Experiences from conception to age six have the most important influence of any time in the life

Attachment and Child Health (ATTACH)

Visit the ATTACH™ Program: attach.teachable.com

Attachment and Child Health (ATTACH™) Program: Promoting Vulnerable Children's Health At Scale

Summary of the Project

Through integrated Knowledge Translation (iKT) and Patient Engagement (PE) approaches, where stakeholders (patients, health care professionals and health system administrators) are partners, and along with our numerous provincial and national SPOR collaborators, we are conducting an effectiveness-implementation hybrid (EIH) Type II study of ATTACH™. Examining whether parenting intervention programs like ATTACH™ can buffer impacts of toxic stress on inflammation via immune cell gene expression and DNA methylation, is considered a research priority. ATTACH™ is poised to address this priority. Our past iKT and PE approaches of engaging with patients, health care professionals and health system administrators in agencies, have resulted in adaptation and evaluation of the ATTACH™ intervention program and materials. Key changes included reducing the number of sessions from 12 to 10, making materials more ethnically diverse, developing an intervention fidelity assessment tool and especially creating an e-learning training platform: attach.teachable.com.

Goals and Objectives

Objective 1: Effectiveness of Clinical Intervention

With quasi-experimental methods, evaluate ATTACH™ impacts on:

  • parent-child relationship quality (primary outcome), parental RF and child development,
  • different patient populations (for whom program works best/worst)
  • immune biomarkers indicative of inflammatory disease risk, i.e. gene expression and DNA methylation
  • health professionals’ adherence to ATTACH™ program, via fidelity assessment, and
  • outcomes 3 months postintervention.

For these objectives, we will intervene with 100 families from five community agencies.

Objective 2: Feasibility of implementation

Using qualitative methods, evaluate patients’, health care professionals’ and administrators’ perceptions and experiences of:

  • intervention uptake and fidelity,
  • implementation benefits, facilitators, barriers and challenges and
  • utility of the new ATTACH™ e-learning platform.

For these objectives, we will conduct interviews until data saturation (n~60) using Normalization Process Theory (NPT), a method for promoting integration of innovations in practice.

Members of the Team


Nicole Letourneau
Faculty of Nursing
University of Calgary


Kharah Ross

Faculty of Arts, Humanities and Social Sciences
Athabasca University


Kathryn Birnie
Alberta Children’s Hospital (Calgary)

Ian Graham
Ottawa Hospital Research

Michael Kobor
University of British Columbia

Sarah Merrill
Faculty of Medicine
Medical Genetics, University of British Columbia

Kendra Nixon
Faculty of Social Work
University of Manitoba

Caroline Piotrowski
Faculty of Health Sciences
University of Manitoba

Karen Wood
Department of Sociology, Faculty of Arts and Science
University of Saskatchewan

Attachment and Child Health (ATTACH™): Developing & Testing a Reflective Function Intervention

Summary of the Project

Research Background and Objectives: Parents suffering toxic stress (depression, addiction, violence) are unable to respond sensitively to their infants which interferes with forming secure parent-infant attachments necessary for healthy child development. Secure attachment is influenced by parental Reflective Function (RF); parents’ capacity to understand and thus regulate their own feelings/behaviour toward their child. Few RF interventions exist and focus only on mothers’ understanding of their own psychological caregiving representations but do not promote learning RF skills via practice and ignore co-parents. Building on this research ATTACH has developed and pilot tested a RF intervention designed for mothers and co-parents; intended as an add-on program to existing parenting programs (Nurturing Parenting, Thera-play). The primary objective of the series of ATTACH™ projects is to test the effectiveness of the intervention, which focuses on improving RF, parent-child attachment security and interaction quality and child development, especially for families affected by toxic stress.

Methods: The ATTACHTM study Phase 1 includes pilot studies 1 – 3 and Phase 2 includes pilot studies 4 -7. For ATTACHTM Phase 1 pilots 1-3, a convenience sample of 30 mothers and their infants/young children less than 36 months of age were recruited from two inner city agencies (CUPS and Sonshine Community Center) serving low-income, high psychosocial at-risk families, typically affected by toxic stress. For Phase 2 ATTACHTM pilots 4-7, 34 more families were recruited from CUPS and Discovery House. The ATTACHTM intervention comprised a 10–12-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 ATTACHTM study Phase 1 pilot studies were conducted with mothers and children <36 months of age, with ATTACHTM team facilitators delivering intervention. The Phase 2 pilot studies were conducted with mothers and children <6 years of age, with ATTACHTM team facilitators and trained staff members at partner agencies delivering the intervention.

