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Evaluating the Effect on Infants and Parents Attending the Parent-Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security

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Title: Evaluating the Effect on Infants and Parents Attending the Parent-Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security
Language: English
Authors: Jesús M. Jornet-Meliá (ORCID 0000-0001-6905-497X), Carlos Sancho-Álvarez (ORCID 0000-0001-9489-2502), Purificación Sánchez-Delgado (ORCID 0000-0003-4443-8904), M. Ángeles Cerezo (ORCID 0000-0002-7439-6488)
Source: Evaluation Review. 2025 49(4):708-738.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 31
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Infants, Parents, Parent Child Relationship, Community Programs, Attachment Behavior, Parent Attitudes, Stress Variables, Child Rearing, Social Support Groups, Security (Psychology), Self Efficacy, Program Evaluation
DOI: 10.1177/0193841X251315508
ISSN: 0193-841X
1552-3926
Abstract: The foremost index of caregiving quality is child attachment, as supported by attachment theory. Research supports the relevance of early parenting interventions in improving child outcomes in attachment quality to promote public health because of their long-term effects on mental health and functioning. This study aimed at evaluating the impact on both parenting and child outcomes of the Parent-Child Psychological Support Programme® (PCPS), a community-based program individually tailored to parents and their infants during periodic center-based visits to promote attachment security. The evaluation involved two cohorts from "vulnerable populations" and used the resources embedded in the program design without interfering with the normal functioning of the service. From an evaluative research approach, the effects on mothers and children were assessed using a quantitative approach. Pre- and post-test measures (parenting questionnaires) and child attachment quality assessments through the Strange Situation Procedure were examined. The equivalence of the cohorts was verified and used as a baseline for parenting outcomes. PCPS participants demonstrated increased parental competence and self-efficacy, as well as reduced levels of parenting stress. Analysis of the two cohorts showed a significant difference in the number of visits and proxies for intervention, which were associated with the expected pre-post changes in parenting dimensions. The proportion of securely attached children was significantly higher in the "medium-high intervention" group than in the "no/low intervention" group (72.7% vs 54.5%). Furthermore, compared with international baselines, this proportion showed no differences in the "no-/low-intervention" group but demonstrated expected significant differences in the "medium-high intervention" group.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1471411
Database: ERIC
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  Value: <anid>AN0185232071;evr01aug.25;2025May20.03:04;v2.2.500</anid> <title id="AN0185232071-1">Evaluating the Effect on Infants and Parents Attending the Parent–Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security </title> <p>The foremost index of caregiving quality is child attachment, as supported by attachment theory. Research supports the relevance of early parenting interventions in improving child outcomes in attachment quality to promote public health because of their long-term effects on mental health and functioning. This study aimed at evaluating the impact on both parenting and child outcomes of the Parent–Child Psychological Support Programme® (PCPS), a community-based program individually tailored to parents and their infants during periodic center-based visits to promote attachment security. The evaluation involved two cohorts from "vulnerable populations" and used the resources embedded in the program design without interfering with the normal functioning of the service. From an evaluative research approach, the effects on mothers and children were assessed using a quantitative approach. Pre- and post-test measures (parenting questionnaires) and child attachment quality assessments through the Strange Situation Procedure were examined. The equivalence of the cohorts was verified and used as a baseline for parenting outcomes. PCPS participants demonstrated increased parental competence and self-efficacy, as well as reduced levels of parenting stress. Analysis of the two cohorts showed a significant difference in the number of visits and proxies for intervention, which were associated with the expected pre–post changes in parenting dimensions. The proportion of securely attached children was significantly higher in the "medium-high intervention" group than in the "no/low intervention" group (72.7% vs 54.5%). Furthermore, compared with international baselines, this proportion showed no differences in the "no-/low-intervention" group but demonstrated expected significant differences in the "medium-high intervention" group.</p> <p>Keywords: parenting support; infants; attachment; PCPS; parental self-efficacy; parental satisfaction; program evaluation; parenting stress; first 1000 days of life</p> <hd id="AN0185232071-2">Introduction</hd> <p>Strong evidence supports the critical importance of responsive care in the early months of a child's life for their later life psychological development and adjustment (see [<reflink idref="bib11" id="ref1">11</reflink>]; [<reflink idref="bib10" id="ref2">10</reflink>]; [<reflink idref="bib31" id="ref3">31</reflink>]). Advances in understanding early brain development indicate that brain connectivity is directly related to the quality of relationships and interactions in early life ([<reflink idref="bib62" id="ref4">62</reflink>]). Thus, research supports the relevance of parenting programs focused on early child development ([<reflink idref="bib15" id="ref5">15</reflink>]) to foster healthy development and prevent psychological and behavioral problems because "the scientific evidence on the significant developmental impacts of early experiences, caregiving relationships, and environmental threats is incontrovertible" ([<reflink idref="bib62" id="ref6">62</reflink>], p. 6). The foremost index of caregiving quality is child attachment, supported by attachment theory ([<reflink idref="bib12" id="ref7">12</reflink>]/1982). A large body of literature on caregiver sensitivity and the development of secure child attachment, including meta-analytic studies, shows that improving caregivers' sensitivity enhances child attachment quality ([<reflink idref="bib3" id="ref8">3</reflink>]; [<reflink idref="bib7" id="ref9">7</reflink>]; [<reflink idref="bib63" id="ref10">63</reflink>]). Additionally, attachment insecurity is a significant predictor of public costs in at-risk youths, even after accounting for covariates. These findings add support to the public health case for early parenting interventions to improve child outcomes in attachment quality ([<reflink idref="bib6" id="ref11">6</reflink>]).</p> <p>Becoming a parent is a key life-course transition that requires support ([<reflink idref="bib37" id="ref12">37</reflink>]; [<reflink idref="bib55" id="ref13">55</reflink>]). The transition to parenthood is a stressful event that brings numerous changes in an individual's life. It is associated with worsening physical and mental health and negatively affects relationship quality ([<reflink idref="bib11" id="ref14">11</reflink>]; [<reflink idref="bib54" id="ref15">54</reflink>]; [<reflink idref="bib34" id="ref16">34</reflink>]). Moreover, parents bring their own life experiences to their parenting, which may be adverse ([<reflink idref="bib47" id="ref17">47</reflink>]). These factors affect caregiving practices and can sometimes hinder emotional connection and attunement with infants ([<reflink idref="bib69" id="ref18">69</reflink>]). Parenting programs need to address these aspects to support parents in responding to their infants' communication and emotional needs effectively.</p> <p>These scientific advances have important implications for policymakers, children's mental health administrators, and early childhood program managers. In the past decade, numerous reports from national and international organizations have encouraged decision-makers to apply this body of knowledge (e.g., [<reflink idref="bib53" id="ref19">53</reflink>]). The concept of "nurturing environment" ([<reflink idref="bib9" id="ref20">9</reflink>]) contributes to the prevention of emotional, mental, and behavioral disorders. Central to this nurturing environment is a positive caregiver–child emotional connection and attunement that foster infant emotion regulation with long-term implications for human development. Thus, the effect of caregiving quality is considered a protective factor that precedes the onset of disorders and underlies a broad range of mental health outcomes (Bachmanet al., 2019). Therefore, preventive interventions that support emotion regulation early in life should involve support for parenting infants.</p> <p>The challenge is to transfer this knowledge to real-life settings using affordable, practical, suitable, and evaluable programs ([<reflink idref="bib25" id="ref21">25</reflink>], [<reflink idref="bib26" id="ref22">26</reflink>]). Various prevention programs are available for parents (for a review: [<reflink idref="bib52" id="ref23">52</reflink>]; for group-base parenting programs: [<reflink idref="bib8" id="ref24">8</reflink>]). This study aims to evaluate the impact of the Parent–Child Psychological Support Programme<sups>®</sups> (PCPS), which is universally applicable, not limited to a selected population but personalized and individually tailored to parents and their infants using periodic center-based visits.</p> <hd id="AN0185232071-3">Overview of PCPS</hd> <p>The PCPS is a service with a specific method (procedures and protocols) based on accumulated knowledge in various areas: prevention and early intervention, parenting, parent–infant interaction, child development, and attachment. This method is designed to support and promote healthy socioemotional development in children by providing periodic monitoring and check-ups on infants' well-being. The program structure is designed to promote secure and stable parent–child relationships and the core emotional transactions of secure attachment ([<reflink idref="bib21" id="ref25">21</reflink>]; [<reflink idref="bib59" id="ref26">59</reflink>]). The PCPS model is based on three core elements: (<reflink idref="bib1" id="ref27">1</reflink>) Caring for parents, or "minding the minders," as an integral part of promoting optimal child well-being. (<reflink idref="bib2" id="ref28">2</reflink>) Supporting and guiding the "job" of parenting by enhancing strengths, providing strategies to cope with parental stressors, and developing their sense of parental competence for this special job. This approach facilitates sensitivity and attunement. (<reflink idref="bib3" id="ref29">3</reflink>) Monitoring caregiver–infant interaction to support and promote the caregiver's sensitivity to the infant's signals and synchronous interaction. The attachment quality is used in the PCPS as an index of a child's emotional development and ability to cope with stress. Secure attachment is one of the most fundamental adaptive protective systems that fosters competence in human development, even in the face of adversity.