Video feedback in widescreen: A meta-analysis of family programs
Ruben G. Fukkink ⁎
SCO—Kohnstamm Instituut, Universiteit van Amsterdam, Nieuwe Prinsengracht 130, 1018 VZ Amsterdam, The Netherlands
Received 26 June 2007; received in revised form 23 January 2008; accepted 24 January 2008
Abstract
A meta-analysis of 29 studies (n=1844 families) shows statistically significant positive effects of video feedback interventions
on the parenting behavior and attitude of parents and the development of the child. Parents become more skilled in interacting with
their young child and experience fewer problems and gain more pleasure from their role as parent. Shorter programs appeared to be
more effective in improving parenting skills. The intervention effects were smaller for the attitude domain at parent level. The
experimental outcomes were smaller at child level if the parents belonged to a high-risk group.
© 2008 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
1.1. Research into the effectiveness of video feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
2. Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
2.1. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
2.2. Coding of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
2.2.1. Parent and child population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
2.2.2. Methodological characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
2.3. Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
3.1. Characteristics of the video feedback programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
3.2. Family characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
3.3. Research design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
3.4. Intervention effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
3.5. Effects on parenting behavior of parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
3.6. Effects on parental attitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
3.7. Effects on children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
4. Conclusion and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
References4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913
Available online at www.sciencedirect.com
Clinical Psychology Review 28 (2008) 904–916
⁎ Tel.: +31 20 525 1351; fax: +31 20 525 1200.
E-mail address: R.G.Fukkink@uva.nl.
0272-7358/$ - see front matter © 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2008.01.003
1. Introduction
The use of video in pedagogical programs, whereby parents are filmed taking part in family interactions and then
watch the recordings, is popular. The video in these programs makes it possible to hold a mirror up to parents, to focus
on specific behavior and to see the effects of this behavior on a child for feedback purposes.
The very first studies into video feedback1
were still very much focused on the autonomous, isolated effect of
watching oneself (see Berger, 1978; Fuller & Manning, 1973; Hung & Rosenthal, 1981). Later applications of
video feedback have been both supplemented and refined in various respects. First of all, video feedback is usually
part of a multimodal approach which use is also made of instruction, therapeutic counseling and/or other forms of
parental support (Brisch et al., 1997). Furthermore, family programs use special strategies in the application of
video feedback and the therapist works according to a protocol when filming, editing the recordings and in leading
the session when watching the video, in keeping with generally formulated principles for this method (see Dowrick,
1991; Wels, 2004 for a review). First, most programs describe the situations to be filmed. The therapist often
records the natural interaction between a parent and a child in a regular setting, for example, when a mother plays
with the child, or feeds or baths her child in the home environment. Subsequently, the therapist carefully edits the
recording to select certain images. In the beginning of the therapy, the selection of fragments may be guided by the
purpose to stimulate reflection, gain insight and motivate change and thus elicit a therapeutic effect. Later during
the therapy, the clinician may also highlight progress or change that has already been made. The duration of the
edited video is usually relatively short, varying from four 30-second excerpts (Schechter et al., 2006) to 15 min
(Benoit, Madigan, Lecce, Shea & Goldberg, 2001). The last stage of viewing the recordings, the actual video
feedback, is especially important. During the replay of the video, a detailed and structured analysis of the video
images using behavior coding, i.e. focusing on specific behaviors, is important. The clinician may stop the edited
video at certain moments or may repeat certain fragments occasionally to highlight specific behavior of the parent
in interaction with the child. The clinician may, for example, focus the parents' attention to highly concrete
behavior (for example, sequences of a baby's signal followed by a parents' response to it) to highlight the importance
of sensitivity, to provide the client feedback or to elicit a discussion. In the final feedback stage, positive
feedback of the therapist is deemed important as it contributes to a cooperative trusting relationship between the
therapist and the family, this in keeping with the parents' (in most cases the mother's) need for support and the
sometimes problematic past as far as relationships with others was concerned (see McDonough, 2005 for example;
see also Claiborn & Goodyear, 2005).
The video feedback family programs vary in their design and procedures, although two major approaches can be
distinguished. Behavior-orientated programs, also referred to as the interactive approach or sensitivity training, are
primarily focused on interactive behavior, which forms both the starting point and the end point of the therapy. In these
forms of therapy, the behavior of the parent and the child and the interaction between them forms the ‘port of entry’ (see
Stern, 1985, 2004). Using this approach, video is a logical aid in making interaction the focus of attention (see
McDonough, 2005 for an example). Using the psychotherapeutic approach, also referred to as the psychodynamic
approach, the mental representations that the mother has of herself, her child and their relationship form the port of
entry for therapy, with particular attention often paid to the mother's own past. Video images are shown as part of this
approach to help speed up access to early memories of the mother's own childhood (Lieberman, 2004; Zelenko &
Benham, 2000). The video images are also used, however, as with the behavior-orientated programs, to focus attention
on the interaction between mother and child, which ties in with consideration of the mother's representations (see
Egeland & Erickson, 2004 for an example). Video feedback therefore has a dual purpose here; it is a catalyst in
psychotherapy and a visual medium for portraying and discussing interaction. The distinction between the two
approaches is not clear cut as some programs combine them both (Beebe, 2003; Cramer, 1998; Egeland, Weinfeld,
Bosquet, & Cheng, 2000).
