Attachment-based therapy (children)
Encyclopedia
Attachment-based therapy is a phrase intended to apply to interventions or approaches based on attachment theory
, originated by John Bowlby
. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development
with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby
himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy
. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder
.
approach to treating disturbed infant-parent relationships based on the theory that disturbances are manifestations of unresolved conflicts in the parent's past relationships. The "patient" is the infant-parent relationship. Infant-parent psychotherapy was expanded by Alicia Lieberman and colleagues into Child-Parent Psychotherapy, a manualized intervention for impoverished and traumatised families with children under the age of 5. In addition to the focus on the parents early relationships the intervention also addresses current life stresses and cultural values. CPP is supported by five randomized trials indicating efficacy in increasing attachment security, maternal empathy and goal-corrected partnerships. The trials also showed a reduction in avoidance, resistance and anger. The therapy is delivered through unstructured weekly sessions involving both parent/s and child over the course of a year. The trials were conducted with low income groups, maltreating families, families with depressed mothers and families where children were exposed to domestic violence.
interactions to a more appropriate developmental pathway. It is stated that it is explicitly based on contemporary attachment
and congruent developmental theories
. Its core constructs are Ainsworth’s ideas of a Secure Base and a Haven of Safety (Ainsworth et al. 1978). The aim of the protocol
is to present these ideas to the parents in a user-friendly, common-sense fashion that they can understand both cognitively and emotion
ally. This is done by a graphic representation of the child's needs and attachment system in circle form, summarising the child's needs and the safe haven provided by the caregiver. The protocol has so far been aimed at and tested on preschoolers up to the age of 4 years.
The aim of the therapy
is:
Its four core principles are: that the quality of the child parent attachment
plays a significant role in the life trajectory of the child; that lasting change results from parents changing their caregiving patterns rather than by learning techniques to manage their childs behavior
s; that parents relationship capacities are best enhanced if they themselves are operating within a secure base
relationship; and that interventions designed to enhance the quality of child-parent attachments will be especially effective if they are focused on the caregiver and based on the strengths and difficulties of each caregiver/child dyad.
There is an initial assessment which utilises the 'Strange Situation' procedure, (Ainsworth 1978), observations, a videotaped interview using the Parent Development Interview (Aber et al. 1989) and the Adult Attachment Interview (George et al. 1984) and caregiver questionnaires regarding the child. The childs attachment pattern is classified using either Ainsworth or the PAC (Preschool Attachment Classification System). The therapy is then 'individualized' according to each dyads attachment/caregiver pattern. The programme, which takes place weekly over 20 weeks, consists of group sessions, video feedback vignettes and psycho-educational and therapeutic discussions. Caregivers learn, understand and then practice observational and inferential skills regarding their children's attachment behaviors and their own caregiving responses.
Circle of Security is being field tested within the 'Head Start'/'Early Head Start' programme in the USA. According to the developers the goal of the project is to develop a theory- and evidence-based intervention protocol that can be used in a partnership between professionals trained in scientifically based attachment procedures, and appropriately trained community-based practitioners. It is reported that preliminary results of data analysis of 75 dyads suggest a significant shift from disordered to ordered patterns, and increases in classifications of secure attachment. The process of validation is not yet completed.
" conclusions on the best intervention practices for attachment
in infants. There were four hypotheses:
The selection criteria were very broad, intending to include as many intervention studies as possible. Sensitivity findings were based on 81 studies involving 7,636 families. Attachment security involved 29 studies and 1,503 participants. Assessment measures used were the Ainsworth sensitivity rating, Ainsworth et al. (1974), the Home Observation for Measurement of the Environment, Caldwell and Bradley (1984), the Nursing Child Assessment Teaching Scale, Barnard et al. (1998) the Erickson rating scale for maternal sensitivity and supportiveness, Egeland et al. (1990).
The conclusion was that "Interventions with an exclusively behavioural
focus on maternal sensitivity appear to be most effective not only in enhancing maternal sensitivity but also in promoting children's attachment security." p212.
Three studies were singled out by Prior and Glaser to illustrate intervention processes which have shown good results. p239-244.
and feelings of failure in bonding or attachment
. The randomly assigned control group undertook psychodynamic psychotherapy
.
