Implementing Attachment and Biobehavioral Catch-Up (ABC) -Infant Meets HHS Criteria

Last updated: August 2020

Implementation experiences

Summary of sources

Information in this section is based on studies included in the HomVEE review. For ABC-Infant*, we reviewed 17 manuscripts, including 11 impact manuscripts describing 4 randomized controlled trials and 6 implementation manuscripts. (Please see Studies for Implementation Experiences for a list of the manuscripts and to link to the characteristics of the samples examined in the impact studies.)

In the following sections, we consider all manuscripts about a particular sample to be a single study. For example, seven manuscripts were based on the same group of participants and are cited as one study. There are 9 distinct studies across the 17 manuscripts.

*The manuscripts HomVEE reviewed for ABC-Infant include research published before 2015 when the model was called the ABC Intervention and research published after the developer renamed the model ABC-Infant once ABC-Toddler was introduced. Although ABC-Infant is designed for families of infants between the ages of 6 and 24 months, some toddlers were part of the research samples in the early studies of the model. This report does not include information on the implementation experiences for ABC-Toddler because it has not met the HHS criteria for an evidence-based model.   

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Characteristics of model participants

Most caregivers in ABC-Infant studies were female (89 to 97 percent); 2 to 10 percent were male (three studies). Thirty-nine to 51 percent of children were female and 49 to 62 percent were male (four studies).

At enrollment, caregivers were on average 25 to 40 years old (four studies). In two of these studies, caregivers ranged from about 16 to 47 years old. Children’s average age at enrollment ranged from 10 to 22 months old (four studies). Two of these studies reported that children’s age at enrollment ranged from about 2 to 27 months. Another study reported that children’s average age at completion of ABC-Infant was 27 months.

Programs served racially and ethnically diverse families (four studies).* The percentage of caregivers who were White ranged from 10 to 98 percent (three studies). One to 61 percent of caregivers were Black (two studies), 9 to 50 percent were biracial (two studies), 16 percent were Native Hawaiian or other Pacific Islander (one study), 5 to 15 percent were Latinx/Hispanic (two studies), and 2 to 9 percent were Asian American (two studies).

Among children, 4 to 68 percent were Asian American (two studies), 10 to 61 percent were Black (three studies), 8 to 39 percent were White (three studies), 5 to 20 percent were biracial (three studies), 11 percent were Latinx/Hispanic (one study), and 2 to 8 percent were another race (three studies).

The percentage of caregivers who did not complete high school ranged from 0 to 68 percent (three studies). In two of these studies, 15 percent finished some college, 8 to 37 percent completed college or technical school, and in one study 48 percent of caregivers attended graduate school. Programs supported families with caregivers who were single, divorced or separated, married, or living with a partner (three studies). In two of these studies, 7 to 94 percent of caregivers were single and 6 to 93 percent were married or living with a partner. One of these studies reported that 10 percent of caregivers were separated or divorced. The third study reported that 49 percent of caregivers were living in two-adult households, 27 percent were single, and 23 percent were living in households with at least three adults.

In one study, all caregivers were involved with the child welfare system.

Two studies included families with adopted children. In one study, all children were adopted internationally. Sixty-three percent of the children were adopted from Asia, 17 percent from Eastern Europe, 13 percent from Africa, and 8 percent from Central America (percentages do not add up to 100 percent because of rounding). In another study, 58 percent of children were internationally adopted, 26 percent were domestically adopted, and 16 percent were in foster care.

*The count of studies for each racial and ethnic category comprises studies that included sample members from the racial or ethnic category. If the study did not include sample members from a particular category, the study is not included in the count.

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Location and setting

Programs were located in a large mid-Atlantic city, Delaware, Hawaii, and a southeastern state. Two studies examined programs across five to six states.

Implementing agencies included a university, a child welfare system, and social service agencies.

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Staffing and supervision

ABC-Infant staff included home visitors, referred to as parent coaches or parent trainers (seven studies) or clinicians (two studies), and a supervisor (one study).

Most home visitors had bachelor’s or post-graduate degrees (five studies). Sixty-seven to 74 percent of home visitors had a master’s degree and 3 to 4 percent had a Ph.D. (two studies). In one of these studies, 23 percent of home visitors had a bachelor’s degree or less, and in the other study, 22 percent had a bachelor’s degree and 4 percent completed high school or less.

Three studies reported home visitors’ experience working with families and children. In two studies, home visitors had an average of 9 to 11 years of experience. In the third study, home visitors’ experience ranged from 0 to 30 years. Another study generally reported that home visitors had experience working with children and strong interpersonal skills.

Parent coaches participated in two- to three-day pre-service training workshops (five studies). In one of these studies, training introduced parent coaches to the model, reviewed the model’s research base, explained “in the moment” commenting (immediate caregiver feedback; described under Model Components) and coding, and provided an overview of manualized content. This training used didactic and active learning, such as role-play, commenting practice, and live coding of video clips.

