Emotional neglect, experiences of violence, threat and traumatization have severe effects on psychological development as has been demonstrated impressively by many clinical, empirical and interdisciplinary studies (Bohleber, 2000; De Bellis and Thomas, 2003; Becker-Stoll et al., 2009; Leuzinger-Bohleber et al., 2017a, 2010, 2020). Findings from various longitudinal studies indicate that such children have a poor prognosis, exhibiting aggressive-destructive behavior and severe psychological problems and performing below-average at school (Green et al., 2000; Helmsen et al., 2012; Petermann and Petermann, 2012). In many studies it is discussed that the specific experience of a child as well as their family and social environment must be taken into account in order to understand the short and long-term consequences of early-life adversities in detail in order to respond to them in an adequate individual way. As will be discussed in the following, one of the strengths of a psychodynamic/psychoanalytic prevention approach is that it always tries to understand such individual characteristics of early childhood adversities and traumatization, which is seen as the presupposition for offering adequate prevention to the individual child and the family.

It is interesting that such individualized prevention strategies increasingly receive interdisciplinary support. To mention just one example: A meta-analysis by Colich et al. (2019) found that early-life adversity (ELA) involving threat (e.g., violence exposure) was associated with accelerated biological aging across multiple metrics, whereas exposure to deprivation (e.g., neglect, institutional rearing) and low socio-economic status (SES) was not. The authors meta-analyzed 46 studies (n = 64,925) the examining association of ELA with pubertal timing and cellular aging (telomere length and DNA methylation age) in order to understand the short and long-term consequences of early-life adversities in detail and to take corrective action in an individual way. The authors systematically reviewed 19 studies (n = 2,276) examining ELA and neural markers of accelerated development (cortical thickness and amygdala-prefrontal cortex functional connectivity) and evaluated whether associations of ELA with biological aging vary according to the nature of adversity experienced. ELA overall was associated with accelerated pubertal timing (d = 0.12) and cellular aging (d = 0.32). “Moderator analysis revealed that ELA characterized by threat (d = 0.26), but not deprivation or SES, was associated with accelerated pubertal development. Similarly, exposure to threat-related ELA was associated with accelerated cellular aging (d = 0.43), but not deprivation or SES. Systematic review revealed associations between ELA and accelerated cortical thinning, with threat. Related ELA was consistently associated with thinning in the ventromedial prefrontal cortex, and deprivation and SES was associated with thinning in frontoparietal, default, and visual networks. There was no consistent association of ELA with amygdala-PFC connectivity. These findings suggest specificity in the types of early environmental experiences associated with accelerated biological aging and highlight the importance of how accelerated aging contributes to health disparities and whether this process can be mitigated through early intervention” (Colich et al., 2019, p. 2).

As these studies show, accelerated biological aging is particularly impacted by exposure to violence. This corresponds to the findings of attachment research that exposure to domestic violence is one of the major factors for the development of a disorganized attachment (see following paragraph) and are a great risk for the development of the children. Therefore, early prevention efforts are particularly important for this group of children. But also children exposed to other early-life adversities have a poor prognosis, exhibiting aggressive-destructive behavior and severe psychological problems as well as performing below-average at school and thus need early additional support and help (Green et al., 2000; Hanson et al., 2011; Bøe et al., 2012; Helmsen et al., 2012; Petermann and Petermann, 2012).