</p> <p>The PCPS is not manualized (i.e., structured as a "parenting course"). The specifically selected and trained PCPS practitioners follow clear procedures and protocols that are flexible enough to adapt to each case (family and baby) at each life stage while maintaining the goals and standards required for the intervention's key point: to support and promote the best attunement and emotional connection with the baby. In PCPS, parents have a space to share their thoughts and feelings with a practitioner with whom they have developed a relationship over two years. One mother described it as her "security blanket."</p> <p>The PCPS addresses all newborns and their parents in the catchment areas. This universal community program is delivered through a quarterly schedule of clinic-based appointments during the infant's first two years of life with a total of six visits.</p> <p>The program calendar of periodic appointments starts when the infant is 3 months old (at 3, 6, 9, 12, 15, and 18 months). The label "3-month" visit covers an age range from 10 to 19 weeks, the "6-month" visit covers infants from 20 to 32 weeks, and so on. Before the infant is 3 months old, there is an initial assessment (Introductory Visit or Visit Zero) with parents to gather information regarding pregnancy, the child, parents' health, and other sociodemographic factors (e.g., level of education, marital status, occupation, age, gender, and prematurity of the child). Parenting questionnaires on factors such as parental sense of competence and parental stress were completed during this initial assessment. This screens for caregivers' risks and strengths and informs the "mind the minder" approach, which is central to the service's ethos. Following this, through periodic visits, the PCPS, in an interview context, provides support to parenting by monitoring the development and growth of the child and offering personalized information about their child's progress, forthcoming developments, and guidelines for solving or preventing conflict (e.g., feeding, sleeping, and crying). Parental empowerment in resolving conflicts is coupled with encouragement and modeling of attuned interaction. This is tailored to each parent–child dyad, as interactions are recorded during the first three visits in a 5-min free-play situation. The analysis, using a sequential coding system, provides the basis for advising parents on achieving good attunement with their child (details in [<reflink idref="bib19" id="ref30">19</reflink>]; [<reflink idref="bib66" id="ref31">66</reflink>]).</p> <p>During the 15-month visit, each child's attachment quality is assessed using the Strange Situation Procedure (SSP) ([<reflink idref="bib3" id="ref32">3</reflink>]). Information on parental sense of competence and parenting stress is collected at the end of the session. At the final visit at 18 months, in the context of the overall progress during the program parents receive feedback on attachment, and, if any issue arises, additional visits are scheduled. Care and health professionals are trained to deliver attachment-informed services. Through the periodic visits, attention is given to any parental factors or stressors that may interfere with the emotional connection with their infant. When additional help is required (i.e., trauma, marital conflict, or addiction) referrals are made to appropriate services, while parents continue to attend PCPS.</p> <hd id="AN0185232071-4">Program Evaluation and Challenges</hd> <p>One challenge in program evaluation, is determining what constitutes credible evidence ([<reflink idref="bib35" id="ref33">35</reflink>]; [<reflink idref="bib36" id="ref34">36</reflink>]), which is related to the validity model. The tools and experiences of social scientists have been developed for laboratories and experiments in academic research (i.e., the Campbellian model). However, health-promotion, and social-betterment programs deal with multidimensional interventions, where outcomes result from multiple interacting factors rather than a single cause. Therefore, these multiple factors require different strategies and designs to address internal validity (effectiveness) not only "randomized controlled trials" that present some limitations for complex programs but also a more comprehensive and integrative validity perspective. From this integrative perspective, different types of evidence are considered, rather than in a hierarchy, to inform judgment. Relevance, viability (feasibility), and generalizability are all important factors in evaluating healthcare interventions. Intervention information must be scientifically credible but also relevant and useful in stakeholder practice (see [<reflink idref="bib27" id="ref35">27</reflink>]).</p> <p>From this perspective, evaluating the effectiveness, efficiency, and functionality ([<reflink idref="bib32" id="ref36">32</reflink>]) of any health- or social-intervention program must be done without disrupting the program's conventional functioning ([<reflink idref="bib4" id="ref37">4</reflink>]; [<reflink idref="bib28" id="ref38">28</reflink>]; [<reflink idref="bib42" id="ref39">42</reflink>]; [<reflink idref="bib65" id="ref40">65</reflink>]; [<reflink idref="bib68" id="ref41">68</reflink>]). Any changes introduced in the operation, for data collection (e.g., recording intervention sessions or including an external observer), may introduce bias and directly affect the validity of the evaluation ([<reflink idref="bib46" id="ref42">46</reflink>], [<reflink idref="bib45" id="ref43">45</reflink>]; [<reflink idref="bib64" id="ref44">64</reflink>]; [<reflink idref="bib70" id="ref45">70</reflink>]). However, to generalize the results, it is advisable to follow classic replication procedures. This involves assessing the program's effects in various cohorts, controlling for the equivalence of the population served, human resources, and available materials. If the same or similar results are observed, evidence can be accumulated regarding the program's generalizability. The concurrence of results helps ensure the program's credibility and usefulness ([<reflink idref="bib46" id="ref46">46</reflink>], [<reflink idref="bib45" id="ref47">45</reflink>]; [<reflink idref="bib56" id="ref48">56</reflink>]; [<reflink idref="bib65" id="ref49">65</reflink>]). This rationale of evaluation of intervention programs supports the evaluative approach adopted in this study for PCPS.</p> <hd id="AN0185232071-5">Antecedents and Aims of this Study</hd> <p>The PCPS is the Irish version of the Programa de Apoyo Psicológico P/Materno-Infantil® (PAPMI), which has been operating in Valencia, Spain, since 1990 ([<reflink idref="bib22" id="ref50">22</reflink>]). The PCPS began operating in Dublin in 2001 under the auspices of the Health Service Executive ([<reflink idref="bib18" id="ref51">18</reflink>]). The PCPS, and the Spanish version PAPMI, demonstrated efficacy in improving attachment security, as measured by the SSP with infants at 15 months ([<reflink idref="bib21" id="ref52">21</reflink>]; [<reflink idref="bib59" id="ref53">59</reflink>]).</p> <p>The PCPS, implemented in two different community locations in Dublin, was conducted by professionals specially trained to deliver it. The program was evaluated at its first location ([<reflink idref="bib16" id="ref54">16</reflink>]; [<reflink idref="bib21" id="ref55">21</reflink>]). At the second location, which covered 72% of annual births, evaluation was also conducted at different times ([<reflink idref="bib39" id="ref56">39</reflink>]; [<reflink idref="bib40" id="ref57">40</reflink>]).</p> <p>The present study is part of a research program to evaluate PCPS regarding parenting outcomes related to child well-being and the central goal of child attachment quality. In real-life implementation, running a universal service with the PCPS method over several years is affected by multiple factors: staff mobility and sick leave, administrative problems (e.g., delays in contacting parents in time to follow the program), technical problems in recording interaction on a particular day, and misunderstandings about protocols (e.g., questionnaires required to be filled out on the premises, being taken home by parents, interfering with the quality of data). This changing reality requires quality control to monitor the implementation and fidelity of the program. The variety of random factors affecting effectiveness needs to be viewed from a broader perspective. As mentioned above, the consistency of findings shows the PCPS method's resilience in achieving expected outcomes, despite these factors, across different settings, circumstances, practitioners, and families.</p> <p>The current evaluation study focused on parenting and child outcomes for children born over two consecutive years, forming two annual cohorts that had not been previously evaluated. These families, as typical in universal services, exhibited differences in terms of the number of visits due to random factors, such as relocation and missed appointments for justified reasons. This provided the opportunity to analyze the differential effect of the program, considering both cohorts and the specific effects on each cohort. Consequently, the approach was holistic and systemic, examining the global effects of the program linked to the intervention, as measured by the total number of visits attended by each family. Therefore, efficacy can be examined in terms of goal achievement, and functionality can be assessed regarding feasibility and applicability in achieving the program's objectives in the context for which it was designed, ([<reflink idref="bib33" id="ref58">33</reflink>]).</p> <p>Regarding parenting outcomes, the study examined two areas: parental sense of competence and parenting stress. Regarding child outcomes, the focus was on child attachment quality.</p> <p>The objectives of this study were based on previous studies on the PAPMI, the Spanish version of the program ([<reflink idref="bib20" id="ref59">20</reflink>], [<reflink idref="bib23" id="ref60">23</reflink>]; [<reflink idref="bib22" id="ref61">22</reflink>]; [<reflink idref="bib58" id="ref62">58</reflink>], [<reflink idref="bib59" id="ref63">59</reflink>]), and PCPS reports and articles ([<reflink idref="bib21" id="ref64">21</reflink>]).</p> <p>The study aimed to examine whether, in parenting outcomes, higher levels of intervention, in terms of visits, were positively associated with a higher parental sense of competence, in terms of perception of self-efficacy, and negatively associated with parenting stress, specifically parental distress and parent–child dysfunctional interaction. Likewise, in child outcomes, a higher proportion of children with secure attachment were expected in dyads with a higher number of visits before attachment assessment. Additionally, based on meta-analytic studies, children with no or low intervention levels were expected to show a similar proportion of secure /insecure attachment to international baselines, whereas children with PCPS intervention were expected to have a significantly higher proportion of secure attachment.