Overview Course: CARE Index - from birth to 24 months
Family Relations Institute
Attachment in infancy
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The CARE-Index is the simplest and most versatile of the DMM measures. It assesses mother-infant
interaction from birth to about two years of age based on a short, videotaped play interaction of 3-5 minutes.
Once the coder is trained, coding of an interaction takes about 15-20 minutes. The measure assesses mothers on three scales:
sensitivity, control and unresponsiveness. There are also four scales for infants: cooperativeness, compulsivity,
difficultness, and passivity. These scales tend to be related to the maternal scales in the order listed.
1. Are highly correlated with the infant Strange Situation assessment patterns of attachment
2. Differentiate abusing from neglecting, abusing-and-neglecting, marginally maltreating, and adequate dyads
3. Can be used during intervention,
4. Can be used to assess the effectiveness of intervention.
The information derived from the CARE-Index can be used as quasi-continuous or categorical data by researchers. In addition, however, the
procedure is easily applied to "live" observations made by nurses, infant teachers, clinicians, and social workers. Needless to say,
such observations cannot be treated as reliable when video is not used, but the method is effective in the same way that other guided
observations or interviews are; furthermore, specific training of what to look for sharpens both one's observation and one's ability to
tell others exactly what the dyad did and why it should be interpreted in a particular manner.
The course is taught from videotapes and depends upon both adult and infant behavior. Non-verbal behavior, interpersonal strategies, and
developmental processes are emphasized. Adult patterns consist of sensitivity, controlling, and unresponsivity; the infant patterns are
cooperative, difficult, compulsive compliant, caregiving or attention, and passive. The course includes a preliminary reliability test based
on a standardized set of American mother-infant dyads.
During the course, participants generate a set of videotapes that reflect their intended applications and culture(s). These tapes are used to
assess the participant's competence in administering the procedure.
A second course on toddlers (15-30 months) is now offered. The patterns include a wider array of compulsive patterns and coercive
patterns (both aggressive and passive) as well as combinations.
As with all courses offered by Dr. Crittenden, participants are given a written and signed statement of their percent agreement with the
standard. This reliability can be reported in research articles. Evidence of reliability should be requested if the participant will code
data for another researcher.
In addition, courses are offered from time to time for people who wish to become trainers. There are also advanced clinical seminars offered
to international groups of experienced coders. These are held in central Italy and on the coast of Nova Scotia, Canada.
To inquire about the course in general, interested parties can contact Dr. Crittenden directly. To register for courses,
individuals should check the local events section listed on this web page and contact the relevant organizer. Dr. Crittenden
does not handle registration or fee payment. Requests to run a new course can be directed to Dr. Crittenden.
Studies Using The CARE-Index
1. Adolescent mothers
Pacquette, D., Bigras, M., Zoccolillo, M., Tremblay, R., Labelle, M-» & Azar, R. (2001). Comparison de la sensibilitè parentale
entre des mëres adolescentes et des mëres adultes peu scolarisèes. Revue de Psychoèducation et d'Orientation,
30, 283-298. See also Leadbeater, et al. and Linares et al., below
2. Drug abusing mothers; drug exposed infants
Ciotti, F., Lambruschi, F., Pittino, B., & Crittenden, P. (1998). La valutazione della relazione precoce madre-bambino in una popolazione di madri con una storia di tossicodipendenza attraverso l'uso del CARE-Index. Psicoterapia Cognitiva e Comportamentale, 4, 53-59.
See also Linares et al.
3. Maternal psychiatric disorder
Hughes, S. (1993). The relationship between maternal psychiatric disorder and mother-child responsivity. Dissertation presented to
the Faculty of McGill University, Montreal, Canada.
Leadbeater, B. J., Bishop, S. J., & Raver, C. C. (1996). Quality of mother-toddler interaction, maternal depressive symptoms, and
behavior problems of adolescent mothers. Developmental Psychology, 32, 280-288.
Linares, L. O. (in press). Substance abusing mothers involved in the child welfare system. Women's Health System
Leventhal, A., Jacobsen, T., & Miller, L. J. (in press). Parenting attitudes and parenting behavior among mothers with mental
illness. Psychiatric Services.
Mullick, M., Miller, L. J., Jacobsen, T. (2001). Insight into Mental Illness and Child Maltreatment Risk in Mothers with Major
Psychiatric Disorders. Psychiatric Services, 52, 488-492.