This is why an emerging body of research proposes early prevention programs for children with low family income, migration background and other early-life adversities (Ludwig and Phillips, 2008; Leuzinger-Bohleber et al., 2013). Several studies of early prevention programs displayed an improvement in cognitive, emotional, and behavioral development and a decrease in delinquency and crime in adulthood (Nelson et al., 2003; Emde and Leuzinger-Bohleber(eds), 2014). Especially findings of research on attachment styles revealed a correlation between type of attachment and psychological and cognitive performance. In 1951, Bowlby identified infants’ biological need to form attachment to caregivers to build a secure base from which they can explore the world. According to Bowlby, human attachment behavior is biologically programmed and a means of survival, as it directs the infant to seek proximity to his/her caregiver when he/she needs protection from danger or emotional support. The infant’s attachment to his/her caregivers allows him/her to build trust and thereby explore his/her surroundings and assume social relationships (Bowlby, 1951). Ainsworth expanded on Bowlby’s seminal work and conducted empirical research on attachment which involved investigating the effects of early traumatization on attachment patterns and children’s subsequent development (Cassidy and Shaver, 2008). She found a strong correlation between neglect during early childhood and emotional problems during adolescence (Wolraich et al., 1996; Gunnar et al., 2000; Dozier et al., 2002; Teicher et al., 2002; De Bellis and Thomas, 2003; Cassidy and Shaver, 2008; Maheu et al., 2010; Rutherford and Mayes, 2014) which often led to anxiety disorders, depression, and even suicide (Pine, 2003, 2007). According to Ensink et al. (2017) not only secure attachment but also the acquirement of the ability of mentalization (symbolization) is crucial in terms of a healthy psychological development. Humans who are exposed to violence, threat or severe trauma show most likely a disturbed ability of mentalization and poor emotional processing. Fonagy and Allison (2014) linked studies from the field of attachment and mentalization research with studies on epistemic trust. Secure attachment and a well-developed capability to mentalize, which can also be seen in children with low SES and a migration background, lead to epistemic trust allowing e.g., children in the age of 5–6 years to trust their own perceptions in conflictual situations which subsequently is of course a great advantage for the cognitive, affective and social development (Correau and Rochette, 2009). Therefore, it is very important to offer early prevention to children-at risk particularly in environments with an increased risk for violence, threat and trauma, i.e., an early prevention offer that explores ways to prevent violence, that strengthens resilience of these children, that encourages prosocial behavior, and that supports social integration.

Psychoanalysts are especially knowledgeable on early neglect, domestic violence and traumatization due to their clinical experience with such patients as well as due to numerous developmental studies (see e.g., Stern, 1985; Emde and Leuzinger-Bohleber(eds), 2014). Adopting the insight of mostly US-based prevention studies the Sigmund-Freud-Institut (SFI) repeatedly conducted early prevention studies in cooperation with the institute for Analytical Child and Adolescence Psychotherapy (VAKJP) and the Centre for Research on individual Development and Adaptive Education of children at risk (IDeA) of the federal funding initiative for excellence in Hesse (LOEWE). One such study, exploring the effects of early prevention – the representative Frankfurt Prevention Study (FP) carried out in 14 daycare centers in Frankfurt from 2003 to 2006 with 4,500 children from low-SES, middle-SES and high-SES backgrounds showed, that aggressive (p = 0.02) and anxious (p = 0.03) behavior of boys and girls and hyperactivity (p = 0.001) in girls-only was reduced significantly through implementation of a psychoanalytically based early prevention program (Leuzinger-Bohleber, 2007; Leuzinger-Bohleber et al., 2016). These results encouraged the research group to replicate this study with a specific focus on the differential effects of two established prevention programs – Early Steps (ES; Leuzinger-Bohleber, 2010; Leuzinger-Bohleber and Fischmann, 2010; Leuzinger-Bohleber et al., 2010) and Faustlos (FA; German version of Second Step; Cierpka, 2004; Schick and Cierpka, 2006) in a population of children-at-risk (EVA study) in a cluster randomized controlled trial (CRCT) based on criteria of SES, Aggression, Anxiety and Hyperactivity. Considering one of the major findings of the Head Start program (Emde, 2014), the main hypotheses of the EVA study is that for children at great developmental risk (i.e., with a disorganized attachment pattern) the elaborated, individualized and psychoanalytically oriented ES program will show long-lasting positive effects on children’s social behavior and enable them to achieve more secure attachment behavior than in the standardized, not individualized FA program.

The Early Steps program integrates research results from both attachment theory and psychoanalytic development and prevention research (see e.g., Emde and Leuzinger-Bohleber(eds), 2014; Leuzinger-Bohleber, 2015) focusing on change of children’s Inner Working Models (IWM) from an insecure IWM exhibiting insecure attachment representations toward safe IWMs with secure attachment representations.

The EVA project was strongly influenced by the well-known large prevention program, the Early Head Start community-based program for low-income families (Elicker et al., 2013), which links families with needed services such as medical, mental health, nutrition, and education and additionally provides a place for children to experience consistent, nurturing relationships and stable, ongoing routines (Love, 2010). An Early Head Start evaluation showed that caregiver–child relationships were generally positive in terms of attachment security after fostering a supportive, relationship between mother and program staff (Love et al., 2005).