</p> <hd id="AN0185232071-6">Method</hd> <p></p> <hd id="AN0185232071-7">Participants</hd> <p>In total, 457 children and their mothers from two cohorts (226 and 231, respectively) participated in the program. A cohort refers to all children born in the same year in an area. Given that the service was extended for each child for approximately 18 months, the two PCPS cohorts spanned a period of three and a half years of service: from the first babies of the first cohort born in January 2011 to the last babies of the second cohort born in December 2012, plus 18 months until their last visit. Therefore, the study data covers the period from 2011 to 2015. Approximately 25% of fathers attended some visits with the mothers, a percentage comparable to other cohorts. Moreover, 32.8% were (mother) single-parent families, and child attachment was assessed with the mother in 97% of cases. For this analysis, mothers were considered the primary caregivers, and sociodemographic profile was collected for mothers and infants.</p> <p>The two cohorts did not differ significantly for any of the sociodemographic characteristics presented in the table, except for the mother's age; mothers in cohort 1 were younger than those in cohort 2 (<emph>M</emph> = 27.82 vs. 29.16; <emph>SD</emph> = 6.17 and 5.88). These differences were statistically significant (<emph>F</emph> (1 451) = 5.63, <emph>p</emph> =.018). According to the NPSR (Health Research and Development Division, 2013) the average age of mothers in Ireland increased from 30.60 years in 2003 to 31.9 in 2012. Data from the catchment area showed this tendency.</p> <p>Of the 457 cases, from four hundred and fifty-four families because three families had twins, 9.69% families made contact and provided some preliminary sociodemographic information but did not start the program, with eight families (18.18%) leaving the area. Of those who came to the visits with their infants, 6.83% (31 families) left the program for justifiable reasons (e.g., relocation, illness, or a new baby). Of the total number of families who dropped out of visits, the remaining 39.74% left for reasons unrelated to the program. Dropouts, defined as those missing two consecutive visits without rescheduling, numbered 47 families (10.35%). Therefore, 332 participants completed the program fully or partially.</p> <p>The catchment area is a densely populated district with high levels of social deprivation. According to the Irish Central Statistics Office (CSO), the unemployment rate in this area was twice the national average, and over 30% of households were headed by single parents, nearly three times the national average (CSO, 2009). The program covered 73% of the catchment area for these cohorts, similar to the 72% reported by [<reflink idref="bib39" id="ref65">39</reflink>].</p> <p>Participants were compared with those who did not continue the program due to relocation, health issues, or other justified reasons (<reflink idref="bib39" id="ref66">39</reflink>, 31.96%) and those who missed consecutive visits without reason (<reflink idref="bib83" id="ref67">83</reflink>, 68.03%). Attrition analysis showed no significant differences in child characteristics (i.e., sex, premature birth, and weight) or mother characteristics (i.e., teenage mother, nationality, length of education, total number of children, and single parenting), as well as in family economic problems, health problems affecting parenting, accepted pregnancies, and breastfeeding. A significant difference was found in mothers' employment: those who participated in the program were more likely to report being employed than nonparticipant (55.2% vs. 39.8%). (<emph>chi-square</emph> (<reflink idref="bib1" id="ref68">1</reflink>, _I_N_i_ = 448) = 8.16, <emph>p</emph> =.003). However, the analysis per cohort showed that these differences were significant only in cohort 1 (<emph>chi-square</emph> (<reflink idref="bib1" id="ref69">1</reflink>, _I_N_i_ = 220) = 7.59, <emph>p</emph> =.008) and not in cohort 2 (<emph>chi-square</emph> (<reflink idref="bib1" id="ref70">1</reflink>, _I_N_i_ = 220) = 1.28, <emph>p</emph> =.275). The analysis of the number of children across both cohorts showed no statistically significant differences overall, with similar findings for cohort 1. However, in cohort 2, there were more participants with three or more children compared to nonparticipants (23.1% vs. 5.7%). These results are consistent with the absence of systematic trends ([<reflink idref="bib57" id="ref71">57</reflink>]). Mothers with more children are often thought to have more experience with parenting challenges, and therefore, less likely to participate or more prone to logistical issues. However, the results did not support this assumption; in fact, when differences were observed between groups in one cohort, they were in the opposite direction.</p> <p>There were 48 cases with missing data that prevented the analysis of certain factors. Therefore, 262 children and their mothers from both cohorts were included in this study (123 from cohort 1 and 139 from cohort 2). Depending on the analysis, slight variations in N may be observed, given that some families missed some visits, and consequently, some data were missing. For child outcomes, 227 cases were included, excluding those affected by missed visits, technical recording problems and interruptions, or protocol deviations. The study sample was refined to include the maximum number of valid cases, eliminating those in which a lack of information made the analysis of most of the variables unfeasible. The sociodemographic profiles of 262 mothers and infants were collected (see Table 1).</p> <p>Table 1. Socio-Demographic Characteristics for the PCPS Participants (N = 262). Frequencies and percentages (in Italics).</p> <p>Graph</p> <p> <ephtml> <table><tbody valign="top"><tr><td align="left">Mother characteristics (<italic>N</italic> = 262)</td><td align="left" /></tr><tr><td align="left"> Nationality (Irish)1</td><td align="char" char="(">161 (<italic>61.5</italic>)</td></tr><tr><td align="left"> Teenagers (<20)</td><td align="char" char="(">19 (<italic>7.2</italic>)</td></tr><tr><td align="left"> Age 20–21</td><td align="char" char="(">31 (<italic>11.8</italic>)</td></tr><tr><td align="left"> Occupation</td><td align="char" char="(">101 (<italic>38.5</italic>)</td></tr><tr><td align="left">Highest level of education</td><td align="left" /></tr><tr><td align="left"> Primary school</td><td align="char" char="(">5 (<italic>1.9</italic>)</td></tr><tr><td align="left"> Lower secondary</td><td align="char" char="(">36 (<italic>13.7</italic>)</td></tr><tr><td align="left"> Upper secondary</td><td align="char" char="(">113 (<italic>43.1</italic>)</td></tr><tr><td align="left"> Third level</td><td align="char" char="(">80 (<italic>30.5</italic>)</td></tr><tr><td align="left">Total number of children</td><td align="left" /></tr><tr><td align="left"> Mothers for the first time</td><td align="char" char="(">124 (<italic>47.3</italic>)</td></tr><tr><td align="left"> Two children</td><td align="char" char="(">75 (<italic>28.6</italic>)</td></tr><tr><td align="left"> Three children</td><td align="char" char="(">35 (<italic>13.3</italic>)</td></tr><tr><td align="left"> Four or more children</td><td align="char" char="(">18 (<italic>6.9)</italic></td></tr><tr><td align="left"> Health problems</td><td align="char" char="(">54 (<italic>20.6</italic>)</td></tr><tr><td align="left"> Mother breastfeeding</td><td align="char" char="(">81 (<italic>30.9</italic>)</td></tr><tr><td align="left"> Single-parent family</td><td align="char" char="(">65 (<italic>24.8</italic>)</td></tr><tr><td align="left"> Hard discipline in her childhood</td><td align="char" char="(">59 (<italic>22.5</italic>)</td></tr><tr><td align="left" colspan="2">Child Characteristics (<italic>N</italic> = 262)</td></tr><tr><td align="left"> Low birth-weight</td><td align="char" char="(">25 (<italic>9.5</italic>)</td></tr><tr><td align="left"> Premature</td><td align="char" char="(">16 (<italic>6.1</italic>)</td></tr><tr><td align="left"> Separation after birth</td><td align="char" char="(">28 (<italic>10.7</italic>)</td></tr><tr><td align="left"> Difficult baby</td><td align="char" char="(">22 (<italic>8.4</italic>)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0185232071-8">Variables and Instruments</hd> <p></p> <hd id="AN0185232071-9">Program Variable</hd> <p>PCPS is delivered by professionals who are specifically selected, trained, and supervised in the methods, protocols, and approaches of intervention. Specific PCPS intervention guidelines are available to help practitioners tailor interventions to the characteristics and circumstances of each family. Moreover, as part of the procedure, the practitioner conducting the intervention filled in a protocol that allowed for an additional qualitative evaluation regarding whether the parents had followed personalized recommendations on how to interact with their baby in attuned ways. In this part of the research program, the intervention was operationalized using the proxy of visit to the program. For the assessment of children's outcomes and attachment quality, the intervention was considered in two ways: attending the service visit and attending plus reporting that recommendations were followed.</p> <hd id="AN0185232071-10">Sociodemographic Factors</hd> <p></p> <hd id="AN0185232071-11">Regarding the Mother</hd> <p>The mother's educational level referred to the highest level of completed education. Four levels were considered: (<reflink idref="bib1" id="ref72">1</reflink>) "Primary Level," including no formal education, (<reflink idref="bib2" id="ref73">2</reflink>) "Lower Secondary Level," (<reflink idref="bib3" id="ref74">3</reflink>) "Upper Secondary Level: Leaving Certificate," and (<reflink idref="bib4" id="ref75">4</reflink>) "Third and Postgraduate Levels." The mother's highest educational level was considered a proxy for socioeconomic status. Other sociodemographic factors included the mother's age, nationality, employment status, being a single mother, teenage mother (<20 years old), number of children, reporting health problems that could affect parenting, economic problems, breastfeeding, and pregnancy acceptance (less than three months after knowing of it; otherwise, it was considered an "unplanned pregnancy"). <emph>Regarding the child</emph>. Sociodemographic factors included sex and prematurity.