1
The video feedback method has been given various names in its history, such as video self-modelling (Meharg & Woltersdorf, 1990) or, in older
publications, video confrontation (Berger, 1978; Fuller & Manning, 1973), self-confrontation (Dowrick, 1991) and videotaped recorded playback
(Hung & Rosenthal, 1981; Ray & Saxon, 1992).
905R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
1.1. Research into the effectiveness of video feedback
Empirical effect research into video feedback is summarized in a number of qualitative reviews, covering the field of
education (Hitchcock, Dowrick, & Prater, 2003; Hung & Rosenthal, 1981), children with a handicap (Dowrick, 1999)
and applications in a variety of settings (Meharg & Woltersdorf, 1990). Results of these qualitative review studies are
unanimously positive: video feedback leads to an improvement in trained behavior. As yet there is no meta-analytic
review of the effects of video feedback on parents. A small number of relevant studies that specifically focus on the
parents' sensitivity, are included in the meta-analysis of Bakermans-Kranenburg, van IJzendoorn, and Juffer (2003). In
their review study, effects of sensitivity programs that include video feedback compared favorably with other
programs, in terms of sensitivity of the parents. However, video feedback was not found to be more effective in
influencing attachment of children. Interestingly, Bakermans-Kranenburg et al. also found that programs with fewer
sessions were more effective than extensive treatments, supporting their ‘Less is more’ hypothesis.
In this meta-analysis (Cooper & Hedges, 1994; Wampler, Reifman, & Serovich, 2005), we summarize findings from
the studies into the effects of video feedback for the population of parents, focusing on different aspects of the behavior
(a) and the attitude domain (b).2
We also research effects of video feedback treatments on the children in the families
being treated (see Lundahl, Risser, & Lovejoy, 2006 for a comparable approach). This study concentrates on four
research questions. Based on previous reviews (Dowrick, 1999; Hitchcock et al., 2003; Hung & Rosenthal, 1981;
Meharg & Woltersdorf, 1990), including a review for the population of parents (see Bakermans-Kranenburg et al.,
2003), we study the question whether video feedback improves parenting behavior (1). Furthermore, we extend this
research question to the domain of parental attitudes (2) and behavior of children (3). The following questions are
central to this study:
1. Are video feedback interventions effective in improving parenting behavior?
2. Do video feedback interventions lead to an improvement of parents' attitude towards parenting?
3. Are video feedback interventions effective in improving children's behavior?
In an explorative fashion, we study possible relationships between program characteristics and study outcomes that
may shed more light on the question as to whether certain video feedback methods are more effective than others
(Cramer, 1998; Wels, 2004). The meta-analysis of Bakermans-Kranenburg et al. (2003) suggests a possible relationship
between the duration of programs and study outcomes: shorter programs are more effective in improving parenting
behavior. We investigate this relationship, studying not only the number of sessions (a), but also the intervention
duration (b) and total program duration (c).
2. Methods
2.1. Literature search
Various methods were used to search for relevant literature. A general search was first carried out using the Social Sciences
Citation Index (SSCI) and PsychInfo electronic databases. Terms for the relevant intervention [self-model⁎, self-confrontation, selfobservation,
feedback, playback, parental training, intervention, treatment and video⁎] were combined in the search profile with
terms for particular family populations [parent⁎, family⁎, child⁎, marital, mother⁎, and father⁎]. Various reference books and
reviews were also consulted (Bakermans-Kranenburg et al., 2003; Barnard, 1997; Berlin, Ziv, Amaya-Jackson, & Greenberg, 2005;
Levy, 2000; Lieberman & Zeanah, 1999; Osofsky & Fitzgerald, 2000; Sameroff, McDonough, & Rosenblum, 2004; Shonkoff &
Meisels, 2000; Vangelisti, 2004; Zeanah, 2000). Publications of the Video Interaction Guidance International Research Network
were also inventoried. The second phase consisted of searching for references to other studies in the relevant studies found using the
‘snowball method’. References to earlier studies were searched for in the written sources. Citation links in the hits found in the
electronic SSCI files were also searched with the forward method in order to trace later studies. One unpublished paper (Meharg,
1989; see Meharg & Woltersdorf, 1990) was unfortunately unobtainable.