The primary work is between mother and therapist. It is based on the notion of the infant as initiator in infant-parent psychotherapy. For half the session the mother gets down on the floor with the infant, observes it and interacts only on the infant's initiative. The idea is that it increases the mother's sensitivity and responsiveness by fostering an observational reflective stance, whilst also being physically accessible. Also the infant has the experience of negotiating their relationship with their mother. For the second half the mother discusses her observations and experiences.
Infants in the watch, wait and wonder group were significantly more likely to shift to a secure or organised attachment classification
than infants in the psychodynamic psychotherapy group although there was no differential treatment effect in maternal sensitivity. It has been pointed out however that specific caregiver responses to attachment (the precursors to secure attachments) were not measured.
It was found that these infants scored significantly higher than the control infants on sociability, self soothing and reduced crying. All maternal components improved. Further, a 'strange situation' assessment carried out at 12 months showed only 38% classified as insecure compared to 78% in the control group.
Follow ups at 18, 24 and 42 months using Ainsworth's Maternal Sensitivity Scales, the Bayley Scales of Infant Development, the Child Behaviour Checklist (Achenbach) and the Attachment Q-sort showed enduring significant effects in secure attachment classification, maternal sensitivity, fewer behaviour problems, and positive peer relationships.
and colleagues. They developed an experimental paradigm informed by attachment theory called the Clinician Assisted Videofeedback Exposure Sessions to test whether traumatized mothers, who often suffered psychological sequalae from a history of abuse and violence, could "change their mind" about their young children. The technique used was to watch video-excerpts of play, separation and similarly stressful moments in the presence of a clinician who asks the mother to think about what she (and her child) might be thinking and feeling at the time of the excerpt and at the moment of videofeedback. It applies the principles of mentalization
as an aide to emotional regulation with these traumatized parents. It also involves elements of prolonged exposure treatment, the video-based treatment Interaction Guidance, and psychodynamically-oriented child-parent psychotherapy. Schechter and colleagues showed a significant change in the way mothers perceived their own child and their relationship together.
is supporting such teams being established in other states.
has to deal with the loss of attachment figures at a time when maintaining contact with attachment figures is vital. It targets key issues: providing nurturance for infants when the carers are not comfortable providing nurturance, overriding tendencies to respond in kind to infant behaviors and providing a predictable interpersonal environment
.
It is essentially a training programme for surrogate caregivers. It has four main components based on four propositions:
Caregiver and child behaviors are assessed before and after intervention, as is the child's regulation of neuroendocrine function. The intervention consists of 10 sessions administered in caregivers homes by professional social workers. Sessions are videotaped for feedback and for fidelity. The intervention is currently being assessed in a randomized clinical trial involving 200 foster families, supported by the National Institute of Mental Health. Half the infants are assigned to the Developmental Education for Families programme as a comparison intervention. (DEF:Dozier 2003). The developers themselves point out that they do not test for caregiver commitment although they state this may or may not be a critical omission as they consider caregiver commitment to be a crucial variable in terms of child outcomes.
A modified version has been introduced for birth parents.which is currently being tested in a small group.
in 1998. The program is designed to address the developmental
and health needs of children under the age of 5 who have been maltreated and placed in foster care
. It is funded by the state government of Louisiana and private funds. It is a multidisciplinary approach involving psychiatrists
, psychologists
, social workers, paediatricians and paraprofessionals - all with expertise in child development
and developmental psychopathology
.
The aim of the intervention is to support the building of an attachment relationship
between the child and foster carers, even though about half of the children eventually return to their parents after about 12 to 18 months. The designers note Mary Doziers program to foster the development of relationships between children and foster carers (ABC) and her work showing the connection between foster children's symptomology and foster carers attachment status. Work is based on findings that the qualitative features of a foster parents narrative descriptions of the child and relationship with the child have been strongly associated with the foster parents behavior with the child and the child's behavior with them. The aim was to develop a programme for designing foster care as an intervention.
The theoretical base is attachment theory
. There is a conscious effort to build on recent, although limited, research into the incidence and causes of Reactive attachment disorder
and risk factors for RAD and other psychopathologies.
Soon after coming into care the children are intensively assessed, in foster care, and then receive multi modal treatments. Foster carers are also formally assessed using a structured clinical
interview which includes in particular the meaning of the child to the foster parent. Individualised interventions for each child are devised based on age, clinical presentation and information on the child/foster carer match. The assessment 'team' remains involved in delivering the intervention. Those running the programme maintain regular phone and visit contact and there are support groups for foster parents.