</p> <hd id="AN0185232071-12">Parent and Child Variables</hd> <p>Standardized questionnaires were used to assess parenting dimensions. The parents completed these questionnaires at the Introductory Visit or Visit Zero (pre-program), before they started the calendar visits, and again when the 15-month visit finished, which was the fifth calendar visit (post-program). These data are routinely collected as part of the PCPS. Similarly, regarding child outcomes, the quality of attachment quality was assessed using Ainsworth's SSP.</p> <hd id="AN0185232071-13">Parental sense of competence (PSOC)</hd> <p>This consists of parental self-efficacy (PEff) and parental satisfaction (PSat). PEff and PSat were evaluated using a 16-item questionnaire, called the PSOC, which the authors ([<reflink idref="bib41" id="ref76">41</reflink>]) used as an equivalent to parenting self-esteem. Perceived self-efficacy was explored with items such as "being a parent is manageable and any problems are easily solved." The parental-satisfaction scale included items such as "Even though being a parent could be rewarding, I am frustrated now while my child is at his/her present age." The rating scale ranged from strongly agree (<reflink idref="bib1" id="ref77">1</reflink>) to strongly disagree (<reflink idref="bib6" id="ref78">6</reflink>). Some items were scored inversely.</p> <p>The PSOC total score was the sum of the scores obtained for PEff and PSat. The three scores were used as dependent variables (DVs). Therefore, for all items, higher scores indicate higher self-esteem. The Cronbach's alpha coefficients reported by [<reflink idref="bib41" id="ref79">41</reflink>] were.70 and.82 for self-efficacy and satisfaction, respectively. Further psychometric studies reported acceptable internal consistency for the total PSOC score (alpha.79), and for the factor scores: self-efficacy score (seven items) (.76), and satisfaction score (nine items) (.75) ([<reflink idref="bib44" id="ref80">44</reflink>]), with satisfactory test–retest reliability that ranged from.46 to.82 with mothers of infants ([<reflink idref="bib29" id="ref81">29</reflink>]). Mothers' PSOC scores reportedly predicted maternal behavior during play and task interaction with their hyperactive children and showed lower levels in abusive mothers than in non-abusive mothers ([<reflink idref="bib51" id="ref82">51</reflink>]).</p> <hd id="AN0185232071-14">Parental Stress</hd> <p>Parental stress was assessed using the "Parenting Stress Index-Short Form" (PSI-SF; [<reflink idref="bib2" id="ref83">2</reflink>]). The PSI, a 36-item parent self-report with a five-point Likert scale (<reflink idref="bib5" id="ref84">5</reflink>, strongly disagree ; 1, strongly agree) provided a global score of parenting stress compiled from the scores on three scales: "Parental Distress" (PD), referring to personal factors and parental role factors; "Parent-Child Dysfunctional Interaction" (P-CDI), regarding the parent's perception of the quality of interaction with their child; and the "Difficult Child" (DC) scale about perceived child characteristics. The PSI-SF total score correlated.94 with the full-length version of the instrument. Coefficient alpha was reported from.70 to.84 for these subscales ([<reflink idref="bib2" id="ref85">2</reflink>]). The PSI total score reportedly had high levels of internal consistency, with an alpha coefficient of.95 ([<reflink idref="bib1" id="ref86">1</reflink>]). Several studies on the temporal stability of the PSI reported that test–retest reliabilities ranged from.55 to.96, depending on the specific population tested and the length of the inter-test interval ([<reflink idref="bib1" id="ref87">1</reflink>]). Construct validity was supported by theoretically meaningful correlations between PSI scores and other constructs such as child adjustment. Studies showed higher (more stressed) PSI-SF scores among neglectful, drug-addicted, maladjusted, and abusive parents ([<reflink idref="bib2" id="ref88">2</reflink>]; [<reflink idref="bib38" id="ref89">38</reflink>]).</p> <hd id="AN0185232071-15">Quality of Attachment</hd> <p>The quality of the child's attachment to the main caregiver was assessed using the internationally recognized Ainsworth's SSP ([<reflink idref="bib48" id="ref90">48</reflink>]). The SSP was administered during the 15-month visit (fifth PCPS calendar visit). The attachment factor was operationalized through the coding of the SSP ([<reflink idref="bib3" id="ref91">3</reflink>]). This study aimed to assess the security of the infant–mother attachment relationship by activating the infant's stress through eight three-minute episodes with two separations and two reunions with the mother. Reactions to separations and reunions are expected to reflect the extent to which an infant's working model of interaction-based expectations regarding the mother's availability and responsiveness contributes to the infant's feelings of security and trust ([<reflink idref="bib13" id="ref92">13</reflink>]). In the two reunion episodes, four infant behaviors were coded on a 7-point rating scale: proximity seeking, contact maintaining, resistance, and avoidance. Based on these behaviors, attachment types were classified. Attachment quality was classified according to the classical ABC classification ([<reflink idref="bib3" id="ref93">3</reflink>]) where "B" indicates securely attached children, and "A" (avoidant) or "C" (resistant-ambivalent) indicate insecure children. Furthermore, disorganized traits were assessed, and the "D" category was applied to children who met the criteria of [<reflink idref="bib49" id="ref94">49</reflink>] for insecure or disorganized attachment. Out of all the attachments, 10% (<emph>n</emph> = 23) were randomly selected for coding by two independent observers. The percentage agreement values were 100% for secure versus insecure classification and 87.5% for other types.</p> <hd id="AN0185232071-16">Procedure</hd> <p></p> <hd id="AN0185232071-17">Parent Outcomes</hd> <p>At the end of the penultimate visit to the program, when children were approximately 15 months (14–16 months), the parents completed the PSOC and PSI questionnaires, mentioned in the "Instruments and Variables" section. Therefore, during the final closing visit, information from the scored questionnaires was integrated with the remainder of the file as a part of the evaluation package. Additionally, during the Introductory Visit, parents completed the same parenting questionnaires as part of the program protocol. In this interview, the parents provided consent for the data used in this study.</p> <hd id="AN0185232071-18">Child Outcomes</hd> <p>The SSP for assessing attachment quality was conducted during the 15-month visit and the fifth calendar visit. At the beginning of the program practitioners informed mothers about the infant's assessment plan during the PCPS calendar visits. Additionally, at the start of the visit, the mothers were given instructions for the procedure and were informed the session would be recorded; they provided their consent. For detailed procedures and instructions, see [<reflink idref="bib3" id="ref95">3</reflink>], pp. 323–324). The experiment took place in a room with rugs on the floor and age-appropriate toys. The door had a glass panel at the top that allowed the mother to see the child without alerting them, so as not to affect the procedure. Predetermined signals were given to the mother and the "stranger" knocking gently on the door. The procedure lasted up to 20 minutes.</p> <p>The Ethics Committee of the Faculty of Psychology at the University of Valencia approved this study.</p> <hd id="AN0185232071-19">Overview of the Analyses</hd> <p>To select the hypothesis contrast tests, following the recommendations of Tukey (1977) and Ferrer et al. (1992), an exploratory data analysis (EDA) was conducted on data distribution, assessing skewness, kurtosis, and the Kolmogorov–Smirnov test to examine normality and homogeneity of variance for all the variables under study. Therefore, an EDA was conducted on the data distributions of the two PSOC scales (PEff and PSat) and PSOC total score, PSI scales (PD, P-CDI, and CD), and PSI total score, both pre- and post-test, considering the two cohorts as a group and individually for each cohort. This EDA revealed that normality distribution requirements were not met across different groups and subgroups analyzed for pre- to post-test changes. Similarly, subgroups based on the number of visits showed different numbers of cases. Therefore, nonparametric tests were used in this study.</p> <p>Pre- and post-intervention changes in PSI and PSOC total scores and scale scores were compared between the two cohorts using the Wilcoxon signed-rank test. Subsequently, pre–post changes in each cohort were examined, and as a first step, the results of both questionnaires were compared before the intervention (pre-intervention) using the Mann–Whitney U test to determine whether both cohorts had similar pre-intervention scores. Cohorts were compared based on the number of visits using the chi-square test for parenting outcomes. The chi-square test was also applied to the attachment data grouped by the level of intervention.</p> <hd id="AN0185232071-20">Results</hd> <p></p> <hd id="AN0185232071-21">Parenting Outcomes: Parental Sense of Competence and Parenting Stress</hd> <p>Two sets of analyses were conducted for the parenting dimensions examined: one set for the total group, and another for each cohort. Nonparametric tests were used to analyze the pre-post changes because the normality distribution requirements were not met.</p> <hd id="AN0185232071-22">Parental Sense of Competence (PSOC), Parental Self-Efficacy (PEff), and Parental Satisfaction...</hd> <p>First, analyses were conducted for all the cases from both cohorts. A Wilcoxon signed-rank test was conducted to determine differences between pre and post scores for PSOC, the total score, and the two scales (<emph>n</emph> = 247). As expected, results showed that the post-intervention PSOC score (<emph>Mdn</emph> = 82; Range = 69) was significantly higher than the pre-intervention score [(<emph>Mdn</emph> = 80; Range = 61): <emph>z</emph> = −2.449, <emph>p</emph> =.014]. Similarly, the PEff post score (<emph>Mdn</emph> = 40; Range = 32) was significantly higher than the PEff pre-score [(<emph>Mdn</emph> = 39; Range = 33): <emph>z</emph> = −2.196, <emph>p</emph> =.028]. No differences were found for the PSat scale. Therefore, parents showed a higher sense of parental competence after the program, primarily due to increased parental self-efficacy.</p> <p>Next, changes in each cohort were tested. The Wilcoxon signed-rank test showed quite different results between cohorts 1 and 2. Cohort 1 showed no pre-post changes in PSOC or its scales (PEff and PSat), whereas the cohort 2 (<emph>n</emph> = 127) showed significant pre-post differences for the three scores. In cohort 2, the total PSOC score increased from 79.15 to. 82.96 [(<emph>Mdn</emph> = 80 vs. 82; Range = 58 for both):<emph>Z</emph> = −3.212, <emph>p</emph> =.001]; PEff increased from 38.15 to 39.30 [(<emph>Mdns</emph> = 39 vs. 40 ; Ranges = 31 and 30): <emph>Z</emph> = −2.202, <emph>p</emph> =.028], and PSat increased from 41.29 to 43.50 [(<emph>Mdns</emph> = 42 vs. 44; Ranges = 30 and 32): <emph>Z</emph> = −3.211, <emph>p</emph> =.001] (See Figure 1).