaron en un pequeño número de bases de datos, junto con Google Scholar. Su lista de estudios incluidos difiere de la actual revisión, en gran medida porque incluyeron estudios que utilizaron la retroalimentación con vídeos junto con otras intervenciones que se excluyeron en la presente revisión. Concluyeron que la retroalimentación con vídeos parece ser efectiva para mejorar la sensibilidad de los padres, la conducta de los padres y la conducta de los niños, una conclusión más amplia que la de la presente revisión.
Van den Broek 2017 realizó una revisión sistemática de los estudios que examinaron los problemas que se deben tener en cuenta al proporcionar retroalimentación con vídeos a niños con discapacidad visual. Incluyeron una variedad más amplia de diseños de estudios que las de la presente revisión y no identificaron ECA ni ensayos cuasialeatorizados. También se realizaron búsquedas en un número menor de bases de datos que en la revisión actual. En sus conclusiones destacaron los temas y aspectos que es importante tener en cuenta a la hora de adaptar la retroalimentación con vídeos para los niños con discapacidad visual.
NICE 2016 recomendó que la retroalimentación con vídeos es una de las pocas intervenciones para las cuales existe evidencia de calidad baja sobre la eficacia con respecto a la mejora del apego materno para los niños que se encuentran en el límite de edad para la atención. Dicha recomendación se basó en la evidencia recopilada a través del propio proceso de búsqueda sistemática de la guía NICE correspondiente (NICE 2015). Los hallazgos de la presente revisión fueron más contradictorios, aunque la población de interés fue más amplia.
Finalmente, los autores de la VIPP publicaron recientemente un capítulo de un libro que resume los resultados de una revisión de 12 ECA de VIPP, donde informan un tamaño del efecto de 0,47 (IC del 95%: 0,34 a 0,60) para la sensibilidad (Juffer 2018). Incluyeron dos estudios que se excluyeron de esta revisión porque no tenían un grupo control apropiado o no estaban publicados, e informaron los datos de forma diferente. Por ejemplo, en la revisión actual se informa que Poslawsky 2015 no muestra evidencia de repercusión sobre los padres con riesgo de autismo, lo que es consistente con los hallazgos informados en el artículo original; Juffer 2018 presenta el subdominio de no intrusión de la Emotional Avaliability Scale, que muestra evidencia de efectividad, mientras que en la presente revisión se utiliza el subdominio de sensibilidad, que no muestra evidencia de efectividad. Sin embargo, desde el punto de vista cualitativo, los hallazgos de la presente revisión sobre la repercusión de una serie de tipos de retroalimentación con vídeos sobre la sensibilidad son similares.
Por lo tanto, en general sus resultados son consistentes con lo de otras revisiones.
95 Study flow diagram
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
Funnel plot of comparison: 1. Primary outcomes, outcome: 1.1 parental sensitivity (postintervention ‐ 6 months)
Observed versus predicted intervention effects following moderator analysis
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 1 Parental sensitivity (postintervention ‐ 6 months).
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 2 Attachment security, measured by Strange Situation Procedure (odds of being securely attached) (postintervention).
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 3 Attachment security, measured by Attachment Q‐sort (any duration of follow‐up).
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 4 Adverse events: parental stress (postintervention or short‐term follow‐up).
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 5 Adverse events: parental anxiety (short‐term follow‐up).
Comparison 1 Video feedback versus no intervention or inactive comparator, Outcome 6 Child behaviour (long‐term follow‐up).
