Peer-Reviewed Publications

Effect of Attachment and Child Health (ATTACH™) Parenting Program on Parent-Infant Attachment, Parental Reflective Function, and Parental Depression. (2022).

Authors: Lubna Anis, Kharah M. Ross, Henry Ntanda, Martha Hart, Nicole Letourneau


High-risk families exposed to toxic stressors such as family violence, depression, addiction, and poverty, have shown greater difficulty in parenting young children. In this study, we examined the effectiveness of ATTACH™, a 10–12 session manualized one-on-one parental Reflective Function (RF)-based parenting program designed for high-risk families. Outcomes of parent-child attachment and parental RF were assessed via the Strange Situation Procedure (SSP) and Reflective Function Scale (RFS), respectively. The protective role of ATTACH™ on parental depression was also assessed. Data were available from caregivers and their children < 6 years of age who participated in five pilot randomized control trials (RCTs) and quasi-experimental studies (QES; n = 40). Compared with the control group, caregivers who received the ATTACH™-program demonstrated a greater likelihood of secure attachment with their children (p = 0.004) and higher parental RF [self (p = 0.004), child (p = 0.001), overall (p = 0.002)] in RCTs. A significant improvement in parental RF (p = 0.000) was also observed in the QES within ATTACH™ group analysis. As attachment security increased, receiving the ATTACH™ program may be protective for depressed caregivers. Results demonstrated the promise of ATTACH™ for high-risk parents and their young children.

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Study protocol for Attachment & Child Health (ATTACH™) program: promoting vulnerable Children’s health at scale. (2022).

Authors: Anis, L., Letourneau, N., Ross, K. M., Hart, M., Graham, I., Lalonde, S., ... & West, Z.


Children’s exposure to toxic stress (e.g., parental depression, violence, poverty) predicts developmental and physical health problems resulting in health care system burden. Supporting parents to develop parenting skills can buffer the effects of toxic stress, leading to healthier outcomes for those children. Parenting interventions that focus on promoting parental reflective function (RF), i.e., parents’ capacity for insight into their child’s and their own thoughts, feelings, and mental states, may understand help reduce societal health inequities stemming from childhood stress exposures. The Attachment and Child Health (ATTACH™) program has been implemented and tested in seven rapid-cycling pilot studies (n = 64) and found to significantly improve parents’ RF in the domains of attachment, parenting quality, immune function, and children’s cognitive and motor development. The purpose of the study is to conduct an effectiveness-implementation hybrid (EIH) Type II study of ATTACH™ to assess its impacts in naturalistic, real-world settings delivered by community agencies rather than researchers under more controlled conditions.

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The ATTACH™ Program and immune cell gene expression profiles in mothers and children: A pilot randomized controlled trial. (2021).

Authors: Kharah M. Ross, Steve Cole, Harleen Sanghera, Lubna Anis, Martha Hart, Nicole Letourneau


Children exposed to adversity and toxic stress are at increased risk for poor health across the lifespan, possibly through alterations to immune pathways. Parenting interventions could buffer the effect of adversity on child immune activity. The purpose of this study was to test whether mothers and children who were randomly assigned to a parenting intervention (ATTACH™) had healthier post-intervention immune cell gene expression patterns, as indexed by the Conserved Transcriptional Response to Adversity (CTRA), compared with mothers and children in a wait-list control group.

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Fidelity Assessment Checklist Development for Community Nursing Research in Early Childhood. (2021).

Authors: Lubna Anis, Karen M. Benzies, Carol Ewashen, Martha J. Hart, Nicole Letourneau


Nurses play an important role in promoting positive childhood development via early interventions intended to support parenting. Despite recognizing the need to deliver vital parenting programs, monitoring fidelity has largely been ignored. Fidelity refers to the degree to which healthcare programs follow a well-defined set of criteria specifically designed for a particular program model. With increasing demands for early intervention programs to be delivered by non-specialists, rigorous yet pragmatic strategies for maintaining fidelity are needed. This paper describes the step-by-step development and evaluation of a program fidelity measure, using the Attachment and Child Health (ATTACH™) parenting program as an exemplar. The overall quality index for program delivery varied between “very good” to “excellent,” with a mean of 4.3/5. Development of checklists like the ATTACH™ fidelity assessment checklist enables the systematic evaluation of program delivery and identification of therapeutic components that enable targeted efforts at improvement. In future, research should examine links between program fidelity and targeted outcomes to ascertain if increased fidelity scores yield more favorable effects of parenting programs.

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Effect of the Attachment and Child Health Parent Training Program on Parent-Child Interaction Quality and Child Development. (2020).