</p> <p>Graph: Figure 1.Means of the PSOC total and its scales: Parental Self-Efficacy and Parental Satisfaction for both cohorts and for cohort 1 and 2.</p> <p>Further analyses were performed. The Mann–Whitney U test showed no statistically significant pre-intervention differences between the cohorts in terms of their total PSOC score or the PEff or PSat scales. However, in cohort 2, the total PSOC post-intervention scores were significantly higher than the post-intervention scores in cohort 1. Specifically, the post-PSat score in cohort 2 (<emph>Mdn</emph> = 44; Range = 32) was higher than for cohort 1 [(<emph>Mdn</emph> = 41; Range = 36):U = 5822, <emph>Z</emph> = −3.209, <emph>p</emph> =.001]. Similarly, the total post-PSOC score for cohort 2 (<emph>Mdn</emph> = 82; Range = 58) was higher than for cohort 1 [(<emph>Mdn</emph> = 81; Range = 67): U = 6271, <emph>Z</emph> = −2.405, <emph>p</emph> =.016], while the post-Eff scores in both cohorts, showed no significant differences. These results indicate that combining data from both cohorts obscured the observable effects seen in cohort 2, where an improvement in parental competence from baseline (pre-test) to post-test was expected. Specifically, it should be noted that in the significant differences in PSat dimension were only observed in cohort 2, while no differences were observed in the total group between pre- and post-test. These results highlight differences between the cohorts that warrant further analysis (Figure 2).</p> <p>Graph: Figure 2.Age profile in weeks of children on their first attendance in Cohort 1 and 2.</p> <p>The factor "number of visits" to the program, used as a proxy of intervention, was recorded. From the initial visit to the visit when the post-questionnaires were completed, the maximum number of visits was six. Therefore, the visits were grouped into low (2–3), medium (<reflink idref="bib4" id="ref96">4</reflink>), and high (5–6) categories and compared between cohorts using a chi-square test for independence. The relation between the two variables was significant [<emph>X</emph><sups>2</sups> (<reflink idref="bib2" id="ref97">2</reflink>, _I_N_i_ = 247) = 10.184, <emph>p</emph> =.006]. Cohort 2 had more visits than cohort 1, with a higher percentage of participants in the "high number of visits" group (5–6) compared to cohort 1 (74.0 % vs. 57.5%), and a lower percentage in the "low number of visits" group (3.90% vs. 13.30%).</p> <p>Parents in cohort 2 received more interventions, as indicated by the number of visits, which served as a proxy. Cohort 1 joined the program later than cohort 2 due to administrative issues in contacting them, as reflected in the age (in weeks) at which the babies joined (<emph>M</emph><emph>c1</emph> = 15.88, <emph>M</emph><emph>c2</emph> = 13.99; <emph>SD</emph><emph>c1</emph> = 2.54, <emph>SD</emph><emph>c2</emph> = 2.49). These differences were statistically significant (<emph>F</emph> (<reflink idref="bib1" id="ref98">1</reflink>, 274) = 36.19, <emph>p</emph> = <.001). The delay in obtaining birth information prevented cohort 1 from joining the program earlier, reducing their exposure to its components. This issue was corrected through monitoring implementation once detected.</p> <hd id="AN0185232071-23">Parenting Stress Index (PSI), the Scales Parental Distress (PD), Parent–Child Dysfunctional I...</hd> <p>First, data from both cohorts were analyzed. The Wilcoxon signed-rank test showed statistically significant pre-post differences in the PSI total score and its three scales (<emph>n</emph> = 260). As expected, the results showed that the post-intervention PSI score (<emph>Mdn</emph> = 59; Range = 69) was significantly lower than the pre-intervention score (<emph>Mdn</emph> = 61; Range = 89), <emph>z</emph> = −3.144, <emph>p</emph> =.002. Likewise, PD, which refers to personal and parental role factors, showed post-intervention scores (<emph>Mdn</emph> = 23; Range = 45) lower than pre-intervention scores [(<emph>Mdn</emph> = 24; Range = 37):<emph>Z</emph> = −3.287, <emph>p</emph> =.001], and so did the P-CDI scale, which refers to the parent's perception of the quality of interaction with their child (<emph>Mdn</emph><emph>post</emph> = 15; Range<emph>post</emph> = 20; <emph>Mdn</emph><emph>pre</emph> = 17; Range<emph>pre</emph> = 24), <emph>Z</emph> = −4.996, <emph>p</emph> <.001). Regarding the DC scale, the post intervention score was collected when the child was 15 months old and was significantly higher than the pre-intervention scores when the child was 2–3 months old [(<emph>Mdn</emph><emph>post</emph> = 20; Range<emph>post</emph> = 33; <emph>Mdn</emph><emph>pre</emph> = 19; Range<emph>pre</emph> = 31), <emph>Z</emph> = −2.107, <emph>p</emph> =.035].</p> <p>Next step was to analyze whether both cohorts contributed similarly to these results. The analysis showed a different profile of results for each cohort. Cohort 1 presented no pre-post differences for either the PSI total score or PD. It exhibited significant pre-post decrease differences in P-CDI, while there was an increase in the perception of DC from pre- to post- intervention. In contrast, cohort 2 results showed strong pre-post decreases in the total PSI score and all scales, except for DC (see Table 2).</p> <p>Table 2. Comparison of Parental Stress Scores in Two Times (Pre- and Post-test) for Each Cohort.</p> <p>Graph</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left" rowspan="2" /><th align="center">Time 1 (PRE)</th><th align="center">Time 2 (POST)</th><th align="center" rowspan="2"><italic>Z</italic></th><th align="center" rowspan="2"><italic>p</italic></th></tr><tr><th align="left">Mdn (range)</th><th align="center">Mdn (range)</th></tr></thead><tbody valign="top"><tr><td align="left">Cohort 1</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"> PSI Total score</td><td align="char" char="(">63 (77)</td><td align="char" char="(">62 (66)</td><td align="char" char=".">−0.015</td><td align="center">ns</td></tr><tr><td align="left"> Parental distress</td><td align="char" char="(">24 (37)</td><td align="char" char="(">25 (31)</td><td align="char" char=".">−0.351</td><td align="center">ns</td></tr><tr><td align="left"> Parent–child dysfunctional interaction</td><td align="char" char="(">17 (23)</td><td align="char" char="(">16 (20)</td><td align="char" char=".">−2.274</td><td align="center">.023</td></tr><tr><td align="left"> Difficult child</td><td align="char" char="(">19 (31)</td><td align="char" char="(">21 (33)</td><td align="char" char=".">2.329</td><td align="center">.020</td></tr><tr><td align="left">Cohort 2</td><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"> PSI Total score</td><td align="char" char="(">60 (89)</td><td align="char" char="(">56 (69)</td><td align="char" char=".">−4.280</td><td align="center"><.001</td></tr><tr><td align="left"> Parental distress</td><td align="char" char="(">24 (37)</td><td align="char" char="(">21 (45)</td><td align="center">−4728</td><td align="center"><.001</td></tr><tr><td align="left"> Parent-child dysfunctional interaction</td><td align="char" char="(">16 (24)</td><td align="char" char="(">14 (19)</td><td align="char" char=".">−4.695</td><td align="center"><.001</td></tr><tr><td align="left"> Difficult child</td><td align="char" char="(">19 (30)</td><td align="char" char="(">19 (27)</td><td align="char" char=".">−0.668</td><td align="center">ns</td></tr></tbody></table> </ephtml> </p> <p>The Mann–Whitney U test showed that both cohorts were similar and showed no significant differences in their pre-intervention (baseline measure) total PSI score and its three scales. However, the post scores were significantly higher for parents from cohort 2 than for their counterparts in cohort 1 in both the total PSI score and the PD scales (see median and range values in Table 2), and marginally significant for P-CDI. Specifically, cohort 2 scores were lower than those in cohort 1 for PSI total score (<emph>U</emph> = 66664, <emph>z</emph> = −2.91, <emph>p</emph> =.004; for PD score: <emph>U</emph> = 6104, <emph>z</emph> = −3.839, <emph>p</emph> <.001); and for P-CDI, which was the only factor where cohort 1 showed a pre-post decrease, with cohort 2 showing a lower score at a marginal level (<emph>U</emph> = 7280, <emph>z</emph> = −1921, <emph>p</emph> =.055).</p> <p>For the PSI factor, the two cohorts exhibited significant differences in the level of intervention received using visits as a proxy. The chi-square test of independence showed that the relation between the two variables was significant [<emph>X</emph><sups>2</sups> (<reflink idref="bib2" id="ref99">2</reflink>, _I_N_i_ = 260) = 14.589, <emph>p</emph> =.001]. Cohort 2 had more visits than cohort 1, with a higher proportion of cases having 5–6 visits (73.7% vs. 57.7%) and a lower proportion of cases having low number of visits: (1.5% vs. 12.2%) (Figure 3).</p> <p>Graph: Figure 3.Means of the PSI total and its scales: Parent Distress (PD), Parent–Child dysfunctional interaction (P-CDI), Difficult Child (DC) for both cohorts and for cohort 1 and 2.</p> <p>In summary, after the program, parents exhibited a higher sense of parental competence, primarily due to increased parental self-efficacy. Regarding the stress connected with parenting, there was a significant decrease in the PSI, primarily due to lower Parental Distress and improved perceptions of the quality of interaction with their child, as measured by the P-CDI scale. However, how difficult the child was perceived increased after the program.</p> <p>Table 3. Calendar Visits Before the Attachment Assessment.</p> <p>Graph</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left" colspan="2" /><th align="center" colspan="2">Proxy of Intervention</th></tr><tr><th align="left" colspan="2">Calendar visits before the attachment assessment</th><th align="center">Only attending visit (n)</th><th align="center">Reported recommendations followed (n)</th></tr></thead><tbody valign="top"><tr><td align="left">No intervention</td><td align="left">0–1</td><td align="char" char=".">8</td><td align="char" char=".">16</td></tr><tr><td align="left">Low intervention</td><td align="left">2</td><td align="char" char=".">25</td><td align="char" char=".">23</td></tr><tr><td align="left">Medium intervention</td><td align="left">3</td><td align="char" char=".">65</td><td align="char" char=".">73</td></tr><tr><td align="left">High intervention</td><td align="left">4–5*</td><td align="char" char=".">129</td><td align="char" char=".">115</td></tr><tr><td align="left" colspan="2">Total</td><td align="char" char=".">227</td><td align="char" char=".">227</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note.</emph> N size for groups considering two approaches to the proxy of "intervention" (There was only one case with an extra visit before the one in which the attachment was assessed. Therefore, this case had five visits. To avoid any confusion the group of high intervention including this case, from now onwards will be referred as the "high intervention 4 visits").