| Video feedback versus no intervention or inactive alternative intervention for parental sensitivity and attachment | ||||||
| Patient or population: parent‐child dyads (including foster or adoptive carers), where the child was aged between birth and four years 11 months (inclusive), and where problems had been identified that were impacting or might impact on the parent's sensitivity | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | Number of participants | Certainty of the evidence (GRADE) | Comments | |
| Risk with no intervention or inactive alternative intervention | Risk with video feedback | |||||
| Parental sensitivity Follow‐up: postintervention or short‐term follow‐up | ‐ | The mean parental sensitivity score in the intervention group was 0.34 standard deviations higher (0.20 higher to 0.49 higher) | ‐ | 1757 dyads (20 RCTs) | ⊕⊕⊕⊝ | Higher scores indicate a better outcome. Effect size of 0.33 standard deviations compares favourably to other similar interventions. |
| Parental reflective functioning | ‐ | ‐ | ‐ | ‐ | ‐ | No study reported this outcome. |
| Attachment security Measured by: Strange Situation Procedure (odds of being securely attached) Follow‐up: postintervention | Study population | OR 3.04 | 166 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a better outcome. | |
| 341 per 1000 | 612 per 1000 | |||||
| Attachment security Measured by: Attachment Q‐sort Follow‐up: postintervention | The mean attachment security score across control groups ranged from 0.33 to 0.37 (scores can range from + 1.00 to −1.00) | The mean attachment security score in the intervention group was0.02 standard deviations higher (0.33 lower to 0.38 higher) | ‐ | 131 dyads | ⊕⊝⊝⊝ | Effect size of 0.02 standard deviations indicates no evidence of effectiveness. |
| Adverse events: parental stress Follow‐up: postintervention or short term | ‐ | The mean parental stress score in the intervention group was 0.09 standard deviations lower (0.26 lower to 0.09 higher) | ‐ | 537 dyads (8 RCTs) | ⊕⊕⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.09 standard deviations indicates no evidence of effectiveness. |
| Adverse events: parental anxiety Follow‐up: short term | ‐ | The mean parental anxiety score in the intervention group was0.28 standard deviations lower (0.87 lower to 0.31 higher) | ‐ | 311 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.28 compares favourably to other similar interventions. |
| Child behaviour Follow‐up: long term | ‐ | The mean child behaviour score in the intervention group was 0.04 standard deviations higher (0.33 lower to 0.42 higher) | ‐ | 119 dyads (2 RCTs) | ⊕⊝⊝⊝ | Higher scores indicate a worse outcome. Effect size of 0.04 standard deviations indicates no evidence of effectiveness. |
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| aDowngraded one level due to inconsistency: moderate heterogeneity, which was not explained by our subgroup analysis. | ||||||
| Issue | Method |
| Searching other resources | We will draft a list of included studies to send to experts in the field and ask them to forward to us any published, unpublished or ongoing work that we may have missed. |
| Measures of treatment effect | Continuous outcome data If necessary, we will compute effect estimates from P values, T statistics, analysis of variance (ANOVA) tables or other statistics, as appropriate. |
| Measures of treatment effect | Multiple outcomes When a study provides multiple, interchangeable measures of the same construct at the same point in time (e.g. multiple measures of maternal sensitivity), we will calculate the average SMD across these outcomes and the average of their estimated variances. This strategy aims to avoid the need to select a single measure and to avoid inflated precision in meta‐analyses (i.e. preventing studies that report on more outcome measures receiving more weight in the analysis than comparable studies that report on a single outcome measure). |
| Unit of analysis issue | Cluster‐RCTs In the event that we identify relevant cluster‐RCTs that meet the inclusion criteria of the review, we will deploy appropriate statistical methods based on the guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Where study authors have dealt appropriately with the clustered design in their analyses, we will try to obtain direct estimates of the effect (e.g. an OR with its CI). Where study authors have not dealt appropriately with the cluster design in their analyses, we will extract or calculate effect estimates and their SEs as for a parallel‐group trial, and adjust the SEs to account for the clustering (Donner 1980). To do this, we will need to identify an appropriate ICC, which describes the relative variability in outcome within and between clusters (Donner 1980). Where available, we will look for this information in the reports of relevant trials. If this is unavailable, we will try to obtain the information from the study authors. If this proves unsuccessful, we will use external estimates obtained from similar studies. We will find closest‐matching scenarios (regarding both outcome measures and types of clusters) from existing databases of ICCs. If we are unable to identify any matches, we will perform sensitivity analyses using a high ICC of 0.1, a moderate ICC of 0.01 and a small ICC or 0.001, to cover a broader range of plausible values while still allowing for strong design effects for smaller studies (see Sensitivity analysis). Furthermore, we will combine these estimates and their corrected SEs from the cluster‐RCTs with those from parallel designs using the generic inverse variance method in Review Manager 5 (Review Manager 2014). |
| Dealing with missing data | Data imputation Where it has not been possible to obtain any unreported data from authors of included studies, and there is reason to believe that it is not missing at random, we will follow the recommendations in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section16.1), and we will do the following:
|
| Meta‐regression We will assess the sensitivity of any primary meta‐analyses to missing data using meta‐regression to test for any effect of missingness on the summary estimates (Higgins 2011, Section 16.1.2). | |
| Data synthesis | In the occurrence of severe funnel plot asymmetry, we will present both fixed‐effect and random‐effects analyses under the assumption that asymmetry suggests that neither model is appropriate. If both indicate a presence (or absence) of effect we will be reassured; if they do not agree we will report this. |
| Subgroup analyses | We will investigate heterogeneity using subgroup analyses or meta‐regression, if appropriate. We will group the included studies and analyse them according to the intervention approach, including the following.