Thus, it seems that secure attachment and a well-developed capability to mentalize may lead to an ‘epistemic trust’ (Asseburg, previously Hartmann et al., 2015; Bevington et al., 2017; Schwarzer, 2018; Dlugosch and Henter, 2020) and to confer advantages in cognitive, affective and social development as was hypothesized by Fonagy and Allison (2014). In contrast, children with disorganized attachment representations due to neglect, exposure to violence and early traumatic experiences have a poor prognosis, exhibiting aggressive-destructive behavior and severe psychological and emotional problems (De Bellis and Thomas, 2003; Fearon et al., 2010; Groh et al., 2012, 2017; Helmsen et al., 2012; Cassidy and Shaver, 2016; Facompré et al., 2017; Thomason and Marusak, 2017).

Therefore, the following have been the central research questions of the EVA study:

In order to answer these research questions with sufficient external validity, the interdisciplinary research team chose a combination of a naturalistic and an experimental design, despite the fact that a pure experimental design for testing the efficacy of prevention programs according to the criteria of evidence-based medicine is preferred by most researchers because of the high internal validity that such a procedure offers. However, such studies often fail to achieve external validity. Therefore, their results can often hardly be transferred to practice. In contrast, naturalistic studies often have a high external validity, but have to accept some fuzziness in the way intervention programs are implemented in the project.

The interdisciplinary research group of the EVA study, in collaboration with one of the leading statisticians, Prof. Dr. Bernhard Rüger (Institute for Statistics of the University of Munich), tried to find an innovative solution in dealing with the specific challenges of studies in this area by combining naturalistic and experimental components in the design of the EVA study: The research team chose to use the existing professional resources for the promotion of verifiably needy at-risk children in public Kindergartens in the city of Frankfurt (hence “naturalistic study”) on the one hand and on the other applied the highest possible standards in the evaluation of the prevention offers (hence “experimental study”). The details of this design are described in the following sections.

The drifting apart of the developmental chances of children who are better supported in today’s Western societies than in any previous historical period and those who live on the fringes of society has continuously increased in the last decades (see e.g., Emde and Leuzinger-Bohleber(eds), 2014). This promotes processes of division and even splitting in society, which many see as a serious threat to Western democracies. In the Corona crisis these processes could be clearly observed in a dramatic way: as many media reports described, it were again the children from socially disadvantaged families who suffered most from the lock-down, both in terms of their educational opportunities and the risk of being exposed to domestic violence.

To meet this threat more and more professional groups are getting involved in early prevention, so that today we have a wide range of early prevention programs. Unfortunately, only a few have been carefully scientifically evaluated and examined the short and long-term effects of prevention on children-at-risk.

The EVA study aimed specifically at comparing such short- and long-term outcomes of two early prevention offers in a large sample of Kindergarten-aged children at high psychosocial risk, one (ES) being a psychodynamic, attachment-based holistic approach, the other (FA), a classroom-based, psychodynamically inspired prevention.

Baseline data showed that the children examined in EVA can indeed be considered as “children-at-risk”: They had twice as much disorganized attachment representations than those of a normal population (ES: 26.3%; FA: 22%; normal population approx. 11%) which is considered as an indicator that these children had gone through severe early trauma (often in the context of domestic violence) running a serious developmental risk (see Emde and Leuzinger-Bohleber(eds), 2014). These children have not been able to develop stable and sustaining inner working models but rather showed “disorganized attachment patterns,” i.e., they did not develop sufficiently an inner feeling of safety, of confidence in the capability of the self to cope with difficult situations in a creative way and did not find reliable human objects to help them in situations of emergency. From a psychodynamic point of view this is one reason why these children react with panic, aggression and violence or even with a decompensation of their psychic stability in personal and social stress situations (see e.g., Leuzinger-Bohleber, 2010). Therefore, many professionals and researchers have claimed that children exhibiting disorganized attachment representations should receive psychological and psychosocial support as early as possible. The EVA study pursued this ambitious goal although there had been serious doubts if these children-at-risk and their families could be reached by the psychodynamically oriented offers in public Kindergartens.