</p> <p>These general results were further analyzed by examining the contributions of each cohort. First, regarding PSOC, both cohorts had similar pre-intervention scores. However, no pre-post changes were found for cohort 1, whereas cohort 2 showed significant increases in total PSOC, self-efficacy perception, and satisfaction with their parental role. Additionally, cohort 2 post intervention scores were significantly higher than those for cohort 1.</p> <p>Second, regarding parenting stress, both cohorts showed similar pre-intervention scores. However, the expected changes were exhibited in cohort 2, where parents significantly reduced their total parenting stress by decreasing their PD and interaction-CDI, while cohort 1 only showed decreases in the P-CDI scale. Regarding parental perception of the child as difficult, in cohort 1 there was a significant increase while in cohort 2 there were no differences. It should be pointed out that the post-intervention scores were collected when the child was a toddler, while the pre-intervention scores were collected when the child was approximately three months old. Additionally, cohort 2 post intervention scores were significantly lower than those for cohort 1 in terms of total parenting stress and PD, and marginally lower in terms of P-CDI.</p> <p>Further analysis showed that cohort 1 had fewer interventions compared to cohort 2. Therefore, these findings show that combining both the cohorts obscured the results.</p> <hd id="AN0185232071-24">Child Outcomes: Quality of Attachment</hd> <p>In total, 227 children were included in the analysis. As presented in the preliminary information processing section, there were two ways to consider the level of intervention. The first was more general and considered "intervention" as any visit attended by the main caregiver who also attended the SSP for child attachment. The second approach was more refined requiring not only attendance but also reporting that the recommendations received were followed (Table 3).</p> <hd id="AN0185232071-25">Using the First Approach, that is, as a Proxy of Intervention any Visit to the Service</hd> <p>Analyses were conducted to examine whether the number of visits attended was related to the attachment quality. As this variable was assessed at the fifth calendar visit, the maximum number of visits was four. The groups of "none" and "low" intervention (none, one or two visits) were combined and contrasted with the "medium" and "high" intervention groups (three or four visits), also combined. The analyses contrasting the two groups by the four attachment types, showed that the differences were statistically significant (<emph>chi-square</emph> (<reflink idref="bib3" id="ref100">3</reflink>, _I_N_i_ = 227) = 11.0, <emph>p</emph> =.012).</p> <p>Although the analyses showed that the differences were statistically significant, two cells had fewer than five expected frequencies. Therefore, to avoid this statistical problem, two types of insecure but organized attachments (avoidant and resistant; types A and C) were grouped. The analysis (two groups by three types of attachment) showed that the differences were statistically significant (<emph>chi-square</emph> (<reflink idref="bib2" id="ref101">2</reflink>, _I_N_i_ = 227) = 7.90, <emph>p</emph> =.019). Given that the analysis still indicated that one cell had less than five expected frequencies, the children were grouped into secure and insecure attached children in a 2 × 2 table. The results showed statistically significant differences in the two intervention groups (<emph>chi-square</emph> (<reflink idref="bib1" id="ref102">1</reflink>, _I_N_i_ = 227) = 4.42, <emph>p</emph> =.036). None of the cells had less than five expected frequencies (Table 4).</p> <p>Table 4. Attachment Type and Level of Intervention in Terms of Visits Attended (Percentages in Italics).</p> <p>Graph</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left" rowspan="3">Visits/intervention</th><th align="center" colspan="6">Attachment</th></tr><tr><th align="center">Secure</th><th align="center" colspan="3">Insecure</th><th align="center" rowspan="2">Total</th><th align="center" rowspan="2"><italic>p</italic></th></tr><tr><th align="center">Type B</th><th align="center">Type A</th><th align="center">Type C</th><th align="center">Type D</th></tr></thead><tbody valign="top"><tr><td align="left">No & low (0–2 visits)</td><td align="center">18(<italic>54.5</italic>)</td><td align="center">5(<italic>15.2</italic>)</td><td align="center">5(<italic>15.2</italic>)</td><td align="center">5(<italic>15.2</italic>)</td><td align="char" char=".">33</td><td align="left" rowspan="2">.012</td></tr><tr><td align="left">Med-high (3–4 visits)</td><td align="center">141(<italic>72.7</italic>)</td><td align="center">34(<italic>17.5</italic>)</td><td align="center">11(<italic>5.7</italic>)</td><td align="center">8(<italic>4.1</italic>)</td><td align="char" char=".">194</td></tr><tr><td align="left">Total</td><td align="center">159</td><td align="center">39</td><td align="center">16</td><td align="center">13</td><td align="char" char=".">227</td><td align="left" /></tr><tr><td align="left">No & low (0–2 visits)</td><td align="center">18(<italic>54.5</italic>)</td><td align="center" colspan="2">10(<italic>30.4</italic>)</td><td align="center">5(<italic>15.2</italic>)</td><td align="char" char=".">33</td><td align="left" rowspan="3">.019</td></tr><tr><td align="left">Med-high (3–4 visits)</td><td align="center">141(<italic>72.7</italic>)</td><td align="center" colspan="2">45(<italic>23.2</italic>)</td><td align="center">8(<italic>4.1</italic>)</td><td align="char" char=".">194</td></tr><tr><td align="left" /><td align="center">159</td><td align="center" colspan="2">55</td><td align="center">13</td><td align="char" char=".">227</td></tr><tr><td align="left">No & low (0–2 visits)</td><td align="center">18(<italic>54.5</italic>)</td><td align="center" colspan="3">15(<italic>45.5</italic>)</td><td align="char" char=".">33</td><td align="left">.036</td></tr><tr><td align="left">Med-high (3–4 visits)</td><td align="center">141(<italic>72.7</italic>)</td><td align="center" colspan="3">53 (<italic>27.3</italic>)</td><td align="char" char=".">194</td><td align="left" /></tr><tr><td align="left">Total</td><td align="center">159</td><td align="center" colspan="3">68</td><td align="char" char=".">227</td><td align="left" /></tr></tbody></table> </ephtml> </p> <p>Of the children with three or four visits to the PCPS, 73% were securely attached versus 54% among those who attended none, one, or two visits. Moreover, 4% of the children with more visits showed a disorganized attachment versus 15% children with the lowest number of visits.</p> <p>In contrast to the A and C insecure attachment types, children with D-type attachment did not develop a coherent strategy for dealing with stress and, in socioemotional terms, presented itself as being disoriented. According to the literature, these children are more likely to experience psychological adjustment difficulties ([<reflink idref="bib31" id="ref103">31</reflink>]; [<reflink idref="bib67" id="ref104">67</reflink>]). When considering three groups with zero to two, three, and four visits, the incidence of D-type attachment decreased with an increasing number of visits [15.20%, 4.6%, and 3.9%, respectively (r<subs>xy</subs> = −.892) ].</p> <p> <emph>The second approach to assessing the level of intervention</emph> focused only on visits attended by the main caregiver who reported following the recommendations. The types of attachment were analyzed across three groups based on the number of visits: secure (Type B), insecure organized (Types A and C), and disorganized (Type D). The analysis showed that the differences were statistically significant [<emph>chi-square</emph> (<reflink idref="bib2" id="ref105">2</reflink>, _I_N_i_ = 227) = 9.15, <emph>p</emph> =.010]. To address one cell with fewer than five expected frequencies, the children were grouped into securely versus insecurely attached children in a 2 × 2 table. The results showed statistically significant differences between securely and insecurely attached children in the two intervention groups (<emph>chi-square</emph> (<reflink idref="bib1" id="ref106">1</reflink>, _I_N_i_ = 227) = 7.90, <emph>p</emph> =.005). None of the cells had fewer than five expected frequencies (Table 5).</p> <p>Table 5. Attachment Type and Level of Intervention: Visits in Which Following Recommendations was Reported (Percentages in Italics).</p> <p>Graph</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left" rowspan="3">Visits/intervention</th><th align="center" colspan="5">Attachment</th></tr><tr><th align="center">Secure</th><th align="center" colspan="2">Insecure</th><th align="center" rowspan="2">Total</th><th align="center" rowspan="2"><italic>p</italic></th></tr><tr><th align="center">Type B</th><th align="center">Types A or C</th><th align="center">Type D</th></tr></thead><tbody valign="top"><tr><td align="left">No & low (0–2 visits)</td><td align="center">20(<italic>51.3</italic>)</td><td align="center">14(<italic>35.9</italic>)</td><td align="center">5(<italic>12.8</italic>)</td><td align="char" char=".">39</td><td align="char" char="." rowspan="2">.010</td></tr><tr><td align="left">Med-high (3–4 visits)</td><td align="center">139(<italic>73.9</italic>)</td><td align="center">41(<italic>21.8</italic>)</td><td align="center">8(<italic>4.3</italic>)</td><td align="char" char=".">188</td></tr><tr><td align="left">Total</td><td align="center">159</td><td align="center">55</td><td align="center">13</td><td align="char" char=".">227</td><td align="left" /></tr><tr><td align="left">No & low (0–2 visits)</td><td align="center">20(<italic>51.3</italic>)</td><td align="center" colspan="2">19(<italic>48.7</italic>)</td><td align="char" char=".">39</td><td align="char" char="." rowspan="2">.005</td></tr><tr><td align="left">Med-high (3–4 visits)</td><td align="center">139(<italic>73.9</italic>)</td><td align="center" colspan="2">49(<italic>26.1</italic>)</td><td align="char" char=".">188</td></tr><tr><td align="left">Total</td><td align="center">159</td><td align="center" colspan="2">68</td><td align="char" char=".">227</td><td align="left" /></tr></tbody></table> </ephtml> </p> <hd id="AN0185232071-26">Comparison of Quality of Child's Attachment in PCPS Children with International Baselines</hd> <p>The quality of attachment results in children with PCPS was compared with those in the international literature. The proportion of securely attached children is lower in contexts with accumulated socioeconomic risks ([<reflink idref="bib30" id="ref107">30</reflink>]). Parents are more stressed and have fewer resources to cope with life stressors that affect their attention processes with the demanding task of child-rearing, compromising the quality of their caregiving. This relationship is more likely to be affected, and the quality of child attachment is based on the quality of that relationship. The data used as a baseline for these comparisons presented the information in the meta-analytic study by [<reflink idref="bib67" id="ref108">67</reflink>]. This included data from middle-class (15 studies and more than 2000 children) and lower-class families (seven studies and 586 children). The data were from a North American, nonclinical population, and the proportion of secure/insecure children reported was similar to that reported in European countries, even conservative, considering a recent meta-analytical study ([<reflink idref="bib48" id="ref109">48</reflink>]). Furthermore, [<reflink idref="bib67" id="ref110">67</reflink>] present data on lower-class families. Therefore, the baseline information used here was derived from North American studies.