|
| Sensitivity analysis | We will assess the robustness of findings to decisions made in obtaining them by conducting sensitivity analyses. We will perform sensitivity analyses by conducting the following reanalysis.
|
| CI: confidence interval; ICC: intra‐class correlation coefficient; OR: odds ratio; RCT: randomised controlled trial; SD: standard deviation; SMD: standardised mean difference; VIG: Video Interaction Guidance; VIPP‐R: Video‐feedback to promote Positive Parenting ‐ Representational level; VIPP‐SD: Video‐feedback to promote Positive Parenting ‐ Sensitive Discipline | |
| Study | Date contact initiated | Reason for contacting study authors | Response received |
| 9 July 2019 (Smith 2019a [pers comm]) | The study data for maternal sensitivity were reported in the published paper as part of a composite measure. We requested maternal sensitivity subscore. We also requested study data for overall child behaviour, as the published report only contained externalising behaviour. | The study author provided the maternal sensitivity and child behaviour data for inclusion in the meta‐analysis (Barone 2019 [pers comm]). They excluded children aged 5 years and over from the data sent over, as the original study did include these children. | |
| 12 January 2018 (Smith 2018b [pers comm]) | The reported data were not labelled sufficiently clearly in the published paper to be used in the meta‐analysis. We requested clarification from the study authors. | The study author provided the necessary, additional study data, so they could be included in meta‐analysis (Bovenschen 2019 [pers comm]). | |
| 2 June 2017 (Smith 2017a [pers comm]) | We requested study data relating to parental stress outcomes, reanalysed for children within included age range. | We received no response. As a result, we did not subsequently request the study data on Harmonious Parent‐Child Interaction to be analysed for children within included age range. | |
| 16 January 2017 (O'Hara 2017a [pers comm]) | We requested missing study data relating to parental sensitivity outcomes. | The study author provided the missing data so they could be included in the meta‐analysis (Van Bakel 2017 [pers comm]). | |
| 8 February 2018 (Smith 2018c [pers comm]) | The study data for maternal sensitivity were reported in the published paper as part of a composite measure. We requested maternal sensitivity subscore. | The study author provided maternal sensitivity data for inclusion in the meta‐analysis (Hoivik 2018 [pers comm]). | |
| 21 February 2018 (Smith 2018g [pers comm]) | The outcomes data for maternal stress were not included in published studies. | The corresponding author provided us with the missing data for the purposes of meta‐analysis (Bakermans‐Kranenburg 2018 [pers comm]). | |
| 8 February 2018 (Smith 2018d [pers comm]) | The study data for maternal sensitivity were reported in the published paper as part of a composite measure. We requested maternal sensitivity subscore. | We received no response. | |
| 2 June 2017 (Smith 2017b [pers comm]) | The published study data for maternal sensitivity outcomes included children aged 5 years and over. We requested outcomes data with those children excluded. | The study author provided the data with those children aged 5 years and over excluded (Lam‐Cassettari 2018 [pers comm]). | |
| 1 February 2018 (Smith 2018i [pers comm] | We requested a copy of the conference abstract. | We received no response. | |
| 3 June 2017 (O'Hara 2017b [pers comm]) | The maternal sensitivity outcomes were reported as means without standard deviations or standard errors. We requested these data so they could be used in the meta‐analysis. | The corresponding author no longer had access to the data due to retirement, so could not provide the information (Moran 2017 [pers comm]). | |
| 12 January 2018 | The published study data for maternal sensitivity outcomes included children aged 5 years and over, We requested outcomes data with those children excluded. | We received an initial response from the study authors but they did not subsequently provide the data (Dubois‐Comtois 2018 [pers comm]). | |
| 12 January 2018 (Smith 2018e [pers comm]) | The maternal stress outcomes data were not reported in the published paper, so we requested this information for the purposes of the meta‐analysis. | The study author provided these data for the purposes of meta‐analysis (Pereira 2018 [pers comm]). | |