Barriers to attachment are considered to be as follows;
Interventions include supporting foster parents to learn to help the child in regulating emotion
s, to learn to respond effectively to the child's distress and to understand the child's signals, especially 'miscues' as the signals of such children are often confusing as a consequence of their often frightening, inconsistent and confusing past relationships. Foster carers are taught to recognize what such children actually need rather than what they may appear to signal that they need. Such children often exhibit provocative and oppositional behaviors which may normally trigger feelings of rejection in caregivers. Withdrawn children may be overlooked and seemingly independent, indiscriminate children may be considered to be managing much better than they are. Foster carers are regularly contacted and visited to assess their needs and progress.
As of 2005, 250 children had participated in the programme. Outcome data published in 2001 revealed a 68% reduction in maltreatment recidivism for the same child returning to its parent(s)and a 75% reduction in recidivism
for a subsequent child of the same mother. The authors claim the programme not only assists the building of new attachments to foster parents but also has the potential impact a families development long after a returned child is no longer in care.
. (However, the use of the terms "attachment therapy" and "attachment-based therapy" is not consistent in literature and on the Internet
). Attachment therapy, also known as 'holding therapy', is a group of unvalidated therapies characterized by forced restraint of children in order to make them relive attachment-related anxieties; a practice considered incompatible with attachment theory and its emphasis on 'secure base'. The conceptual focus of these treatments is the child's individual internal pathology
and past caregivers rather than current parent-child relationships or current environment
. This form of therapy
, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology
or, despite its name, to be based on attachment theory
, with which it is considered incompatible. In 2006, the American Professional Society on the Abuse of Children
(APSAC) Task Force reported on the subjects of attachment therapy, reactive attachment disorder
, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorder
s. The Taskforce was largely critical of attachment therapy's theoretical base, practices, claims to an evidence base, non-specific symptoms lists published on the internet, claims that traditional treatments do not work and dire predictions for the future of children who do not receive attachment therapy. The controversy also extends to the theories, diagnoses
, diagnostic practices, beliefs, and social group norms
and patient recruitment and advertising practices.
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
, originated by John Bowlby
John Bowlby
Edward John Mostyn "John" Bowlby was a British psychologist, psychiatrist and psychoanalyst, notable for his interest in child development and for his pioneering work in attachment theory.- Family background :...
. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development
Developmental psychology
Developmental psychology, also known as human development, is the scientific study of systematic psychological changes, emotional changes, and perception changes that occur in human beings over the course of their life span. Originally concerned with infants and children, the field has expanded to...
with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby
John Bowlby
Edward John Mostyn "John" Bowlby was a British psychologist, psychiatrist and psychoanalyst, notable for his interest in child development and for his pioneering work in attachment theory.- Family background :...
himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy
Attachment Therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques...
. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder
Attachment disorder
Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors...
.
Child-Parent Psychotherapy (CPP)
This intervention was developed from "infant-parent psychotherapy", a psychoanalyticPsychoanalysis
Psychoanalysis is a psychological theory developed in the late 19th and early 20th centuries by Austrian neurologist Sigmund Freud. Psychoanalysis has expanded, been criticized and developed in different directions, mostly by some of Freud's former students, such as Alfred Adler and Carl Gustav...
approach to treating disturbed infant-parent relationships based on the theory that disturbances are manifestations of unresolved conflicts in the parent's past relationships. The "patient" is the infant-parent relationship. Infant-parent psychotherapy was expanded by Alicia Lieberman and colleagues into Child-Parent Psychotherapy, a manualized intervention for impoverished and traumatised families with children under the age of 5. In addition to the focus on the parents early relationships the intervention also addresses current life stresses and cultural values. CPP is supported by five randomized trials indicating efficacy in increasing attachment security, maternal empathy and goal-corrected partnerships. The trials also showed a reduction in avoidance, resistance and anger. The therapy is delivered through unstructured weekly sessions involving both parent/s and child over the course of a year. The trials were conducted with low income groups, maltreating families, families with depressed mothers and families where children were exposed to domestic violence.