Results: Results are available from ATTACHTM study Phase 1; developing strong therapeutic alliances between mothers and ATTACHTM facilitators was key to participant engagement, partner agencies’ support, very low attrition and sustaining a nurturing environment. In multiple pilot studies, we found significant improvements in parental RF, parent-child interaction quality, and child development and in one pilot, significant improvements in parent-child attachment security, with an overall trend toward the positive. See Table 1 at the bottom of the page. We are currently scaling and spreading the program across the Prairie Provinces, with new funding provided by CIHR-SPOR.

Conclusion. Over 25% of Canadian children are vulnerable to cognitive and behavioral problems. Not surprising the World Health Organization has called for programs like ATTACHTM to address persistent discrepancies in child development to “close the gap”. Understanding the effectiveness of programs like the ATTACHTM intervention contributes to improved programs and services to promote healthy development of children affected by toxic stress. Overall, incorporating ATTACHTM contributed to effective programming for vulnerable families with young children. 

Funded by: 

  • Palix Foundation
  • Alberta Centre for Child, Family & Community Research (ACCFCR)
  • Anonymous Donor
  • Harvard Frontiers of Innovation
  • Calgary Foundation

Members of the Team


Name and Title: Dr. Nicole Letourneau (PI), Professor and ACHF Research Chair in Parent-Infant Mental Health (AllerGen Investigator)

Email Address: nicole.Letourneau@ucalgary.ca

Name and Title: Dr. Martha Hart (Co-PI), Project Manager, Faculty of Nursing, University of Calgary

Email Address: mhart@ucalgary.ca



Name and Title: Carlene Donnelly, Executive Director, Calgary Urban Project Society 

Name and Title: Dean Schroeder, Senior Director – Developmental Strategy, Calgary Urban Project Society 


Effects of a Parenting Intervention on Immune Cell Gene Expression in Children Exposed to Toxic Stress

This sub-project builds on Dr. Letourneau’s existing ATTACH™ program by adding an important marker of physical health: immune cell function. High quality maternal-child attachment can buffer the effect of toxic stress on child neuroendocrine pathways [e.g. hypothalamic-adrenalpituitary (HPA) and sympathetic-adrenal-medulla (SAM) axes], with beneficial downstream effects on child immune system activity, i.e. reduced risk for allergies and reduced low-grade inflammation, a risk factor for poor future health. This sub-project extends previous research by taking advantage of an ongoing, effective parenting intervention to test whether improved mother-child relationship qualities and attachment in the context of toxic stress has additional benefits for preschoolers’ immune function immediately following the intervention.

Methods. Dried blood spot (DBS) collection from children enrolled in the ATTACH™ Phase 2 scale-up at study end. This study enrolled mother-child pairs from vulnerable families exposed to domestic violence and residing at Discovery House. With DBS collection, a finger is pricked, and blood drops are collected onto specially prepared filter paper cards and dried at room temperature. Immune cell gene expression (mRNA) will be assayed from DBS samples. DBS has been validated for immune cell gene expression (mRNA), an indicator of immune cell activity

Results. Results to be shared soon.

Conclusion. To our knowledge, this sub-project represents the first prospective examination of the impact of a parenting intervention on immune function in the preschool period.

Funded by:

  • Alberta Children’s Hospital Research Institute (ACHRI)

Members of the Team


Name and Title: Dr. Nicole Letourneau (PI), Professor and ACHF Research Chair in Parent-Infant Mental Health (AllerGen Investigator)

Email Address: nicole.Letourneau@ucalgary.ca

Name and Title: Dr. Kharah Ross (Co-PI), Owerko Postdoctoral Fellow, Alberta Children’s Hospital Research Institute, University of Calgary

Email Address: Kharah.Ross@ucalgary.ca