Studies were chosen if they concerned the experimental study of an intervention which made use of video feedback aimed at
parents. Studies which reported on the effects of video instruction on parents (videotape modelling or videotape vignettes) were not
selected as they do not concern the filming of parents who then watch themselves (see for example Black & Teti, 1997; Webster-
2
Intervention effects of video feedback in the knowledge domain have not been studied to our knowledge.
906 R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
Stratton, 1994 for such programs). The effect on parents of filming as a measurement method (see Field & Ignatoff, 1981) was also not
considered as these methodological orientated studies do not involve intervention programs. A few studies involved video feedback,
but it was such a small and/or optional part of a broader intervention with various other parts (see Feinfield & Baker, 2004; Larrieu &
Zeanah, 2004), that the experimental results could not be properly correlated with the central focus of this study. Studies also had to
report on the effects on parenting behavior, parenting-related attitudes and/or child development. One study was not included for this
reason (Brenes & Cooklin, 1983).
For the meta-analysis it was also necessary that the studies give quantitative data necessary for the determination of a statistical
effect size. Experimental single subject studies (for example Juffer, van IJzendoorn, & Bakermans-Kranenburg, 1997; Leifer,
Wax, Leventhal-Belfer, Fouchia, & Morrison, 1989; Meharg & Lipsker, 1992; Reamer, Brady, & Hawkins, 1998), qualitative
case-studies (see Beebe, 2003; Fivaz-Depeursinge, Corboz-Warnery, & Keren, 2004; Marvin, Cooper, Hoffman, & Powell, 2002;
Larrieu & Zeanah, 2004; Mayers, 2005; McDonough, 1995; Ray & Saxon, 1992; Thiel-Bonney, 2002; van Doesum, Hosman &
Riksen-Walraven, 2005; Zelenko & Benham, 2000), other qualitative studies (Häggman-Laitila, Pietilä, Friis, & VehviläinenJulkunen,
2003; Wadsby, Sydsjö, Svedin, 2001) and formative evaluations in intervention development (Jongbloed & Tavecchio,
1995) were not included for this reason. One small-scale study was not included because the statistical information required was
not given. Various papers included descriptive data about parental interventions based on video feedback but did not report on the
experimental results (for example the studies of Marvin et al. (2002), Cramer, 1998; Hofacker & Papoušek, 1998; Hornstein,
Schenk, Wortmann-Fleischer, Schwarz, & Downing, 2006; Vogelvang, 1995. Brisch, Buchheim, Köhntop, Kunzke, Schmücker,
Kächele and Pohlandt, 1996; see also Brisch et al., 1997) describe the planning for a study in progress for which no results have
yet been published.
In total, 29 different experiments were found, which form the unit of analysis in this meta-analysis. These experiments are
described in 26 studies. Studies carried out by Juffer (1997) and Rosenboom (1994) are reviewed in Juffer, Bakermans-Kranenburg,
and Van IJzendoorn (2005), which was used as a primary source. The study carried out by Cramer et al. (1990), which reports on the
provisional results of a research project, has not been included and the later, definitive report by Robert-Tissot et al. (1996) was used
instead. The behavior measures from Sibbing, Kat, Grootenhuis, and Last (2005) were considered to have questionable validity and,
hence, they were not included (i.e., parents indicated in a self-report survey how often they showed highly specific behaviors at
micro-level before and after the treatment); the attitude items from this survey were included, however. In order to code programrelated
characteristics the research literature, where possible and where required, was supplemented with background literature about
the programs from other sources.
2.2. Coding of studies
Each intervention was coded for three types of characteristics: these of the program, the parent and child population, and the
methodology of the studies.
Each intervention was coded according to whether it primarily focused on increasing parent sensitivity or parent representation,
as defined by Egeland, Weinfeld, Bosquet, and Cheng (2000). In keeping with this and other publications (see Cramer & Stern, 1988;
Bakermans-Kranenburg et al., 2003), these two approaches are not considered mutually exclusive categories, and combinations are
therefore possible in practice should different ‘points of departure’ be chosen in order to reach the ultimate objective. The program
duration was also coded (in weeks, subsequently divided into short (≤3 months) and long (N3 months), the average number of
sessions (divided into short and long with ≤7 or N8 sessions respectively) and the average length of a session (in minutes). Based on
this information, the total program ‘dosage’ was determined (in hours) where possible. Also indicated was whether the therapist and/
or trainer were in any way associated with the research institute carrying out the evaluation (the trainer has an academic affiliation, is
member of the research team or is trained by one of the researchers).