| 12 January 2018 (Smith 2018f [pers comm]) | The reported outcomes included children aged 5 years or older. We requested outcomes data with those children excluded. We also requested means and standard deviations for the relevant 3‐month follow‐up outcome (daily hassles). | The corresponding author was unable to provide the requested data (Poswlawsky 2018 [pers comm]). | |
| 22 July 2019 (Smith 2019b [pers comm]) | We requested outcomes data for mental and psychomotor development | We received no response. | |
| 22 May 2018 (Barlow 2018 [pers comm]) | The outcomes data for 'Verbal responses to infant cues' were reported as medians, so we requested the means and standard deviations. | The study authors provided us with these data for the purposes of meta‐analysis (Stein 2018 [pers comm]). |
| Study | Aim | Content/delivery |
| Video‐feedback Intervention to promote Positive Parenting (VIPP; Juffer 2008) | ||
| To test the effect of a parent‐mediated intervention for children at high risk of autism spectrum disorder | Video Interaction for promoting Positive Parenting (iBASIS‐VIPP), a modification for the autism prodome of the VIPP infancy programme. The intervention consisted of 12 sessions (an additional 6 booster sessions compared with VIPP).The intervention uses video feedback "to help parents understand and adapt to their infants' individual communication style to promote optimal social and communicative development" (quote). The study authors describe that "The therapist uses excerpts of parent‐child interactions in a series of developmentally sequenced home‐sessions focusing on interpreting the infant's behaviour and recognising their intentions; enhancing sensitive responding; emotional attunement and patterns of verbal and non‐verbal interaction." (quote) | |
| To test if a video‐feedback intervention to promote positive parenting and sensitive discipline reduces child‐related parental stress in parents with mild learning disabilities in comparison with care as usual | A Video‐feedback Intervention for Positive Parenting and Learning Difficulties (VIPP‐LD) where the original protocol of VIPP‐SD (Juffer 2008) was adapted for mild intellectual disabilities. For VIPP‐LD, in each session, the parent is videoed interacting with their child. The coach and parent review the footage together, drawing attention to instances of sensitive responsiveness and sensitive discipline, and the coach helps the parent look at the child from the child's perspective. The adaptation included shortening of each session, shorter video recordings and more real‐life practice. The study authors describe how "Parents also received a personal scrapbook with skills taken from video recordings and quotes from the parents representing the theme of the session." (quote) | |
| To evaluate the effectiveness of a short‐term, interaction‐focused video‐feedback intervention implemented in families with mothers rated low in maternal responsiveness | A Video‐feedback Intervention to promote Positive Parenting (VIPP). The intervention was applied as per protocol with the main goal "to reinforce mothers' sensitive responsiveness to their infants' signals focusing on different aspects of mother‐infant interactions" (quote). Mothers were also "provided with information on attachment‐related issues by giving them brochures about sensitive parenting." (quote) | |
| To explore if a combination of attention to parental sensitivity and parental attachment representations might lead to firmer and more enduring changes in both parenting behaviour and children's attachment security | A Video‐feedback Intervention to promote Positive Parenting (VIPP). VIPP programs consisted of four home visits lasting 1.5 hours each, with 3‐4 weeks in between. Each session was focused around a specific theme. VIPP‐R included additional discussions on parental representations. | |
| To test the effectiveness of a video‐feedback intervention to promote positive parenting and sensitive discipline in a sample of poor Portuguese mothers and their 1‐4‐year old children | A sensitive discipline video‐feedback intervention to promote positive parenting (VIPP‐SD). The study authors state that "VIPP‐SD is a short term intervention programme that relies on video‐feedback technique to enhance parental sensitivity and positive discipline strategies. The intervention was applied through standardised protocols of six home visits...The VIPP‐SD working method is divided into three steps: (1) Sessions 1 and 2 main goals are building a relationship with the mother, focusing on child behaviour and emphasizing positive interactions in the video feedback; (2) Sessions 3 and 4 actively work on improving parenting behaviours by showing the mother when her parenting strategies work and to what other situations she could apply these strategies; and (3) Sessions 5 and 6 (booster) aim to review feedback and information from the previous sessions in order to strengthen intervention effectiveness." (quote) | |