'Circle of Security'
This is a parent education and psychotherapy intervention developed by Glen Cooper, Kent Hoffman, Robert Marvin, and Bert Powell designed to shift problematic or 'at risk' patterns of attachment – caregivingAttachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
interactions to a more appropriate developmental pathway. It is stated that it is explicitly based on contemporary attachment
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
and congruent developmental theories
Child development
Child development stages describe theoretical milestones of child development. Many stage models of development have been proposed, used as working concepts and in some cases asserted as nativist theories....
. Its core constructs are Ainsworth’s ideas of a Secure Base and a Haven of Safety (Ainsworth et al. 1978). The aim of the protocol
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
is to present these ideas to the parents in a user-friendly, common-sense fashion that they can understand both cognitively and emotion
Emotion
Emotion is a complex psychophysiological experience of an individual's state of mind as interacting with biochemical and environmental influences. In humans, emotion fundamentally involves "physiological arousal, expressive behaviors, and conscious experience." Emotion is associated with mood,...
ally. This is done by a graphic representation of the child's needs and attachment system in circle form, summarising the child's needs and the safe haven provided by the caregiver. The protocol has so far been aimed at and tested on preschoolers up to the age of 4 years.
The aim of the therapy
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
is:
- To increase the caregivers sensitivity and appropriate responsiveness to the child’s signals relevant to its moving away from to explore, and its moving back for comfort and soothing;
- To increase their ability to reflect on their own and the child’s behavior, thoughts and feelings regarding their attachment – caregiving interactions; and
- To reflect on experiences in their own histories that affect their current caregiving patterns. This latter point aims to address the miscuing defensive strategies of the caregiver.
Its four core principles are: that the quality of the child parent attachment
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
plays a significant role in the life trajectory of the child; that lasting change results from parents changing their caregiving patterns rather than by learning techniques to manage their childs behavior
Behavior
Behavior or behaviour refers to the actions and mannerisms made by organisms, systems, or artificial entities in conjunction with its environment, which includes the other systems or organisms around as well as the physical environment...
s; that parents relationship capacities are best enhanced if they themselves are operating within a secure base
Attachment in adults
Attachment in adults deals with the theory of attachment in adult romantic relationships.Attachment theory was extended to adult romantic relationships in the late 1980s. Four styles of attachment have been identified in adults: secure, anxious–preoccupied, dismissive–avoidant, and fearful–avoidant...
relationship; and that interventions designed to enhance the quality of child-parent attachments will be especially effective if they are focused on the caregiver and based on the strengths and difficulties of each caregiver/child dyad.
There is an initial assessment which utilises the 'Strange Situation' procedure, (Ainsworth 1978), observations, a videotaped interview using the Parent Development Interview (Aber et al. 1989) and the Adult Attachment Interview (George et al. 1984) and caregiver questionnaires regarding the child. The childs attachment pattern is classified using either Ainsworth or the PAC (Preschool Attachment Classification System). The therapy is then 'individualized' according to each dyads attachment/caregiver pattern. The programme, which takes place weekly over 20 weeks, consists of group sessions, video feedback vignettes and psycho-educational and therapeutic discussions. Caregivers learn, understand and then practice observational and inferential skills regarding their children's attachment behaviors and their own caregiving responses.
Circle of Security is being field tested within the 'Head Start'/'Early Head Start' programme in the USA. According to the developers the goal of the project is to develop a theory- and evidence-based intervention protocol that can be used in a partnership between professionals trained in scientifically based attachment procedures, and appropriately trained community-based practitioners. It is reported that preliminary results of data analysis of 75 dyads suggest a significant shift from disordered to ordered patterns, and increases in classifications of secure attachment. The process of validation is not yet completed.
The Bakermans-Kranenburg, van IJzendoorn and Juffer meta analysis (2003)
This was an attempt to collect and synthesise the data to try to come to "evidence basedEvidence-based medicine
Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments and diagnostic tests...
" conclusions on the best intervention practices for attachment
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
in infants. There were four hypotheses:
- Early intervention on parental sensitivity and infant attachment securityAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
is effective. - Type and timing of programme makes a difference.
- Intervention programmes are always and universally effective.
- Changes in parental sensitivity are causally related to attachment security.
The selection criteria were very broad, intending to include as many intervention studies as possible. Sensitivity findings were based on 81 studies involving 7,636 families. Attachment security involved 29 studies and 1,503 participants. Assessment measures used were the Ainsworth sensitivity rating, Ainsworth et al. (1974), the Home Observation for Measurement of the Environment, Caldwell and Bradley (1984), the Nursing Child Assessment Teaching Scale, Barnard et al. (1998) the Erickson rating scale for maternal sensitivity and supportiveness, Egeland et al. (1990).