It therefore is a first important finding that the results of the EVA study show that indeed both prevention offers affected these children-at-risk: The disorganized attachment representation (D) decreased in the ES group by 3.1% (d = 0.35), in the FA group by 3.73% (d = 0.40). Both prevention groups lead to a significant shift from a disorganized attachment representation (D) to a secure attachment representation (B; ES: d = 0.43; FA: d = 0.45). In the ES groups the disorganized attachment representation decreased more intensively than in the FA group (d = 0.73). Against the background of many long-term studies in the field of attachment research (see e.g., Fonagy and Campbell, 2015), this is an important finding, because it justifies the hope that children who have developed a disorganized attachment due to traumatic early experiences in their first year of life can indeed benefit from prevention programs in public Kindergartens and even ameliorate their problematic attachment. These results have important clinical and social relevance, as disorganized attachment representation is a known risk marker for later externalizing disorder and social difficulty (Fearon et al., 2010; Groh et al., 2012, 2014; Helmsen, et al., 2012; Granqvist et al., 2017).

Therefore, the most important result of the EVA study is that both interventions effectively ameliorated the attachment representations in children: In the ES group the secure attachment representation (B) increased by 6.98% (d = 0.55), in the FA group by 3.73% (d = 0.41). There also was a significant shift from an avoidant attachment representation (A) to a secure attachment representation (B; ES: d = 0.58; FA: d = 0.36). Concerning the secondary outcome measure C-TRF: according to their teacher’s evaluations, children’s behavioral problems decreased in both prevention groups (p < 0.001), where children in the FA group improved particularly in aggressive behavior (p < 0.001).

Changes in attachment representations thus have a positive effect on social behavior, but assumable also on cognitive and affective development. Especially the interaction of modules that focus on the specific, idiosyncratic traumatization of the individual child (such as child therapies and through case supervision) and those that benefit the entire “Kindergarten” system (team supervision, advanced training, Faustlos, parental work) has proven its worth. All these changes can be seen as indicators that the resiliency of these children-at-risk has been improved by the early prevention (see also Hauser et al., 2006; Leuzinger-Bohleber, 2009; Cicchetti, 2010; Goldstein and Brooks, 2013).

In addition to the main outcomes of the EVA study the results of two sub-studies have been summarized in this paper. Neubert (2016) addressed the specific living circumstances of the participating families and examined their effects on children’s behavioral problems. Parental stress level and the experience of violence or trauma within the family appeared to be the most important single risk factors for developing problem behavior. There was also a statistically significant correlation between the number of risk factors and the severity of children’s behavioral disorders: the more risk factors the children were facing, the higher was their SDQ total difficulties score. The main finding refers to the interaction of attachment representation and the number of risk factors in regard to the severity of problematic behavior: The findings indicate that a secure attachment representation acts as a protective factor by preventing children from developing behavioral problems, especially when they are facing a high-risk environment. Based on these findings, the authors argue for the conception of individual prevention and support offers which consider the specific living conditions of children and also have a relationship-based approach.

A second sub-study by Asseburg (prev. Hartmann et al., 2015) examined the impact of psychoanalytic case supervision on the mentalizing capacity of early educational professionals (teachers) in the EVA study. It revealed that teachers’ self-reflective capacities only increased in the ES group. It became apparent that self-reflective skills of teachers are essential to support children-at-risk in a highly individual way in order to strengthen their resilience. The improvement from problematic to less problematic attachment patterns in this high-risk sample is seen as a result of the teachers’ increased vocational competencies.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by LPPKJP – Landeskammer für psychologische Psychotherapeutinnen und -therapeuten und Kinder- und Jugendlichenpsychotherapeutinnen und -therapeuten Hessen. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

ML-B was the PI of the EVA Study. ML-B conceptualized this manuscript and wrote a first draft in close cooperation with TF. TF collected the data and analyzed the data together with FH. FH helped in recruitment, analysis and writing as part of her doctoral thesis in clinical psychology. VN and LA conducted and evaluated the substudies within EVA and wrote their doctoral thesis on the subject. JG and MW supervised all stages of the workincluding conceptualization, analysis, and writing. TF and ML-B are jointly accountable for the content of the work, ensuring that all aspects related to accuracy or integrity of the study are investigated and resolved in an appropriate way. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.