4. Handicapping conditions
Crittenden, P. M. & Bonvillian, J.D. (1984). The effect of maternal risk status on maternal sensitivity to infant cues. American
Journal of Orthopsychiatry, 54, 250-262.
Rauh, H., & Calvet-Kruppa, C. (2001). Bindungssicherheit und Verhaltensentwicklung bei Kindern mit Down-Syndrom. Psychologie in
Erziehung und Unterricht.
5. Maltreated infants
Crittenden, P.M. (1992a). Children's strategies for coping with adverse home environments. International Journal of Child Abuse and
Neglect, 16, 329-343.
Crittenden, P. M. (1988). Distorted patterns of relationship in maltreating families: The role of internal representational models.
Journal of Reproductive and Infant Psychology, 6, 183-199.
Crittenden, P. M. & DiLalla, D. L. (1988). Compulsive compliance: The development of an inhibitory coping strategy in infancy.
Journal of Abnormal Child Psychology, 16, 585-599.
Crittenden, P. M. (1987). Non-organic failure-to-thrive: Deprivation or distortion? Infant Mental Health Journal, 8, 56-64.
Crittenden, P. M. (1985). Social networks, quality of child-rearing, and child development. Child Development, 56, 1299-1313.
Crittenden, P. M. (1984). Sibling interaction: Evidence of a generational effect in maltreating families. International Journal of
Child Abuse and Neglect, 8, 433-438.
Crittenden, P. M. (1981). Abusing, neglecting, problematic, and adequate dyads: Differentiating by patterns of interaction.
Merrill-Palmer Quarterly, 27, 1-18.
Jacobsen, T., & Miller, L. J. (1998). Compulsive compliance in a young maltreated child. Journal of the American Academy of
Child and Adolescent Psychiatry, 37(5), 462-463.
Leadbeater, B., & Bishop, S. J. (1994). Predictors of behavior problems in preschool children of inner city Afro-American
and Puerto Rican mothers. Child Development, 65, 638-648.
Ward, M. J., Kessler, D. B., && Altman, S. C. (1993). Infant-mother attachment in children with failure to thrive. Infant
Mental Health Journal, 14, 208-220.
Patino, F. L. (1993). Mothers' prenatal attachment history, attachment status, and social support satisfaction as predictors of
postnatal maternal sensitivity. Dissertation Abstracts International, 53 (7-B): 3787.
Predictive Longitudinal Studies
Simó, S., Rauh, H., & Ziegenhain, U. (2000). (English title: Mother-infant interaction during the first eighteen months and attachment
security at the end of the second year.) Mutter-Kind-Interaktion in den ersten 18 Lebensmonaten und Bindungssicherheit am Ende des 2.
Lebensjahres. Psychologie in Erziehung und Unterricht, 47, 118-141.
Ward, M.J., & Carlson E.A. (1995). The predictive validity of the Adult Attachment Interview for adolescent mothers. Child
Bigras, M. & Pacquette, D. (2000). L'interdèpendance entre les sous-systëstemes conjugal et parental: Une analyse
personne-processus-contexte. Psicologia: Teoria e Pesquisa, 16, 91-102.
Cramer, B., Robert-Tissot, C., Stern, D. N., & Serpa-Rusconi, S. (1990). Outcome evaluation in brief mother-infant psychotherapy:
A preliminary report. Infant Mental Health Journal, 11, 278-300.
Crittenden, P. M. (1985). Maltreated infants: Vulnerability and resilience. Journal of Child
Psychology and Psychiatry, 26, 85-96.
Linares, L. O. (in press). The effects of an early intervention program on polydrug infants and their families in foster care.
In J. Silver (Ed.), Serving the needs of young children
involved in the child welfare system.
Linares, L.O., Jones, B., Sheiber, F.J. & Rosenberg, F.B. (1999). Early intervention for drug-exposed infants in foster care.
In. J. Silver, B. J. Amster & Haecker (Eds.),
Young Children and Foster Care (pp. 373-397). Baltimore: Brookes.
Pacquette, D., Zoccolillo, M., & Bigras, M. (1999). L'efficacitè des interventions en foyers de groupe pour mëres en
difficultè d'adaptation. Dèfi Jeunesse, VI, 30-35.
Robert-Tissot, C., Cramer, B., Stern, D., Serpa, S. et-al. (1996). Outcome evaluation in brief mother-infant psychotherapies:
Report on 75 cases. Infant Mental Health Journal, 17, 97-114.