Open Access Study protocol

A randomized controlled trial comparing Circle of Security Intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill mothers: Study Protocol

Brigitte Ramsauer1*, Annett Lotzin1, Christine Mühlhan1, Georg Romer2, Tobias Nolte3, Peter Fonagy4 and Bert Powell5

Author Affiliations

1 Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center (UKE) Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany

2 Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Münster, Schmeddingstrasse 50, 48149 Münster, Germany

3 Anna Freud Centre, 12 Maresfield Gardens, London NW3 5SU, UK

4 Educational and Health Psychology Department of Clinical, Educational and Health Psychology, University College London, Chandler House, 1-19 Torrington Place, London WC1E 7HB, UK

5 Marycliff Institute, 35 W Main Ave, Spokane, WA, US

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BMC Psychiatry 2014, 14:24  doi:10.1186/1471-244X-14-24

Published: 30 January 2014



Psychopathology in women after childbirth represents a significant risk factor for parenting and infant mental health. Regarding child development, these infants are at increased risk for developing unfavorable attachment strategies to their mothers and for subsequent behavioral, emotional and cognitive impairments throughout childhood. To date, the specific efficacy of an early attachment-based parenting group intervention under standard clinical outpatient conditions, and the moderators and mediators that promote attachment security in infants of mentally ill mothers, have been poorly evaluated.


This randomized controlled clinical trial tests whether promoting attachment security in infancy with the Circle of Security (COS) Intervention will result in a higher rate of securely attached children compared to treatment as usual (TAU). Furthermore, we will determine whether the distributions of securely attached children are moderated or mediated by variations in maternal sensitivity, mentalizing, attachment representations, and psychopathology obtained at baseline and at follow-up. We plan to recruit 80 mother-infant dyads when infants are aged 4-9 months with 40 dyads being randomized to each treatment arm. Infants and mothers will be reassessed when the children are 16-18 months of age. Methodological aspects of the study are systematic recruitment and randomization, explicit inclusion and exclusion criteria, research assessors and coders blinded to treatment allocation, advanced statistical analysis, manualized treatment protocols and assessments of treatment adherence and integrity.


The aim of this clinical trial is to determine whether there are specific effects of an attachment-based intervention that promotes attachment security in infants. Additionally, we anticipate being able to utilize data on maternal and child outcome measures to obtain preliminary indications about potential moderators of the intervention and inform hypotheses about which intervention may be most suitable when offered in a clinical psychiatric outpatient context.

Trial registration

Current Controlled Trials ISRCTN88988596