</p> <p>Cross-cultural studies have shown that the proportion of secure children is similar across cultures, with variations in the proportion of Avoidant or Resistant children ([<reflink idref="bib67" id="ref111">67</reflink>]; [<reflink idref="bib48" id="ref112">48</reflink>]). Therefore, analyses were conducted by grouping secure versus insecure to maximize the clarity and size of the groups.</p> <p>The two approaches to the program visits as a proxy for "level of intervention" were contrasted with both baselines, middle- and lower-class groups. It was expected that the program "no-/low-intervention" (0, 1, or 2 visits) group will show no differences with the baselines, regarding the distribution of secure/insecure attached children. The analysis showed that the differences between the PCPS "no/low intervention" and the baselines in the attachment type proportion (secure/insecure) were not statistically significant in either case: middle-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref113">1</reflink>, _I_N_i_ = 2137) =.711, <emph>p</emph> =.399; and low-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref114">1</reflink>, _I_N_i_ = 619) =.516, <emph>p</emph> =.473. Likewise, using "no/low intervention" in the second approach, the expected lack of differences was found in both case: middle-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref115">1</reflink>, _I_N_i_ = 2143) = 1.77, <emph>p</emph> =.183; and low-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref116">1</reflink>, _I_N_i_ = 625) =.146, <emph>p</emph> =.702 (Table 5).</p> <p>Second, according to expectation, there would be a higher proportion of securely attached children in the program's medium-high intervention groups than in the either of two baselines, middle- or low-class baseline groups (Table 6).</p> <p>Table 6. Data From [<reflink idref="bib67" id="ref117">67</reflink>] for Middle Class and Low Class Groups and Programme's Data for "None-Low Intervention" and "Medium-High Intervention" Intervention Groups. Percentages in Italics.</p> <p>Graph</p> <p> <ephtml> <table><thead valign="top"><tr><th align="left" colspan="2" /><th align="center" colspan="2">Attachment Type</th><th align="center" /></tr><tr><th align="left" colspan="2">Group</th><th align="center">Secure (Type B)</th><th align="center">Insecure (A or C or D)</th><th align="center">N Total</th></tr></thead><tbody valign="top"><tr><td align="left" rowspan="2"><xref ref-type="bibr" rid="bibr67">Van IJzendoorn et al., 1999</xref></td><td align="left">Middle class baseline</td><td align="char" char="(">1299 (<italic>62.0</italic>)</td><td align="char" char="(">805 (<italic>38.0</italic>)</td><td align="char" char=".">2104</td></tr><tr><td align="left">Low class baseline</td><td align="char" char="(">282 (<italic>48.1</italic>)</td><td align="char" char="(">304 (<italic>51.9</italic>)</td><td align="char" char=".">586</td></tr><tr><td align="left" rowspan="4">PCPS®</td><td align="left">No intervention/ Low intervention'</td><td align="char" char="(">18 (<italic>54.5</italic>)</td><td align="char" char="(">15 (<italic>45.5</italic>)</td><td align="char" char=".">33</td></tr><tr><td align="left">No intervention/ Low intervention'*</td><td align="char" char="(">20 (<italic>51.3</italic>)</td><td align="char" char="(">19 (<italic>48.7</italic>)</td><td align="char" char=".">39</td></tr><tr><td align="left">Medium–high intervention</td><td align="char" char="(">141 (<italic>72.7</italic>)</td><td align="char" char="(">53 (<italic>27.3</italic>)</td><td align="char" char=".">194</td></tr><tr><td align="left">Medium–high intervention*</td><td align="char" char="(">139 (<italic>73.9</italic>)</td><td align="char" char="(">49 (<italic>26.1</italic>)</td><td align="char" char=".">188</td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Note.</emph> Intervention equals to visits attended in which the main caregiver reported having followed the recommendations given.</p> <p>The analysis showed that the differences between the program medium-high level intervention and baselines in the attachment type proportion (secure/insecure) were statistically significant in both cases: middle-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref118">1</reflink>, _I_N_i_ = 2298) = 9.09, <emph>p</emph> =.003; and low-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref119">1</reflink>, _I_N_i_ = 780) = 35.4, <emph>p</emph> = <.0001. In these cases, the intervention was equal to the number of visits attended by the mother as the main caregiver who also attended the assessment of her child's attachment. Similarly, analyses using interventions such as visits, in which the mother also reported having followed the recommendations showed similar results. Thus, the differences were statistically significant in both cases (Figure 4): middle-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref120">1</reflink>, _I_N_i_ = 2292) = 11.0, <emph>p</emph> =.001; and low-class <emph>chi-square</emph> (<reflink idref="bib1" id="ref121">1</reflink>, _I_N_i_ = 774) = 38.2, <emph>p</emph> <.0001.</p> <p>Graph: Figure 4.Percentage of Secure versus Insecure Attachment compared with international baseline (*) visits in terms of having followed the recommendations. Note: N = 194 & 33 in PCPS® Medium-High and No & Low intervention, respectively, and for (*) N = 188 and 39.</p> <hd id="AN0185232071-27">Summary</hd> <p>First, child attachment quality was significantly different between groups of children with different levels of intervention. A higher proportion of securely attached children was observed in the group that received medium-high level of intervention compared to those with no or low intervention, meaning (72.7% vs. 54.5%). This difference was also found when the proxy for intervention considered the parent report regarding whether or not they had followed the recommendations about attunement (73.9% vs. 51.3%). These results are consistent with other studies involving different populations and practitioners using the PCPS, providing further evidence for its generalizability. Thus, according to [<reflink idref="bib59" id="ref122">59</reflink>], the results showed that "the significant differences occurred when the family had attended four visits (<emph>t</emph> = 4.40, <emph>p</emph> =.001) and when they had attended three visits (<emph>t</emph> = 3.26, <emph>p</emph> =.001), but not after two visits" (p.478). [<reflink idref="bib40" id="ref123">40</reflink>] also reported that "most infants of parents attending the program were securely attached at the point of testing (after at least three sessions)" (p. 5). Likewise, [<reflink idref="bib21" id="ref124">21</reflink>] reported that the results showed significant differences in the expected direction: higher dose, higher proportion of securely attached children (<emph>chi-square</emph> = 11.34, <emph>df</emph> = 4, <emph>p</emph> =.02)" (p. 18).</p> <p>Second, the proportion of secure versus insecure children in the no or low intervention group was consistent with baseline findings, showing no statistically significant differences. In contrast, children who received medium-to-high levels of intervention showed a significantly higher proportion of securely attached children than the baseline distribution, with both proxies of intervention, number of visits attended, and visits where the recommendations, were reported to have been followed.</p> <hd id="AN0185232071-28">Discussion and Conclusions</hd> <p>This study examined the relationship between the level of intervention, parenting, and child outcomes among participants in the PCPS program.</p> <hd id="AN0185232071-29">Regarding Parenting Outcomes</hd> <p>Parents who participated in the PCPS method and procedures, as expected and congruent with previous studies, showed a pre-post increase in their parental sense of competence, which is considered equivalent to parenting self-esteem. This increase was mainly driven by a significant improvement in perceived parental self-efficacy, rather than in the parental satisfaction component. Likewise, the results showed that the participants in the program reduced their global parenting stress index scores from pre- to post- intervention. This reduction was due to a decrease in parental distress (that involves personal and parental role factors), and a reduction in parent–child dysfunctional interaction score.</p> <p>It can be argued that the pre-post change analysis presented a weakness in terms of internal validity, so the changes cannot be attributed to the intervention. However, two arguments support this intervention effect.</p> <p>First, the consistency of the parenting outcome findings has been notable across different implementation settings and practitioners, staff mobility, sick leave, and all other real-life service variations. When the objective of a program is verified in the findings obtained in successive studies, each including a variety of extraneous variables, different groups and circumstances, and these findings show consistency across diversity, this consistency can be considered as supporting internal validity.</p> <p>The second argument comes from this study: findings considering the cohorts' contribution to the general results showed that, although both reported similar levels of parenting competence and stress pre-intervention, cohort 1 showed no change after the intervention in any of these dimensions, while cohort 2 showed clear significant changes in the expected direction. Although cohort 1 showed a significant reduction in the specific component related with parent–child dysfunctional interactions, as did cohort 2, cohort 2 also showed an expected increase in parental self-efficacy and satisfaction, and a decrease in parental distress.</p> <p>The difference between the two cohorts was related to implementation issues. The PCPS administration delayed access to birth details of families for several months, which affected all children born in that year (cohort 1), causing them to join later than planned, resulting in less exposure to the intervention and fewer visits, as the post-hoc analysis showed. This highlights the importance of maintaining quality control. An administrative problem was detected at the time and corrected; however, evidence of its impact was not revealed until this study was conducted. The specific results regarding the perception of child characteristics, as measured by the PSI DC scale, showed that cohort 1 had a pre-post increase, while cohort 2, with more intervention, showed no increase. This pointed to the difficulty associated with parenting toddlers compared to young babies. However, this finding requires further investigation because there are no PSI-specific norms for this age group.