| To evaluate a video‐feedback intervention aimed at improving parent‐child interaction for parents of children with a visual or visual and intellectual disability | A Video‐feedback Intervention to promote Positive Parenting adapted to parents of children with a visual or visual and intellectual disability (VIPP‐V). The study authors state that the intervention was based on VIPP, but "this new intervention [is] applicable for use in families with a young child with a visual or visual‐and‐intellectual disability. Particular attention was devoted to increasing (safe) exploration, joint attention, and parent’s abilities to recognize and understand the signals and emotions of their child" (quote). The intervention consists of 7 home visits (5 primary visits plus 2 booster sessions). | |
| To evaluate the early intervention programme, video‐feedback intervention to promote positive parenting adapted to autism, with primary caregivers and their child with autism spectrum disorder | VIPP adapted to autism (VIPP‐AUTI). The intervention comprised 5 home visits lasting 60‐90 minutes every 2 weeks. Sessions included: (1) "Attachment and Exploration" (quote); (2) "Speaking for the Child" (quote); (3) "Sensitivity Chain" (quote); (4) "Sharing Emotions" (quote); (5) "Booster session" (quote). | |
| To test the video‐feedback intervention to promote positive parenting and sensitive discipline in "a large sample of families screened for their children's relatively high scores on externalizing behaviour." (quote) | The study applied VIPP‐SD, aimed at parental sensitivity and sensitive parental discipline. The first four intervention sessions each had their own themes, (1) "exploration versus attachment" (quote); (2) "centered around speaking for the child" (quote); (3) "the intervener stressed the importance of adequate and prompt responses to the child’s signals" (quote); (4) "the importance of sharing—both positive and negative—emotions (sensitivity) and promoting empathy for the child" (quote); (5 & 6) "aimed at consolidating intervention effects by integrating—in video feed‐back and discussion—all tips and feedback given in the previous sessions" (quote). | |
| "To test the effectiveness of the video feedback intervention to promote positive parenting and sensitive discipline adapted to the specific child‐rearing context of Turkish families (VIPP‐TM) in the Netherlands" (quote), including second‐generation Turkish immigrant families with toddlers at risk for the development of externalising problems | "The VIPP‐TM program is a culturally sensitive adaptation of the VIPP‐SD program for Turkish minority families in the Netherlands, but follows the general procedures of the original program...The VIPP‐SD program is described in a detailed protocol and consists of six home visits. The first four visits each have their own themes regarding sensitivity and discipline, and the last two sessions are booster sessions in which the themes from previous sessions are reviewed once more." (quote) | |
| Video Interaction Guidance (VIG) | ||
| "To assess the potential of video interaction guidance to increase sensitivity in parents of preterm infants." (quote) | The study authors report that "VIG is a strengths‐based form of video feedback in which parents are invited to jointly observe and reflect on their own successful interactions with their baby...The core aspects of the model involve three home visits comprising (a) video recording the parent‐infant interaction during play or other aspects of care giving, (b) editing of the recording to select micro‐moments of interaction that demonstrate the infant's contact initiatives and the parents attuned response to these signals and (c) joint reviewing of the recordings with the parent." (quote) | |
| To evaluate the effectiveness of hospital‐based video interaction guidance in parents with moderately and very preterm babies | "Video recordings of parent‐infant interactions and the feedback from a VIG professional provide an opportunity for parents to observe, analyse and discuss the infant's behaviour and contact initiatives" (quote). In this study "VIG consisted of three sessions during the first week after birth" (quote), and included "(1) video‐recording parent‐infant interaction; (2) editing the video recordings; (3) reviewing the edited recordings with parents." (quote) | |