The coded study characteristics specific to the video intervention are: a focus on parenting behavior; a focus on parents' mental
representations (characteristic of the psychotherapeutic approach); length of recording (in minutes), whether or not the recording was
edited before being shown to the parents and whether the recording was watched by a parent, parent or parents and trainer, a group of
parents or a group of parents and trainer. The descriptions of the interventions were also used to determine whether or not the
recording, editing and/or viewing of the video recording was carried out in a systematic manner. This is the case if the recording
situation, the editing method and/or the viewing of the recording was carried out according to a preconceived plan. Klein Velderman
(2005), for example, varied the filmed situation according to a fixed protocol. The choice of video fragments (such as selecting a
sequence including a child's signal, the corresponding response of an adult and the reaction of the child, which is the central theme
for a particular session) and the viewing with the parent also varied in this intervention (for example, use of the ‘speaking for the
baby’ technique in the second session, see Carter, Osofsky, & Hann, 1991). Another specific video category is the use of the video
recall. In video recall, the therapist recalls a particular moment using video images and then asks the parent what he or she was
thinking at the time, or what he or she is currently thinking. The accent is therefore on perceptions of family interactions (see Welsh
& Dickson, 2005). The final video-specific category is the use of feedforward, as defined by Dowrick (1991, 1999). With video
feedforward, successful fragments from various recordings are edited into one recording in order to specifically illustrate the desired
behavior. In so doing, a person does not look back at his or her ‘old’ behavior (feedback), but thanks to the editing sees a video of him
907R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
or herself showing the desired, future behavior (feedforward). This editing technique therefore makes it possible to show exemplary
model behavior based on the raw film material from various recordings.
2.2.1. Parent and child population
The following demographic information regarding parents was coded: average age, socio-economic status (low or medium-high)
and first-time parents. Presence of certain risk factors at parent level was also coded. This category was broadly defined, following
Zeanah (2000), which provides an overview of relevant risk factors (e.g. depression, poverty, single parenthood, and teenage parents).
The diagnosis ‘dismissing’ or ‘preoccupied’ in the ‘Adult Attachment Interview’ (see Van IJzendoorn, 1995) was also considered a risk
factor at parent level, following the design of the studies in question. Whether or not the parents came from a clinical population was also
coded (referral by a doctor or psychologist, possibly a DSM diagnosis). For the child population, age was coded, presence of a clinical
syndrome (a developmental or a behavioral disorder, for example, such as excessive crying or hyperactivity, or a clinical score on the
Child Behavior Checklist) and whether or not the child was adopted.
2.2.2. Methodological characteristics
The coded methodological characteristics were: presence/absence of control group; the control group received no intervention
(possibly a placebo) or an alternative intervention; random assignment; and inclusion of a pretest measurement (also the effect size at
the pretest was determined).
Each study was coded by two raters with an inter-rater reliability of .70 or higher (Cohen's kappa was determined for nominal
variables and the intra-class correlation coefficient for interval variables); variables which were coded with inadequate inter-rater
reliability were not included in the analyses.
2.3. Analyses
The experimental effect was determined for each study result using the Hedges' g as effect size, which allows a small
correction in the calculation for a small sample bias (Hedges & Olkin, 1985). The study unit is the individual experimental
comparison, or the effect size per variable (Wampler et al., 2005). The majority of the effect sizes were calculated based on the
reported averages and standard deviations; in a few cases the effect size was derived from the statistical test value or taken from
the report. The experimental results for ‘negative’ variables (for example, parental stress) were converted so that all positive
results had a positive value. The population (parent or child) and the domain (attitude or skills/behavior) were coded for each
study result.
Part of the experimental comparisons concerned “within designs”. The standard error for the effect sizes of these designs was
determined using the Becker formula (1988; see also Morris, 2000). Correlations between the pretest and the posttest were never
reported and a conservative estimation of .5 was used in the calculation. There are 41 study results for the behavior domain, 26 for
the attitude domain for the parent population and 28 for the behavior domain for the child, derived from 29 experiments. There were
no study results within the knowledge domain among parents, and, as expected, only behavior was examined among children.
The experimental effects were then separately aggregated for the behavioral domain, the attitude domain of the parents and the
behavioral domain of the child. A multi-level random effects model (Hedges & Olkin, 1985) was used, which does justice to the
hierarchical structure of the data, in which the study results (the lowest level) are nested under interventions (the highest level). A
multi-level regression model was then used to analyze whether results in the three domains were moderated by the study
characteristics.3
Methodological variables were first checked for significant relationships with study results, before testing the
formulated research questions. The models were determined using the restricted maximum likelihood method (Rasbash et al., 2000;
Hox, 2002). Finally, the model residual variance was checked using the formula proposed by Bryk and Raudenbush (2002).
3. Results
3.1. Characteristics of the video feedback programs
The majority of the family programs (27 out of 29 experiments) had a behavioral focus; this is not surprising considering the
use of video images in family interactions. In five programs the focus was on parent representation. Most programs had one
central focus (20), though some had combinations (see Table 1). The interventions were theoretically embedded in attachment
theory, psychoanalytic theory or various social learning theories. This last category includes various theories which emphasize the
importance of general parent–child interaction for development in the social–emotional and/or cognitive sphere, often tailored to
3
For some analyses the average was used in place of a study characteristic value where the predictor was missing (e.g. number of program
sessions).