The conclusion was that "Interventions with an exclusively behavioural
Behavior
Behavior or behaviour refers to the actions and mannerisms made by organisms, systems, or artificial entities in conjunction with its environment, which includes the other systems or organisms around as well as the physical environment...
focus on maternal sensitivity appear to be most effective not only in enhancing maternal sensitivity but also in promoting children's attachment security." p212.
Three studies were singled out by Prior and Glaser to illustrate intervention processes which have shown good results. p239-244.
"Watch, wait and wonder". Cohen et al. (1999)
This intervention involved mothers and infants referred for a community health service. Presenting problems included feeding, sleeping, behavioural regulation, maternal depressionClinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and feelings of failure in bonding or attachment
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
. The randomly assigned control group undertook psychodynamic psychotherapy
Psychodynamic psychotherapy
Psychodynamic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. In this way, it is similar to psychoanalysis. It also relies on the interpersonal relationship between client...
.
The primary work is between mother and therapist. It is based on the notion of the infant as initiator in infant-parent psychotherapy. For half the session the mother gets down on the floor with the infant, observes it and interacts only on the infant's initiative. The idea is that it increases the mother's sensitivity and responsiveness by fostering an observational reflective stance, whilst also being physically accessible. Also the infant has the experience of negotiating their relationship with their mother. For the second half the mother discusses her observations and experiences.
Infants in the watch, wait and wonder group were significantly more likely to shift to a secure or organised attachment classification
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
than infants in the psychodynamic psychotherapy group although there was no differential treatment effect in maternal sensitivity. It has been pointed out however that specific caregiver responses to attachment (the precursors to secure attachments) were not measured.
"Manipulation of sensitive responsiveness", van den Boom (1994), (The Leiden Programs)
This intervention focused on low socio-economic group mothers with irritable infants, assessed on a behavioural scale. The randomly assigned group received 3 treatment sessions, between the ages of 6 and 9 months, based on maternal responsiveness to negative and positive infant cues. Intervention was based on Ainsworth's sensitive responsiveness components, namely perceiving a signal, interpreting it correctly, selecting an appropriate response and implementing the response effectively.It was found that these infants scored significantly higher than the control infants on sociability, self soothing and reduced crying. All maternal components improved. Further, a 'strange situation' assessment carried out at 12 months showed only 38% classified as insecure compared to 78% in the control group.
Follow ups at 18, 24 and 42 months using Ainsworth's Maternal Sensitivity Scales, the Bayley Scales of Infant Development, the Child Behaviour Checklist (Achenbach) and the Attachment Q-sort showed enduring significant effects in secure attachment classification, maternal sensitivity, fewer behaviour problems, and positive peer relationships.
"Modified Interaction Guidance" Benoit et al. (2001)
This intervention aimed to reduce inappropriate caregiver behaviours as measured on the AMBIANCE (atypical maternal behaviour instrument for assessment and classification). Such inappropriate behaviours are thought to contribute to disorganized attachment. The play focused intervention (MIG) was compared with a behaviour modification interventio focused on feeding. A significant decrease in inappropriate maternal behaviours and disrupted communication was found in the MIG group.Video-Feedback Intervention to Promote Positive Parenting (VIPP)
Developed and evaluated by Juffer, Bakermans-Kranenburg and van Ijzendoorn, this collection of interventions aim to promote maternal sensitivity through the review of taped infant-parent interactions and written materials. The programme can also be expanded to include the parents internal working models (VIPP-R) and/or sensitive disciplinary practices (VIPP-SD). Findings from randomized controlled trials are mixed but overall supportive of efficacy, particularly for "highly reactive infants" and in reducing later externalising behaviours. The various versions show promise but research continues.Clinician Assisted Videofeedback Exposure Sessions (CAVES)
Developed by Daniel SchechterDaniel Schechter
Daniel S. Schechter is an American psychiatrist currently living in Geneva, Switzerland. He is known for his clinical work and research on intergenerational transmission or "communication" of violent trauma and related psychopathology involving parents and very young children...
