Behavioral difficulties and social and emotional problems are the most common reasons for clinical assessment amongst 2–5-year olds (Keenan and Wakschlag 2000). Difficulties in these domains are relatively stable over time, with approximately 50% of all 2–3-year olds with problematic behavior receiving a diagnosis of a behavioral disorder 42–48 months later (Alink et al. 2006). Diagnosed children are at a greater risk for more severe problems by the time they reach school age (Shaw et al. 2003), with persistent behavior problems contributing to impairments in social and cognitive development (Stams et al. 2002; Stright et al. 2008), increased inter-personal conflicts with peers (Menting et al. 2011), and low levels of academic competence and performance (Stright et al. 2008). In the longer term, these children are more likely to use mental health services (Essex et al. 2009) with estimates suggesting that an additional £70,000 per individual is needed to fund services by the time they reach 30 years old (Scott et al. 2001). It is widely accepted that the development of psychopathology is best understood in the context of early parent–child interactions and that precursors can be detected during infancy (Skovgaard et al. 2007, 2008). Consequently, early assessment and identification is paramount to ensuring the best outcomes for all children and families. Some observational measures can be used to identify children and families in need of intervention, to monitor their progress, and to evaluate programs as part of research. However, they must satisfy stringent psychometric criteria of reliability and validity to ensure assessment accuracy in order that families receive relevant offers of support and reliable monitoring of their progress.
The quality of early parent–child (birth to 5 years) interactions provide the foundation for all future social interactions and are considered an important component for conceptualizing and assessing behavioral and emotional difficulties in infancy (Zeanah 2009). For example, research indicates that sensitive and responsive parenting that is tailored to an infant’s developmental needs predicts secure attachment (Kim et al. 2017), social and emotional competence (Leerkes et al. 2009; Raby et al. 2015), advanced cognitive abilities (Bernier et al. 2010, 2012; Evans and Porter 2009), and good quality language outcomes (Costanstini et al. 2011; Gridley et al. 2016; Hudson et al. 2015). In contrast, children exposed to less sensitive or responsive parenting, or to repetitive and punitive caregiving, are at greater risk for developmental disadvantage by 16 years (Bender et al. 2007) unless effective treatments and interventions are received (Barlow et al. 2016).
Parent programs are the preferred preventative intervention/treatment for childhood behavior, social, and emotional problems (Bywater 2017). There is an increasing awareness amongst researchers and practitioners that the process of identifying, assessing, and evaluating should be supported by the use and implementation of robust measures that provide reliable and valid outcomes (Arora et al. 2016). Unfortunately, many measures used routinely with older children are adopted for use with younger age groups without consideration as to whether they are acceptable or psychometrically sound (Pontoppidan et al. 2017). As a result, commonly used measures in research and practice may be unfit for purpose and there is a need to re-assess the level of psychometric evidence when used with this younger age group.
Observational methods are considered the gold standard assessment of parent–child interaction (Hawes and Dadds 2006) because they provide objective, fine-grained, details of the relationship that may occur without awareness (Wysocki 2015). In contrast to other assessment measures (i.e., questionnaires) observational assessments can identify both the strengths and difficulties that occur during early dyadic interactions that might influence the trajectory of a child’s development (Bennetts et al. 2016), and they directly measure behavior as it happens in real time (Dishion et al. 2017). Moreover, as most observations can be conducted in the home without being prescriptive (Bagner et al. 2015) they are often regarded as essential to a multi-component assessment which provides a comprehensive evaluation of the caregiving environment (Bagner et al. 2012; Aspland and Gardner 2003). As supporting parent–child interaction is often the key goal of early intervention programs (Gottwald and Thurman 1994) the use of observational tools as outcome measures is now seen by many as being integral to understanding change at a meaningful level (NICE 2017).
There are a number of observational measures available to researchers and practitioners to assess early parent–child interactions, but these measures target a broad range of constructs (i.e., dyadic synchrony, maternal responsivity/sensitivity, emotional availability, affect, learning support, intrusiveness), and subsequently utilize different units for coding target behavior (Aspland and Gardner 2003; Lotzin et al. 2015). Coding schemes are typically classified into two categories; macro or micro (Dishion et al. 2017; Rosenberg et al. 1986). Macro observations utilize broad categories (i.e., responsivity/sensitivity) to summarize substantial amounts of information into usable components. These schemes typically utilize global ratings to make judgements based on the number of acts observed over a period of time, and as a consequence such schemes require less rigorous training in order for users to become reliable (Rosenberg et al. 1986). In contrast, micro observational schemes encompass specific and narrowly defined categories, which capture moment-to-moment behaviors as miniature chunks of information either via interval coding, or continuous recording (Dishion et al. 2017; Morawska et al. 2014; Rosenberg et al. 1986). Due to their complexity micro observational schemes require extensive training, but it is argued that these measurements of parent–child dynamics are more sensitive to change following intervention (Dishion et al. 2017; Morawska et al. 2014). Due in part to methodological variation between measures, there is little agreement in the literature as to which is accepted as the single standard for measuring parent-infant interaction (Lotzin et al. 2015). Consequently, when researchers and practitioners are selecting the most appropriate measure to be used for their purpose it is argued that careful consideration of a measure’s reliability and validity should be taken into account (Lotzin et al. 2015; Rosenberg et al. 1986).