908 R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
the specific target group (for example, mothers with eating disorders, mothers with a history of violence and neglect, hyperactive
children etc.).
The average program duration was 26.2 weeks, or about half a year (SD=30.4, min–max: 5–154). An average of 15 sessions was
held during this period (SD=17; min–max: 3–65) with an average duration of 1.5 h (91 min, SD=44, min–max: 38–210). The
estimated total time, or program dosage (based on n=20), averaged about 20 h. Longer programs (more than 3 months) were more
frequent that shorter (59% and 41% respectively). Programs with relatively few sessions (less than 7) and programs with relatively
many sessions were more or less equally represented (52% and 48% respectively).
The trainer background varied in the selected studies. The trainer was often a professional connected in some way with the
university (in 13 cases). In other cases, the trainer was a professional with no academic affiliation (8 cases) or a student trainee (6
cases), and in 2 experiments it was not possible to determine the trainer's background. In most cases, the trainer was briefly
described; for example, it was often impossible to determine the trainer's general work experience and specific experience in the
program being investigated.
It was not possible to determine the video-specific characteristics for every study due to the concise description of the treatment in
a number of reports. Short recordings were usually made in the video feedback interventions (on average 11 min, SD=6.2, min–
max: 5–30 min; n=15).
In most cases, fragments of these recordings were used for later viewing with the parents (16 of the 24 cases, 5 unknown). The
length of the edited tape was on average somewhat less, at about 7 min (SD=4.4; n=6). Attention during feedback discussion of the
video images was often focused on general behavioral dimensions (17 times). In a number of programs attention was also paid to
more specific micro behaviors, such as ethologically oriented categories (eye contact, confirming reception etc.) or the sensitive
Table 1
Summary of program characteristics
Study Program
name
Focus Academic
trainer
Duration Sessions Session
length
Edited
video
Video
recall
Bakermans et al. (1998): I Video B Yes 14 4 135 Yes No
Bakermans et al. (1998): II Video +
discussion
B+R Yes 14 4 135 Yes No
Benoit et al. (2001) Interaction
Guidance
B No 5 5 90 No No
Egeland et al. (2000) STEEP B+R No 65 65 – – Yes
Eliëns (2005) VHT/VIB B No 8 – – Yes No
Jansen and Wels (1998a) VHT B No 32 8 – Yes No
Janssens and Kemper (1996b) VHT B No 32 – – Yes No
Juffer et al. (2005): with birth children – B Yes 12 3 60 Yes No
Juffer et al. (2005): withoutbirth children group – B Yes 12 3 60 Yes No
Kemenoff et al. (1995) – R Yes 5 5 60 No No
Kemper (2004) VHT B No 40 35 67 Yes No
Kim and Mahoney (2005) – B – 12 12 105 No No
Klein Velderman (2005) VIPP B Yes 16 4 90 Yes No
Klein Velderman (2005) VIPP-R B+R Yes 16 4 180 Yes No
Landry et al. (2006) PALS B Yes 10 10 90 – No
Mahoney and Powell (1988) TRIP B No 44 44 – No No
Mendelsohn et al. (2005) – B – 154 12 38 No No
Moran et al. (2005) – B No 5 8 60 No No
Robert-Tissot et al. (1996) Interaction
Guidance
B Yes 9 7 60 No No
Schechter et al. (2006) CAVES R Yes 0 1 – Yes Yes
Seifer et al. (1991) – B No 40 40 210 No No
Sibbing et al. (2005) VHT B No – – – Yes No
Stein et al. (2006) – B Yes 28 12 60 Yes No
Van Zeijl (2006) VIPP-SD B Yes 16 6 90 Yes No
Vogelvang (1993) VHT B No 60 40 86 Yes No
Weiner et al. (1994) VHT/Orion B No 14 14 90 Yes No
Wels et al. (1994) VHT B No – – – – No
Wijnroks (1994) – B Yes 26 4 60 – No
Ziegenhain et al. (2004) – B No 12 7 – – No
Note: Focus = behavior-oriented (B), representation-oriented (R), or both (B+R); duration = program duration in weeks; sessions = average number
of sessions; session length = in minutes; edited video = the recording is edited; video recall: images used to stimulate recall in parent. Not applicable
or information missing reported using ‘–‘.
909R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
responsivity sequence ‘signal from child, response from parent, reaction from child’ (as in the Leiden VIPP course). Consultation
almost always took place on a one-to-one basis, with parent and trainer. One notable exception was the Kim and Mahoney (2005)
study, in which the parents, following instruction in the group and in the home environment, watched the video recordings alone, i.e.
without a trainer. Most programs followed a fixed pattern of recording, editing (where relevant) and viewing of the images (16
cases). In the other programs the recorded situation (4 times), editing method (6 times) or manner of viewing the recordings (7 times)
changed. Dowrick's (1999) special feed-forward method was not included in any of the programs examined.