</p> <hd id="AN0185232071-30">Regarding the Child's Quality of Attachment</hd> <p>The findings showed that, as expected, a higher proportion of children in the medium-high intervention group were securely attached compared to their counterparts in the no/low intervention group (72.7% vs. 54.5%). When the proxy for the number of visits included a qualitative analysis by checking those parents who reported following recommendations regarding attunement, the findings showed a consistent result (73.9% vs. 51.3%) with 4.4% higher difference in the expected direction. Additionally, the proportion of securely attached children in the general population has been extensively documented across countries and could therefore be considered as a baseline. The catchment area, a district with a documented high level of social deprivation, is expected to have a lower proportion of securely attached children (see [<reflink idref="bib30" id="ref125">30</reflink>]). The findings in our study showed that the proportion of securely attached children who participated was significantly higher than expected, even for the middle-class population, using both the number of visits attended and only visits where recommendations were reported to have been followed as a proxy of intervention.</p> <p>The focus of this study was to evaluate the effectiveness of the program and provide references for its functionality. A holistic consideration of the program provides evidence that the number of intervention sessions (visits) is a key factor in achieving effectiveness. Administrative issues, such as differences in incorporating families into the program between cohorts, allowed us to create a methodological strategy for planning the evaluation from a global perspective, using the number of visits as a reference factor to assess the effectiveness in achieving objectives.</p> <p>The efficiency factors of the evaluative research on PCPS, require further investigation. Internal factors that can help optimize program results, include the relevance of the personal/professional characteristics of those applying the program, the importance of monitoring the degree to which practitioners strictly follow protocols, and staff adherence to the PCPS ethos. In this context, a formative evaluation approach, in line with [<reflink idref="bib61" id="ref126">61</reflink>], aimed at the internal improvement of the program, can also address questions such as "can administrative management processes for collecting information be improved?"</p> <p>Lessons learned include the necessity of increasing administrative control and service management to avoid the negative effects of inappropriate actions. Additionally, quality control is required to revise and maintain high operational standards.</p> <p>Finally, future research should include more qualitative information in line with mixed models ([<reflink idref="bib5" id="ref127">5</reflink>]; [<reflink idref="bib17" id="ref128">17</reflink>]; [<reflink idref="bib24" id="ref129">24</reflink>]; [<reflink idref="bib43" id="ref130">43</reflink>]; [<reflink idref="bib60" id="ref131">60</reflink>]). The generalizability theory model (TG) can be used to identify the differential weight of various factors (e.g., who applies the intervention or possible variables identified from a qualitative perspective) in achieving goals related to parenting and secure child attachment. Although TG was proposed to identify factors that could explain the sources of random error in standardized tests and thereby improve the reliability of measurement instruments ([<reflink idref="bib14" id="ref132">14</reflink>]), TG is also relevant in program evaluation for identifying differential factors associated with program efficiency, as demonstrated by some researchers in educational fields ([<reflink idref="bib50" id="ref133">50</reflink>]). Altogether, various lines of in-depth study can be established to increase the program's efficiency in further studies, given its effectiveness and functionality are already supported by sufficient evidence.</p> <hd id="AN0185232071-31">Ethical Statement</hd> <p></p> <hd id="AN0185232071-32">Ethical Approval</hd> <p>The study was approved by the Ethics Committee of the Faculty of Psychology of the University of Valencia.</p> <hd id="AN0185232071-33">ORCID iDs</hd> <p>Jesús M. Jornet-Meliá https://orcid.org/0000-0001-6905-497X</p> <p>Carlos Sancho-Álvarez https://orcid.org/0000-0001-9489-2502</p> <p>Purificación Sánchez-Delgado https://orcid.org/0000-0003-4443-8904</p> <p>M. Ángeles Cerezo https://orcid.org/0000-0002-7439-6488</p> <ref id="AN0185232071-34"> <title> References </title> <blist> <bibl id="bib1" idref="ref27" type="bt">1</bibl> <bibtext> Abidin R. R. (1990). Introduction to the special issue: The stresses of parenting. 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  Data: Evaluating the Effect on Infants and Parents Attending the Parent-Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security
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  Data: <searchLink fieldCode="AR" term="%22Jesús+M%2E+Jornet-Meliá%22">Jesús M. Jornet-Meliá</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6905-497X">0000-0001-6905-497X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Carlos+Sancho-Álvarez%22">Carlos Sancho-Álvarez</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-9489-2502">0000-0001-9489-2502</externalLink>)<br /><searchLink fieldCode="AR" term="%22Purificación+Sánchez-Delgado%22">Purificación Sánchez-Delgado</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-4443-8904">0000-0003-4443-8904</externalLink>)<br /><searchLink fieldCode="AR" term="%22M%2E+Ángeles+Cerezo%22">M. Ángeles Cerezo</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7439-6488">0000-0002-7439-6488</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Evaluation+Review%22"><i>Evaluation Review</i></searchLink>. 2025 49(4):708-738.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: <searchLink fieldCode="DE" term="%22Infants%22">Infants</searchLink><br /><searchLink fieldCode="DE" term="%22Parents%22">Parents</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Child+Relationship%22">Parent Child Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Community+Programs%22">Community Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Attachment+Behavior%22">Attachment Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Attitudes%22">Parent Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Rearing%22">Child Rearing</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Support+Groups%22">Social Support Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Security+%28Psychology%29%22">Security (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Efficacy%22">Self Efficacy</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Evaluation%22">Program Evaluation</searchLink>
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  Data: 10.1177/0193841X251315508
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  Data: 0193-841X<br />1552-3926
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  Label: Abstract
  Group: Ab
  Data: The foremost index of caregiving quality is child attachment, as supported by attachment theory. Research supports the relevance of early parenting interventions in improving child outcomes in attachment quality to promote public health because of their long-term effects on mental health and functioning. This study aimed at evaluating the impact on both parenting and child outcomes of the Parent-Child Psychological Support Programme® (PCPS), a community-based program individually tailored to parents and their infants during periodic center-based visits to promote attachment security. The evaluation involved two cohorts from "vulnerable populations" and used the resources embedded in the program design without interfering with the normal functioning of the service. From an evaluative research approach, the effects on mothers and children were assessed using a quantitative approach. Pre- and post-test measures (parenting questionnaires) and child attachment quality assessments through the Strange Situation Procedure were examined. The equivalence of the cohorts was verified and used as a baseline for parenting outcomes. PCPS participants demonstrated increased parental competence and self-efficacy, as well as reduced levels of parenting stress. Analysis of the two cohorts showed a significant difference in the number of visits and proxies for intervention, which were associated with the expected pre-post changes in parenting dimensions. The proportion of securely attached children was significantly higher in the "medium-high intervention" group than in the "no/low intervention" group (72.7% vs 54.5%). Furthermore, compared with international baselines, this proportion showed no differences in the "no-/low-intervention" group but demonstrated expected significant differences in the "medium-high intervention" group.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1471411
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1471411
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/0193841X251315508
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 31
        StartPage: 708
    Subjects:
      – SubjectFull: Infants
        Type: general
      – SubjectFull: Parents
        Type: general
      – SubjectFull: Parent Child Relationship
        Type: general
      – SubjectFull: Community Programs
        Type: general
      – SubjectFull: Attachment Behavior
        Type: general
      – SubjectFull: Parent Attitudes
        Type: general
      – SubjectFull: Stress Variables
        Type: general
      – SubjectFull: Child Rearing
        Type: general
      – SubjectFull: Social Support Groups
        Type: general
      – SubjectFull: Security (Psychology)
        Type: general
      – SubjectFull: Self Efficacy
        Type: general
      – SubjectFull: Program Evaluation
        Type: general
    Titles:
      – TitleFull: Evaluating the Effect on Infants and Parents Attending the Parent-Child Psychological Support Programme®, a Community-Based Program to Promote Attachment Security
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Jesús M. Jornet-Meliá
      – PersonEntity:
          Name:
            NameFull: Carlos Sancho-Álvarez
      – PersonEntity:
          Name:
            NameFull: Purificación Sánchez-Delgado
      – PersonEntity:
          Name:
            NameFull: M. Ángeles Cerezo
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 08
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0193-841X
            – Type: issn-electronic
              Value: 1552-3926
          Numbering:
            – Type: volume
              Value: 49
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Evaluation Review
              Type: main
ResultId 1