and colleagues. They developed an experimental paradigm informed by attachment theory called the Clinician Assisted Videofeedback Exposure Sessions to test whether traumatized mothers, who often suffered psychological sequalae from a history of abuse and violence, could "change their mind" about their young children. The technique used was to watch video-excerpts of play, separation and similarly stressful moments in the presence of a clinician who asks the mother to think about what she (and her child) might be thinking and feeling at the time of the excerpt and at the moment of videofeedback. It applies the principles of mentalization
Mentalization
Mentalization is a psychological concept that describes the ability to understand the mental state of oneself and others which underlies overt behaviour. Mentalization can be seen as a form of imaginative mental activity, which allow us to perceive and interpret human behaviour in terms of...
as an aide to emotional regulation with these traumatized parents. It also involves elements of prolonged exposure treatment, the video-based treatment Interaction Guidance, and psychodynamically-oriented child-parent psychotherapy. Schechter and colleagues showed a significant change in the way mothers perceived their own child and their relationship together.
Tamars Children
This is a scheme in which a version of the Circle of Security intervention was added to a jail diversion program for pregnant women with a history of substance abuse. Preliminary data indicates a 68% rate of secure infant-mother attachment in the first relatively small (19) sample. This is a rate of secure attachment typically found in low risk samples.Florida Infant Mental Health Pilot Programme
This project tested the provision of 25 sessions of Child–Parent Psychotherapy (see above) for mothers investigated or substantiated for child maltreatment through court based teams. There were no further reports of maltreatment by participants during and immediately after the programme and positive changes in maternal and child behaviours were noted. The advocacy organisation Zero To ThreeZero To Three
Zero To Three is, according to its website, a national, multidisciplinary organization that supports the healthy development and well-being of infants, toddlers and their families...
is supporting such teams being established in other states.
Attachment and Biobehavioral Catch-Up (ABC)
This an intervention programme aimed at infants who have experienced early adverse care and disruptions in care. It aims to provide specialized help for foster carers in recognition of the fact that a young child placed in foster careFoster care
Foster care is the term used for a system in which a minor who has been made a ward is placed in the private home of a state certified caregiver referred to as a "foster parent"....
has to deal with the loss of attachment figures at a time when maintaining contact with attachment figures is vital. It targets key issues: providing nurturance for infants when the carers are not comfortable providing nurturance, overriding tendencies to respond in kind to infant behaviors and providing a predictable interpersonal environment
Social environment
The social environment of an individual, also called social context or milieu, is the culture that s/he was educated or lives in, and the people and institutions with whom the person interacts....
.
It is essentially a training programme for surrogate caregivers. It has four main components based on four propositions:
- "Providing nurturance when it does not come naturally". Based on findings that foster children's attachments are disproportionately likely to be disorganizedAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
and foster mothers with an unresolved or dismissing state of mind were likely to have children with disorganized attachments, the interpretation of Dozier et al. is that foster children have difficulty organizing their attachment systemsAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
unless they have nurturing foster carers. The goal is to help foster parents provide nurturing care even if they are non-autonomous with regard to their own attachment status. - "Infants in foster care often fail to elicit nurturance". Foster carers tend to respond 'in kind' to infants behavior. (Stovall and Dozier 2000). If foster infants behave in an avoidant or resistant manner, foster carers may act as if the infant does not need them. The goal is to train foster carers to act in a nurturing manner even in the absence of cues from the infant.
- "Infants in foster care are often dysregulated at physiological, behavioral and emotional levels". (Dozier et al. 2004) Foster children often show an atypical production of the stress hormone cortisolCortisolCortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
. It is not established whether this is significant for increased risk for later disorders, but very low or very high levels are associated with types of psychopathologyPsychopathologyPsychopathology is the study of mental illness, mental distress, and abnormal/maladaptive behavior. The term is most commonly used within psychiatry where pathology refers to disease processes...
in adults. The goal here is to help foster parents follow the child's lead and become more responsive social partners. - "Infants in foster care often experience threatening conditions". One of the functions of parents is to protect children from real or perceived dangers. This has often broken down for foster children, and worse, the caregiver may have served as a threat themselves. Prime examples are threats contingent upon behavior to have the child removed or taken away. Children experiencing frightening conditions have a limited range of responses and often 'dissociate'DissociationDissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
as a way of coping. Possible evidence for this may be the disproportionate number of disorganized attachment patterns in foster children. The aim is to reduce threatening behavior among foster parents by helping them understand the impact on the child.