3.2. Family characteristics
Parents who took part in the video programs had an average age of 27.9 years (SD=4.7), varying from teenage mothers aged 17
(such as in Egeland et al., 2000; Ziegenhain, Derksen & Dreisörner, 2004) to parents aged 34. The children in the families had an
average age of 2.3 years (SD=2.7), varying from 0 to 8 years old. The family socio-economic status, based on 24 experiments, was
medium-high (38%) but usually lower (63%). Risk factors at parent level were also often present (16 of the 29 studies). Five studies
concerned a clinical parent population. The children came from a clinical child population in about half of the studies (15 out of 29).
3.3. Research design
A quasi-experimental research design with an experimental group and a control group was used in 21 experiments, in 8 of which
measurements were taken before and after the experiment. Random assignment of conditions took place in 13 of the 21 studies
involving a control group (see Table 2).
Table 2
Summary of research characteristics
Study Design Random Alternative treatment Ncon +Nexp Age parent High-risk Age child Child clinical
Bakermans et al. (1998): I B R Yes 10+10 26.8 Yes 0.7 No
Bakermans et al. (1998): II B R Yes 10+10 26.8 Yes 0.7 No
Benoit et al. (2001) B NR Yes 14+13 32.3 No 1.5 Yes
Egeland et al. (2000) B R No 80+74 21 Yes 0.0 No
Eliëns (2005) B R Yes 49+33 31.4 No 0.2 Yes
Jansen and Wels (1998a,b) W – – 27 – No 8.0 Yes
Janssens and Kemper (1996a,b) W – – 10 – No 6.8 No
Juffer et al. (2005): with children B NR No 30+30 – No 0.5 No
Juffer et al. (2005): without children B NR No 20+20 – No 0.5 No
Kemenoff et al. (1995) B R Yes 16+16 – Yes – No
Kemper (2004) W – – 14 – Yes 7.4 Yes
Kim and Mahoney (2005) B N No 10+8 34.0 No 6.2 Yes
Klein Velderman (2005) B R No 27+28 27.8 Yes 0.6 No
Klein Velderman (2005) B R No 27+26 27.8 Yes 0.6 No
Landry et al. (2006) B R Yes 131+133 27.8 Yes 0.6 Yes
Mahoney and Powell (1988) W – – 41 30.4 No 1.0 Yes
Mendelsohn et al. (2005) B R No 51+42 26.5 Yes 0.04 No
Moran et al. (2005) B R No 50+49 18.4 Yes 0.5 No
Robert-Tissot et al. (1996) B R Yes 42+33 30.6 Yes 1.3 Yes
Schechter et al. (2006) W – – 32 30.0 Yes 2.7 No
Seifer et al. (1991) B NR Yes 17+23 28.0 No 0.7 Yes
Sibbing et al. (2005) W – – 63 – No 4.5 Yes
Stein et al. (2006) B R Yes 39+38 31.0 Yes 0.4 No
Van Zeijl (2006) B R No 117+120 33.0 Yes 2.3 Yes
Vogelvang (1993) W – – 15 30.4 Yes 6.4 Yes
Weiner et al. (1994) B NR No 52+74 – Yes 3.2 No
Wels et al. (1994) W – – 5 – No 7.0 Yes
Wijnroks (1994) B NR No 25+25 – No 0.5 No
Ziegenhain et al. (2004) B NR Yes 10+5 17.0 Yes 0.00 No
Note: Design: between design with control group (B) or within design without control group (W); random = random assignment of condition (R) or
not (NR); alternative treatment = alternative program for control group; Nexp +Ncon = number in experimental group+control group; age parent = in
years; high-risk = risk factor present at parent level; age child = age of child (years) at program start; child clinical = child clinically referred. Not
applicable or information missing reported using ‘–‘.
910 R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
Parental behavior was measured using various instruments. In various studies parent sensitivity was measured (for example with
the Ainsworth sensitivity scale, Maternal Behavior Q-sort and other sensitivity scales). Other studies also included instruments
which measured partly related, yet different aspects of the parent–child interaction. These were positive measures, such as contingent
responsiveness, cooperation, emotional-affective support, stimulation, non-intrusiveness, support of the child's focus, suitable
verbal or non-verbal response, early communication and looking at the child. ‘Negative’ variables were also measured, such as low
involvement (disengagement), parental force, maternal intrusion, conflict situations during mealtimes and an unclear (‘fussy’)
parental response to a child's signals. One case studied linguistic development stimulation. Another study (van Zeijl, 2006),
involving parents of somewhat older children, evaluated sensitive disciplining as well as sensitivity.