According to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN; de Vet et al. 2015; Terwee et al. 2007) reliability is defined as the degree to which a measure is free from measurement error. The extended definition distinguishes between four reliability assessments that can be determined for most observational measures. Internal consistency refers to the degree of interrelatedness among items of a given observational tool, and only lends itself to observational tools that utilize non-dichotomous recording methods (i.e., frequency counts or Likert scales). Test–re-test reliability seeks to establish a measure’s stability over time and can be performed on all observational tools where data are available at two timepoints. Finally, inter- and intra-rater reliability are two assessments of coder/rater consistency. Inter-rater assesses scores from different people at the same time, whilst intra-rater assesses scores from the same person at different times. Both inter- and intra-rater reliability are easily applied across all observational coding schemes irrespective of recording method or number of observations and are the most commonly used psychometric assessment for observational measures (Aspland and Gardner 2003).
The COSMIN states validity is the degree to which a measure truly measures the construct it purports to measure. The extended definition distinguishes three types of validity that can be determined for most observational tools. Content validity is the degree to which a measure is an adequate reflection of the construct that it intends to measure. This level of validity is typically determined by agreement amongst experts in the field during coding scheme construction. Criterion validity is the degree to which scores of a measure are an adequate reflection of the gold standard. Given that there is not one single standard for measuring parent–child interaction this aspect of validity is particularly difficult to determine for most observational tools. Finally, construct validity is the degree to which the scores of a measure are consistent with the hypotheses. Construct validity is typically viewed as an umbrella term to describe three aspects of a measures property that are particularly important for observational measures; structural validity, hypothesis testing, and cross-cultural validity. In terms of observational measures structural validity is the degree to which scores of a measure are an adequate reflection of the dimensionality of the construct to be measured typically assessed using factor analysis to confirm composite variables. Hypothesis testing is the degree to which relationships between scores on one measure are sufficiently related (convergent) or unrelated (divergent) to scores on other instruments measuring similar or dissimilar constructs, or different groups of patients (discriminative). Finally, cross-cultural validity is the degree to which performance of the items on a translated or culturally adapted instrument reflect the performance of items in the original version. In addition to reliability and validity, the COSMIN describes a further dimension of a measure’s psychometric properties; responsiveness. Responsiveness is defined as the ability to detect change following intervention and is critical to a measures ability to be used as an outcome measure in research and practice.
Previous reviews have indicated that the most commonly reported psychometric properties for observational measures of parent–child interactions tend to be aspects of reliability, whereas validity is under-reported (Aspland and Gardner 2003). Furthermore, not all components of reliability or validity are tested. For example, a non-systematic review (Munson and Odom 1996) indicated that whilst 94% of the 17 rating scales developed to measure parent-infant interaction from birth to 3 years reported on at least one form of reliability, only 29% provided both internal consistency and inter-rater agreement estimates. In terms of validity, 94% of measures reported evidence for at least one type of validity. Conversely, Bagner et al. (2012) indicated that of the four observational measures reviewed for the detection of emotional and behavioral problems in infancy (birth to 2 years) all reported on and evidenced at least one aspect of reliability and one aspect of validity. Whilst internal consistency and inter-rater reliability were the more commonly reported constructs of reliability, convergent, and discriminative or divergent validity were the most commonly reported aspects of validity. Locke and Prinz (2002) identified 33 observational tools for use with parents and their children aged from 1 to 18 years, with all but one reporting on at least one aspect of reliability and all but three reporting on one aspect of validity. Despite the encouraging findings, there is little information relating to the specific dimensions of reliability assessed, or indeed what the comparators for validation were.
More recent systematic reviews (Hurley et al. 2014; Lotzin et al. 2015; Perrelli et al. 2014) also found that results regarding measurement reliability (for use with children up to 18 years) are generally well reported, yet evidence for validity is scarce. For example, Lotzin et al. (2015) indicated that only 37.5% of the 24 reviewed measures for children under 12 months had supporting evidence of content validity and 66.6% of measures reported evidence for structural validity. Moreover, whilst 15 measures did evidence convergent validity overall the authors failed to find evidence across all five domains of validity, with less than 50% providing evidence across just four domains. For observational tools that focus specifically on nurturing behaviors (for parents of children aged 1–18 years) Hurley et al. (2014) identified that only one of three measures reported content validity, whilst the other two reported on only two dimensions of reliability with relatively acceptable levels.
Despite limitations of earlier reviews (e.g., search strategies and data synthesis methods), the findings highlight significant gaps in the knowledge of all psychometric properties for observational measures used to assess dyadic interactions across the age range of birth up to and including 5 years. Furthermore, it has been argued that there is a need to adopt a standardized method to synthesize findings from multiple reviews of measurement properties using predefined guidelines to allow for easy comparison across reviews (Lotzin et al. 2015; Terwee et al. 2016). As a result, a further systematic review to assess observational measures for parents and their children (aged 0–5 years) adopting a standardized method of synthesis was deemed worthwhile.
The current review had two aims. Firstly, we wanted to identify the most commonly reported observational outcome measures of parent–child interaction used in randomized controlled trial (RCT) evaluations of parenting programs delivered antenatally and/or for parents of children up to and including 5 years. Specifically, we were interested in observational measures that provided an assessment of parent–child interaction, including attachment, bonding, and/or maternal sensitivity. Secondly, we sought to identify and synthesize the current evidence base for each of the included measures psychometric properties via a second systematic search of the scientific literature.
The rationale for focusing specifically on commonly used measures within RCTs of parenting programs was twofold. Firstly, we wanted to find measures in robust evaluations because we assumed these would be the most reliable/valid tools. Secondly, we wanted to build on the consistency that already exists in the field since the parenting field has been well established for several decades. The purpose was to provide further evidence of the strengths and limitations of existing observational tools with the intention of being able to recommend particular tools for practice. Throughout the remainder of this review evidence for each of the included measures psychometric standing will be conceptually organized according to their reliability and validity using the terms and definitions applied by the COSMIN checklist (de Vet et al. 2015; Terwee et al. 2007).