Authors: Lubna Anis, Nicole Letourneau, Karen Benzies, Carol Ewashen, Martha Hart

To test the effectiveness of parental reflective function-focused intervention entitled Attachment and Child Health on parent–child interaction and child development.

We conducted two pilots with vulnerable mothers and children <36 months. Randomized controlled trial (n = 20) and quasi-experimental (n = 10) methods tested the effect of Attachment and Child Health on parent–child interaction via Parent–Child Interaction Teaching Scale (PCITS) and on child development via Ages and Stages Questionnaire (ASQ-3) and Ages and Stages Questionnaire—Social Emotional (ASQSE). We employed analysis of covariance and t-tests to examine the outcomes.

For randomized controlled trial, we found significant improvements in PCITS parent total, combined total, and cognitive growth fostering scores, and ASQ-3 personal-social scores post-intervention. For quasi-experimental study, we found significant improvements in PCITS combined total, sensitivity to cues, response to child’s distress, and responsiveness to caregiver scores.

Incorporating Attachment and Child Health contributed to effective programming for vulnerable families with young children.

This article is available on request. Please contact us at: [email protected]

Attachment & Child Health (ATTACH™) pilot trials: Effect of Parental Reflective Function Intervention for families affected by toxic stress.

Authors: Nicole Letourneau, Lubna Anis, Henry Ntanda, Jason Novick, Miriam Steele, Howard Steele, Martha Hart


Toxic stressors (e.g., parental violence, depression, low income) place children at risk for insecure attachment. Parental reflective function—parents’ capacity to understand their own and their child's mental states and thus regulate their own feelings and behavior toward their child—may buffer the negative effects of toxic stress on attachment. Our objective was to test the effectiveness of the Attachment and Child Health (ATTACH) intervention, focusing on improving reflective function and children's attachment security, for at‐risk mothers and children <36 months of age. Three pilot studies were conducted with women and children from an inner city agency serving vulnerable, low‐income families and a family violence shelter. Randomized control trial (n = 20, n = 10 at enrollment) and quasi‐experimental (n = 10 at enrollment) methods tested the effect of the ATTACH intervention on the primary outcome of reflective function scores, from transcribed Parent Development Interviews. Our secondary outcome was children's attachment patterns from Ainsworth's Strange Situation Procedure. Despite some attrition, mixed methods analysis of covariance and t tests revealed significant differences in maternal, child, and overall reflective function, with moderate effect sizes. While more children whose mothers received the ATTACH program were securely attached posttreatment, as compared with controls, significant differences were not observed, which may be due to missing observations (n = 5 cases). Understanding the effectiveness of programs like the ATTACH intervention contributes to improved programs and services to promote healthy development of children affected by toxic stress.

This article is available on request. Please contact us at: [email protected]

Publications in review

  • Anis, L., Letourneau, N., Benzies, K., Ewashen, C., & Hart, M. (In review). A comparison of methods for testing and mobilizing community health interventions in childhood: A realist review. Children and Youth Services Review.
  • Letourneau, N., Anis, L., Novick, J., Pohl, C., Ntanda, H., and Hart. M. Results from Phase II of the Attachment and Child Health (ATTACHTM) Reflective Function Intervention.


Action Team on Triadic Attachment and Child Health (ATTACH) Phase II Frontiers of Innovation (FOI) Portfolio Project Completion Report

Project Description

The primary objective of the completed project was to test the effectiveness of the Attachment and Child Health (ATTACH) intervention, which focused on improving reflective function and children’s attachment security for mothers and children who had been exposed to toxic stressors (i.e. parental violence, depression, substance abuse, and socioeconomic adversity). For Phase II of this study, two randomized controlled trials (RCTs; pilot studies #4 and #6) were conducted with women and children who resided within inner-city agencies in Calgary, Alberta serving low-income families (Calgary Urban Project Society (CUPS)) and families affected by parental violence (Discovery House (DH)). Quasi-experimental studies (pilot studies #5 and #7) were conducted based on leveraged funding from another foundation in order to provide the ATTACH intervention to control group participants from each RCT.

The intervention comprised a 10 week brief psychoeducational parenting program with dyadic (mother and child) and triadic (mother, child, and co-parenting support person) components to foster parental RF through practice. The first RCT and quasi-experimental study were conducted with mothers and children <36 months of age at CUPS, with ATTACH team facilitators and staff members delivering intervention. The second RCT and quasi-experimental study were conducted with mothers and children <6 years of age at DH, with ATTACH team facilitators delivering the intervention.

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The Attachment and Child Health (ATTACH) integrated knowledge translation project.

Click on this link to view and download the casebook containing our article or view and download it from IKT's website.

Research Poster

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