Caregiver and child behaviors are assessed before and after intervention, as is the child's regulation of neuroendocrine function. The intervention consists of 10 sessions administered in caregivers homes by professional social workers. Sessions are videotaped for feedback and for fidelity. The intervention is currently being assessed in a randomized clinical trial involving 200 foster families, supported by the National Institute of Mental Health. Half the infants are assigned to the Developmental Education for Families programme as a comparison intervention. (DEF:Dozier 2003). The developers themselves point out that they do not test for caregiver commitment although they state this may or may not be a critical omission as they consider caregiver commitment to be a crucial variable in terms of child outcomes.
A modified version has been introduced for birth parents.which is currently being tested in a small group.
New Orleans Intervention/Tulane Infant Team
This is a foster care intervention devised by J.A. Larrieu and C.H ZeanahCharles H. Zeanah
Charles H. Zeanah Jr., M.D. is a child and adolescent psychiatrist who is a member of the Council of the American Academy of Child and Adolescent Psychiatry .-Professional:...
in 1998. The program is designed to address the developmental
Child development
Child development stages describe theoretical milestones of child development. Many stage models of development have been proposed, used as working concepts and in some cases asserted as nativist theories....
and health needs of children under the age of 5 who have been maltreated and placed in foster care
Foster care
Foster care is the term used for a system in which a minor who has been made a ward is placed in the private home of a state certified caregiver referred to as a "foster parent"....
. It is funded by the state government of Louisiana and private funds. It is a multidisciplinary approach involving psychiatrists
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
, psychologists
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
, social workers, paediatricians and paraprofessionals - all with expertise in child development
Child development
Child development stages describe theoretical milestones of child development. Many stage models of development have been proposed, used as working concepts and in some cases asserted as nativist theories....
and developmental psychopathology
Developmental psychopathology
Developmental psychopathology is the study of the development of psychological disorders, such as psychopathy, autism, schizophrenia and depression, with a lifecourse perspective....
.
The aim of the intervention is to support the building of an attachment relationship
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
between the child and foster carers, even though about half of the children eventually return to their parents after about 12 to 18 months. The designers note Mary Doziers program to foster the development of relationships between children and foster carers (ABC) and her work showing the connection between foster children's symptomology and foster carers attachment status. Work is based on findings that the qualitative features of a foster parents narrative descriptions of the child and relationship with the child have been strongly associated with the foster parents behavior with the child and the child's behavior with them. The aim was to develop a programme for designing foster care as an intervention.
The theoretical base is attachment theory
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
. There is a conscious effort to build on recent, although limited, research into the incidence and causes of Reactive attachment disorder
Reactive attachment disorder
Reactive attachment disorder is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts...
and risk factors for RAD and other psychopathologies.
Soon after coming into care the children are intensively assessed, in foster care, and then receive multi modal treatments. Foster carers are also formally assessed using a structured clinical
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
interview which includes in particular the meaning of the child to the foster parent. Individualised interventions for each child are devised based on age, clinical presentation and information on the child/foster carer match. The assessment 'team' remains involved in delivering the intervention. Those running the programme maintain regular phone and visit contact and there are support groups for foster parents.
Barriers to attachment are considered to be as follows;
- The disturbed nature of the child's relationship with its parent(s) before their removal by the state. Serious relationship disturbances are considered likely to be important contributors to difficulties in establishing new attachment relationships. Psychiatric and substance abuseSubstance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
histories and other criminal activities are common. Developmental delays in the children are common and there is a considerable range of regulatory, socioemotional and developmental problems. The child may perceive relationships as inconsistent and undependable. Further, despite harsh and inconsistent treatment many of the children remain attached to their parents, complicating the development of new attachment relationships. - Foster parents may also present barriers to forming healthy attachment relationships. Based on BowlbyJohn BowlbyEdward John Mostyn "John" Bowlby was a British psychologist, psychiatrist and psychoanalyst, notable for his interest in child development and for his pioneering work in attachment theory.- Family background :...
, the caregivingAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
system is seen as a biobehavioral system in adults that is complementary to the child's attachment systemAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
. Not all foster carers have this strong biological disposition as many fear becoming too 'attached' and suffering loss, many are effectively doing it to earn money and some perceive such children as 'damaged goods' and may remain emotionally distant and under involved.