The attitude measures mainly concerned experienced parenting problems and stress (for example, the Parenting Stress Index or
coping measures). A few studies determined the self-appreciation and self-confidence of parents in the parenting role. A few studies
also determined perception of the family climate and one the locus of control. One study measured the attitude of the parents
regarding sensitivity, i.e. the importance the parents attached to a sensitive relationship with their child.
Evaluation of the child focused on various aspects of the behavior domain. Attachment of the child is the central variable in the
selected attachment paradigm studies. Problem behavior of the child is also measured in a number of studies using the Child
Behavior Check List. Other studies also focused on crying, receptive and active language skills, the child's autonomy and wellbeing,
general development and a global measure of the child's behavior (measured using the Child Behavior Rating Scale).
3.4. Intervention effects
Results were analyzed according to parental behavior, parental attitude and the effects on the children (research questions 1, 2 and
3, respectively).
3.5. Effects on parenting behavior of parents
The meta-analysis showed a positive, statistically significant effect for video feedback intervention on the parenting behavior of
parents. The aggregate effect was 0.47 (SE=0.08; see Table 3), which is equal to an average effect, according to Cohen's (1988)
statistical rules of thumb. Results are not homogenous and a moderator analysis was performed to determine with which study
characteristics the effect sizes show a systematic relationship. There is little systematic variance.
The effect on parenting behavior is moderated by the program duration: programs of a shorter duration are more effective (see
Table 4). This intervention duration effect remained statistically significant when this moderator was analyzed together with the
‘parents in a high-risk group’ variable in a single model. No relationship was found between the effects on parent behavior and the
number of sessions and the ‘dosage’ of the program; an additional model with these moderators after the inclusion of the ‘parents in a
high-risk group’ variable showed the same non-significant results. Finally, other relationships with program effects were not found.
3.6. Effects on parental attitude
The video interventions also showed a statistically significant effect on parental attitude. The aggregate effect of 0.37 (SE=0.10)
is between ‘small’ and ‘average’ and is therefore somewhat smaller than for the behavior domain. The attitude domain also shows
heterogeneous results, which were further investigated.
Effects on parenting perception are considerably less under parents from high-risk groups. A model with this single predictor
explains variation in results well and shows acceptable fit (p=0.12; see Table 4).
Table 3
Results for parents: behavior (k=41) and attitude domain (k=26)
Parameters Behavior Attitude
ES SE ES SE
‘Fixed’ effect
Integrated effect 0.47⁎ 0.08 0.37⁎ 0.10
Random effects
Variance between experiments 0.06⁎ 0.03 0.08 0.05
Homogeneity test χ2
=106⁎ χ2
=51⁎
Note: Statistically significant results (pb0.05) are shown with an asterisk.
911R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
3.7. Effects on children
The effects of video feedback interventions were also statistically significant for behavior measures among the child population.
The aggregate effect is between ‘small’ and ‘average’, with an effect size of 0.33 (SE=0.10; see Table 5). The effect sizes from the
child domain were not homogeneous and a moderator analysis was conducted to find statistically significant associations between
study characteristics and experimental outcomes.
The positive effects were, as in the parental attitude domain, smaller when parents were from a high-risk group. This was the case
with or without respondent bias correction. The effects under clinically-referred children were however not less and comparable with
the results from the non-clinical groups.
4. Conclusion and discussion
Interventions with video feedback are effective in families with young children. On completion of the program,
parents are more skilled in interacting with their child and have a more positive perception of parenting. The programs
were also found to have a positive effect on the development of the children in the families being treated. The positive
result is encouraging because it shows that family programs that include video feedback achieve the intended dual level
effect: parents improve their interaction skills which in turn help in the development of their children. It should be noted
that this meta-analysis does not allow specific conclusions pertaining to the unique contribution of the video feedback
as a separate, distinct intervention component. The included video feedback studies involved multimodal and multifaceted
therapeutic interventions which combined video feedback with various other components (for example, social
support of parents). It is therefore not demonstrated that video feedback is the crucial component of the treatments.
The behavior-orientated and psychotherapeutic programs included in this meta-analysis were equally effective in
improving parents' attitude and parenting behavior. The fact that behavior-orientated and psychotherapeutic approaches
often share a focus on parenting behavior (see also Egeland et al., 2000) does not allow a strong test of their differential
effectiveness. However, it seems safe to conclude that programs with a dual focus on parental behavior and representations
are not superior to programs with a single focus on parenting behavior (see also Klein Velderman, 2005).
Results of this meta-analysis are, to some extent, in keeping with earlier studies, which research video feedback
from different but related perspectives. First of all, the positive result of this meta-analysis for the behavior domain fits
Table 5
Results for children's behavior (k=28)
Parameters ES SE
‘Fixed’ effect
Integrated effect 0.33⁎ 0.10
Random effect
Variance between experiments 0.13⁎ 0.06
Homogeneity test χ2
=79⁎
Note: Statistically significant results (pb0.05) are shown with an asterisk.