Supervision included individual and group meetings to monitor and promote implementation fidelity and quality. Three studies indicated that weekly supervision occurred for one year. Another three studies reported on individual elements of the supervision process—two studies reported that supervision occurred weekly and one study reported that supervision occurred for one year. Supervision lasted 1 to 1.5 hours (two studies). During supervision, home visitors and supervisors reviewed the home visitors’ fidelity to the model (five studies), discussed case-specific issues (three studies), and viewed video clips of home visitors’ sessions to assess how home visitors integrated “in the moment” comments with manual content (two studies). As part of the fidelity monitoring process, home visitors coded a video clip of their sessions to self-assess the quantity and quality of their “in the moment” commenting (three studies). Subsequently, home visitors would review their coding with their supervisors, discussing implementation strengths and areas for growth. In one study, the supervisor and home visitor would engage in “live coding,” during which they would collaboratively review, discuss, and code a previously uncoded clip. Another study relied on a microanalytic coding system to quantify “in the moment” commenting. This coding system informed home visitors’ certification, training, and supervision.

No reviewed studies reported a supervisor-to-home visitor ratio, but one study reported that the program’s home visitor supported 19 families.

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Model services

The programs intended to provide 10 home visits (six studies) lasting one hour each (four studies). One study reported that home visits were designed to occur weekly over the course of 10 weeks. Four additional studies reported on the intended frequency or dosage of home visits—two studies reported a target of weekly home visits, and the other two studies reported that home visits were designed to last 10 weeks.

Home visitors followed a manualized curriculum (five studies). The visits focused on the following target caregiver behaviors: (1) nurturance (seven studies), (2) following the child’s lead (seven studies), and (3) non-frightening behavior (six studies). Home visits also included the following:

  • “In the moment” commenting (eight studies). The home visitor gave immediate feedback to the caregiver to reinforce skills, support the caregiver’s efforts, and enhance the relationship between the caregiver and home visitor.
  • Structured activities (three studies). These were opportunities for the caregiver to practice the target caregiver behaviors with the child under the supervision of the home visitor.
  • Video feedback (four studies). The home visitor and caregiver watched a video of the caregiver’s interaction with the child. The home visitor highlighted the caregiver’s strengths, celebrated changes in behavior, and identified areas for improvement.
  • Homework (two studies). Homework gave an additional opportunity for caregivers to practice the skills they learned and record their observations about their and the child’s behavior during the week.

Although most sessions focused on target caregiver behaviors, in one session, caregivers reflected about how their experiences with their own caregivers growing up might have influenced their comfort and ability to display target behaviors (three studies).

None of the studies reviewed included information about assessments.

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Model adaptations or enhancements

None of the studies reviewed included adaptations or enhancements to the model.
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Families received an average of 9 to 10 home visits (five studies). Each home visit lasted one hour (four studies). Home visits occurred weekly for 10 weeks (three studies).
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Lessons learned

Eight studies discussed lessons learned during implementation.

Individualizing services. One study recommended conducting additional research to understand the characteristics of families for whom ABC-Infant works best and then targeting those families. With families for whom ABC-Infant is less successful, efforts to adapt or enhance ABC-Infant to meet their needs are encouraged (two studies). One of these studies noted that if home visitors do not see a change in caregiver behavior after the first few sessions, home visitors should adjust their therapeutic approach.

Fidelity-focused consultation. Six studies reported lessons learned regarding fidelity monitoring and fidelity-focused consultation. One study recommended that home visitors receive pre-service and in-service training on how to evaluate the frequency and quality of their “in the moment” commenting using video clips of their visits. The study also noted that this type of video assessment might encourage peer-based supervision and self-supervision, reducing the necessity of formal supervision. Similarly, one study found that home visitors who received minimal supervision made little improvement in their “in the moment” commenting, suggesting the importance of providing home visitors with thorough training and supervision on the “in the moment” commenting process.* The study also recommended that supervision sessions be individualized to the needs of the home visitor, for example, by modifying the frequency or content of supervision based on the home visitor’s level of comfort or implementation effectiveness.

Four studies of programs that implemented fidelity-focused consultation involving self-assessments suggested that this type of consultation can promote home visitors’ ability to implement ABC-Infant with fidelity. One study suggested that fidelity-focused consultation can help home visitors effectively self-assess their service delivery and, thus, self-supervise. Another study concluded that the process of monitoring one’s own fidelity could lead to a positive feedback loop that increased the home visitor’s receptivity to feedback from his or her supervisor. However, the study also noted that fidelity-focused consultation might only promote fidelity if home visitors also receive standard supervision.

Home visitor candidate screening. One study used a screening interview process to measure the ability of potential home visitors to understand and recognize target caregiver behaviors and use “in the moment” comments to address these behaviors. This study suggested that the screening interview for home visitor candidates could be used to (1) predict home visitors' ability to successfully implement ABC-Infant in real, home-based settings; (2) help identify appropriate levels of training for home visitors; and (3) support staffing decisions and resource allocation, including financial and human resources.

*HomVEE did not review the rigor of the design used in this manuscript because the analysis did not include a comparison group.

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