Interventions include supporting foster parents to learn to help the child in regulating emotion
Emotion
Emotion is a complex psychophysiological experience of an individual's state of mind as interacting with biochemical and environmental influences. In humans, emotion fundamentally involves "physiological arousal, expressive behaviors, and conscious experience." Emotion is associated with mood,...
s, to learn to respond effectively to the child's distress and to understand the child's signals, especially 'miscues' as the signals of such children are often confusing as a consequence of their often frightening, inconsistent and confusing past relationships. Foster carers are taught to recognize what such children actually need rather than what they may appear to signal that they need. Such children often exhibit provocative and oppositional behaviors which may normally trigger feelings of rejection in caregivers. Withdrawn children may be overlooked and seemingly independent, indiscriminate children may be considered to be managing much better than they are. Foster carers are regularly contacted and visited to assess their needs and progress.
As of 2005, 250 children had participated in the programme. Outcome data published in 2001 revealed a 68% reduction in maltreatment recidivism for the same child returning to its parent(s)and a 75% reduction in recidivism
Recidivism
Recidivism is the act of a person repeating an undesirable behavior after they have either experienced negative consequences of that behavior, or have been treated or trained to extinguish that behavior...
for a subsequent child of the same mother. The authors claim the programme not only assists the building of new attachments to foster parents but also has the potential impact a families development long after a returned child is no longer in care.
Differentiation from attachment therapy
It is critical to differentiate therapies based on attachment theory from the "unfortunately named" attachment therapyAttachment Therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques...
. (However, the use of the terms "attachment therapy" and "attachment-based therapy" is not consistent in literature and on the Internet
Internet
The Internet is a global system of interconnected computer networks that use the standard Internet protocol suite to serve billions of users worldwide...
). Attachment therapy, also known as 'holding therapy', is a group of unvalidated therapies characterized by forced restraint of children in order to make them relive attachment-related anxieties; a practice considered incompatible with attachment theory and its emphasis on 'secure base'. The conceptual focus of these treatments is the child's individual internal pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
and past caregivers rather than current parent-child relationships or current environment
Social environment
The social environment of an individual, also called social context or milieu, is the culture that s/he was educated or lives in, and the people and institutions with whom the person interacts....
. This form of therapy
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
or, despite its name, to be based on attachment theory
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
, with which it is considered incompatible. In 2006, the American Professional Society on the Abuse of Children
American Professional Society on the Abuse of Children
American Professional Society on the Abuse of Children is an organization in the USA started by David Corwin. The APSAC website states its mission is "mission is to enhance the ability of professionals to respond to children and their families affected by abuse and violence." Membership is open to...
(APSAC) Task Force reported on the subjects of attachment therapy, reactive attachment disorder
Reactive attachment disorder
Reactive attachment disorder is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts...
, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorder
Attachment disorder
Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors...
s. The Taskforce was largely critical of attachment therapy's theoretical base, practices, claims to an evidence base, non-specific symptoms lists published on the internet, claims that traditional treatments do not work and dire predictions for the future of children who do not receive attachment therapy. The controversy also extends to the theories, diagnoses
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
, diagnostic practices, beliefs, and social group norms
Norm (sociology)
Social norms are the accepted behaviors within a society or group. This sociological and social psychological term has been defined as "the rules that a group uses for appropriate and inappropriate values, beliefs, attitudes and behaviors. These rules may be explicit or implicit...
and patient recruitment and advertising practices.
See also
- Attachment theoryAttachment theoryAttachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
- Attachment measuresAttachment measuresAttachment measures refer to the various procedures used to assess attachment in children and adults.Researchers have developed various ways of assessing patterns of attachment in children. A variety of methods allow children to be classified into four attachment pattern groups: secure,...
- Attachment in childrenAttachment in childrenNewborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
- Child psychotherapyChild psychotherapyFor therapies based on attachment theory see Attachment based therapy .Mental health interventions for children vary with respect to the problem being addressed and to the age and other individual characteristics of the child...
- Dyadic developmental psychotherapyDyadic Developmental PsychotherapyDyadic Developmental Psychotherapy is a treatment approach for families that have children with symptoms of emotional disorders, including Complex Trauma and disorders of attachment. It was originally developed by psychologist Daniel Hughes as an intervention for children whose emotional distress...
- Play therapyPlay therapyPlay therapy is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process...
- Mental healthMental healthMental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
- Parent-Child Interaction Therapy (PCIT)