| To examine "the effect of a family‐focused psychosocial video intervention program on parent‐child communication in the context of childhood hearing loss" (quote) | Parents completed three sessions: "(a) a goal setting session; (b) three filming sessions of parent–child interaction in the family home, and (c) three shared review sessions in which three short video clips (demonstrating attuned responses linked to the family’s goal) were played so families could microanalyze and discuss." (quote) | |
| Video feedback of Infant‐Parent Interaction (VIPI) | ||
| To investigate "in a heterogenic community sample of families with interactional problems, whether VIPI would be more effective than standard care (TAU) received in the community" (quote) | VIPI involves at least 6 consultation sessions over a maximum period of 3 months focusing on (1) "Initiative of the infants to contact caregivers and initiate pauses in the dyadic exchange" (quote); (2) "Responses of caregivers" (quote); (3) "Following the child" (quote); (4) "Naming" (quote); (5) "Step‐by‐step guidance" (quote); (6) "Directing attention towards social interaction and exploration" (quote). In this study, "families in the VIPI group received eight video feedback sessions, with the last two sessions tailored to meet the individual family needs regarding any of the six topics in the manual" (quote). | |
| Video self‐modelling with feedback | ||
| To explore if fathers of late, preterm children who received video self‐modelling with feedback intervention would have better father‐child interaction skills when the child was 8 months old than fathers who received information only | Self‐modelling "involves the father's active participation that increases his cognitive awareness of specific behaviours such as infant cues and how to stimulate development" (quote). The intervention involved video recording a father‐infant play interaction and providing positive feedback and suggestions to enhance the interaction and language development. | |
| Video feedback (non‐specified or other) | ||
| To assess "the effectiveness of an attachment‐based short term intervention using video‐feedback" (quote) | Up to 10 sessions of home‐based video feedback | |
| To test a parent‐child communication‐focused intervention in children with core autism | A parent‐mediated communication‐focused intervention: "The intervention consisted of one‐to‐one clinic sessions between therapist and parent with the child present. The aim of the intervention was first to increase parental sensitivity and responsiveness to child communication and reduce mistimed parental responses by working with the parent and using video‐feedback methods to address parent‐child interaction... incremental development of the child's communication was helped by the promotion of a range of strategies such as action routines, familiar repetitive language and pauses...After an initial orientation meeting, families attended biweekly 2 hour clinic sessions for 6 months followed by booster sessions for 6 months (total 18). Between sessions families were also asked to do 30 mins of daily home practice." (quote) | |
| To evaluate "the effects of video tape instruction and feedback (video‐therapy) on mothering behaviours" (quote) | The intervention group received two home visits. Participants were "video taped during structured mother‐infant teaching episodes in their homes at 1 and 2 months postpartum" (quote). Participants "reviewed the video tapes with feedback from a professionally trained nurse who emphasised positive aspects of maternal behaviour" (quote) | |
| To evaluate "the effectiveness of a brief intervention program designed to support adolescent mothers' sensitivity to their infants attachment signals" (quote) | A brief intervention programme (eight home visits) designed to support the mother's sensitivity to her child. The home visits (lasting approximately one hour) were "designed to provide mutually beneficial play interactions and the mother's enjoyment of her infant" (quote). The four goals of the programme included "to affirm parenting strengths already present in the mother...increase the mother's awareness of how her behaviour influenced her child's behaviour...look for ways to augment the mother's awareness of her infant's signals and for ways to establish positive experiences for both the mother and infant" (quote). | |