Table 4
Relationships between effect size and study characteristics (effect size, ES, and model fit, p)
Parental behavior Parental attitude Child's behavior
ES p ES p ES p
Program duration .005 –
Short 0.68 – –
Long 0.27 – –
Parents from high-risk group .12 .000
Yes – – 0.20 – 0.13 –
No – – 0.68 – 0.64 –
Evaluated by involved person .000
Yes – – – – 0.69
No – – – – 0.29
912 R.G. Fukkink / Clinical Psychology Review 28 (2008) 904–916
in with the positive conclusions from earlier qualitative reviews of the effects of video feedback, all of which focused
on behavior change (Dowrick, 1999; Hitchcock et al., 2003; Hung & Rosenthal, 1981; Meharg & Woltersdorf, 1990).
Further comparison is difficult, though, due to the qualitative nature of these studies and the fact that different
populations were investigated in these reviews. The result of this meta-analysis also fits in with the findings of
Bakermans-Kranenburg et al. (2003). In their study, programs including video feedback showed a positive effect for 8
included randomized experiments in their study (d=0.44, compared with 0.31 for the other programs, 8 studies) and 16
other, non-randomized studies (d=0.74, compared with 0.36 for other programs). This meta-analysis extends this
finding and shows that video feedback is not only effective in increasing parents' sensitivity, as measured with
standardized measures, but can also affect different parental skills, like stimulation and intrusiveness. Furthermore, this
meta-analysis shows that video feedback is also effective in the attitude domain, or, more specifically, in reducing
parental stress and increasing parents' self-confidence.
This meta-analysis shows that the effects of video feedback depend on the program duration (in the behavioral
domain). The meta-analysis result that shorter programs are more effective in the behavior domain is related in part to the
‘less is more’ hypothesis of Bakermans-Kranenburg et al. (2003). The current meta-analysis did not find a direct effect of
the number of sessions, but the relationship with program duration is in the same direction. This study points, slightly
different from the ‘less is more’ hypothesis of Bakermans et al., to a ‘short but powerful’ hypothesis: interventions of a
short duration are, on average, more effective (see also Van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2005).
Another critical factor is the presence of risk factors among parents, which moderates the effects in the attitude
domain for parents and the child domain. A possible explanation for this finding is that video feedback with its specific
focus on behavior of the child and the parent may not be tailored to meeting all the needs of families which face serious
difficulties, due to complicating factors at family level, at child level, or perhaps a combination thereof. Perhaps video
feedback with its focus on the parent–child interaction is more successful in alleviating parental stress that is
specifically related to raising issues (i.e., at parent–child level), but is not tailored to relieve the burden of other
significant problems at parent level (e.g., maternal depression) or family level (e.g., poverty, isolation). This hypothesis
deserves further investigation, however. Future intervention studies with multi-problem families could include attitude
measures at parent–child level, parent level and family level to find out in which domains a relieve of the burden is
experienced by the parents. This line of study should make clear whether video feedback interventions should be
complemented with other types of support to make a significant change for multi-problem families.
A clinician may use the visual medium of video feedback in regular clinical practice as a tool to complement the mainly
verbal nature of the therapy. The method is useful if a clinician wants to focus the attention of clients on their concrete
behavior (as in the behavior-orientated approach) or if video feedback accelerates clients' access to their memories or
thoughts (as in the psychotherapeutic approach). In both applications, the use of video feedback should always be structured
by a protocol that guides the recording, editing and presentation of video images. In a psychotherapeutic approach, the
selection of images should be guided by their assumed value in eliciting thoughts and feelings of the client. According to the
principles of positive self review (see Dowrick, 1991), selection of images in the behavior-orientated approach should
highlight instances of positive behavior that the client should show more often. Delayed video feedback is presumably the
preferable method in most clinical settings because it allows a careful selection of images and a preparation of the presentation
and subsequent discussion with the client. Application of video as a medium in family intervention programs is interesting
because parents are watching themselves and therefore pay more attention and are often more emotionally involved than
usual when watching themselves and their child in the video images (Dowrick, 1999; Fuller & Manning, 1973; Papouŝek,
2000). Video recordings make it possible to watch oneself, but at a distance and with time for reflection. For example, parents
may discover discrepancies between the image they had of themselves or their child and the images they now see of
themselves and their child (Fivaz-Depeursinge et al., 2004; Papouŝek, 2000). By rewinding, using slow motion and freezing
the image, it is possible to intensely analyze each‘split second’ of the parent–child interactions. Using video recordings in this
way sometimes clearly shows parents just how many signals a child is giving which they had not previously seen.
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