| To evaluate the "efficacy of a short‐term attachment‐based intervention for changing risk outcomes for children of maltreating families" (quote) | The intervention consisted of "8 weekly home visits directed at the caregiver–child dyad and focused on improving caregiver sensitivity" (quote). The study authors describe that "All intervention sessions were primarily focused on reinforcing parental sensitive behavior by means of personalized parent–child interaction, video feedback, and discussion of attachment/emotion regulation‐related themes" (quote). | |
| To examine the effects of easy‐to‐use interaction coaching techniques on interaction style and developmental status of a population of mothers and their young children with developmental disabilities | "Interaction coaching" (quote; 10‐month programme). "Sessions lasted six minutes and parents were asked to play with their children as they would during a short break at home...After the initial taping session the video record was viewed by the mother and an interaction coach. Suggestions were then provided by the therapist for the mother to employ during interaction with her child...Another 6 minute interaction was then recorded that was reviewed by the intervener and could be used during the next week’s session. The procedure was repeated for a maximum of 6 sessions." (quote) | |
| To test "whether video‐feedback treatment especially targeting mother‐child interaction would be superior to counselling in improving mother‐child interaction, especially mealtime conflict and infant weight and autonomy" (quote) | "Thirteen 1‐hour treatment sessions were offered in the mothers’ homes beginning when the infants were between 4 and 6 months old and completed by the time the infants were 12 months old. The intervention group received video‐feedback interactional treatment that was a modification of that developed by [Juffer et al]" (quote). Treatment consisted of three stages: "The first concentrated on the infant’s perspective, focusing on his or her signals...The second stage included the mother’s perspective...Third, as treatment progressed, the videotapes were used to help the mother identify and address potential triggers of mealtime conflict" (quote). | |
| IBASIS‐VIPP: Intervention within the British Autsim Study of Infant Siblings ‐ Video‐feedback Interaction to promote Positive Parenting; Mins: Minutes; TAU: Treatment as usual; VIG: Video Interaction Guidance; VIPI: Video‐feedback of Infant‐Parent Interaction; VIPP: Video‐feedback Interaction to promote Positive Parenting; VIPP‐AUTI: Video‐feedback Interaction to promote Positive Parenting ‐ Autism;VIPP‐LD: Video‐feedback Interaction to promote Positive Parenting ‐ Learning Difficulties; VIPP‐R: Video‐feedback Interaction to promote Positive Parenting ‐ Representational level; VIPP‐SD: Video‐feedback Interaction to promote Positive Parenting ‐ Sensitive Discipline; VIPP‐TM: Video‐feedback Interaction to promote Positive Parenting ‐ Turkish Minorities; VIPP‐V: Video‐feedback Interaction to promote Positive Parenting ‐ Visual or visual and intellectual disability. | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Parental sensitivity (postintervention ‐ 6 months) Show forest plot | 20 | 1757 | Std. Mean Difference (Random, 95% CI) | 0.34 [0.20, 0.49] |
| 1.1 VIPP | 10 | 861 | Std. Mean Difference (Random, 95% CI) | 0.24 [0.05, 0.42] |
| 1.2 Other types of video feedback | 10 | 896 | Std. Mean Difference (Random, 95% CI) | 0.44 [0.23, 0.66] |
| 2 Attachment security, measured by Strange Situation Procedure (odds of being securely attached) (postintervention) Show forest plot | 2 | 166 | Odds Ratio (M‐H, Random, 95% CI) | 3.04 [1.39, 6.67] |
| 3 Attachment security, measured by Attachment Q‐sort (any duration of follow‐up) Show forest plot | 2 | 131 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.33, 0.38] |
| 4 Adverse events: parental stress (postintervention or short‐term follow‐up) Show forest plot | 8 | 537 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.09 [‐0.26, 0.09] |
| 5 Adverse events: parental anxiety (short‐term follow‐up) Show forest plot | 2 | 311 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.87, 0.31] |
| 6 Child behaviour (long‐term follow‐up) Show forest plot | 2 | 119 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.33, 0.42] |
