Attachment-based intervention and Assessment in the context of Maltreatment: Comments on Bakermans-Kranenburg and van IJzendoorn

Introduction

Bakermans-Kranenburg and van IJzendoorn's text on "Attachment security and disorganization in maltreating families and institutionalized care" clearly state the need for more research on the effects of parenting support programs for improving the lives of maltreated children.¹ Indeed, such research is of paramount importance if we are to ensure that the specific needs of these children and their primary caregivers are adequately addressed, as well as those of practitioners from Child Protective Services (CPS), who directly deliver the programs to families. 

CPS is generally concerned with two critical tasks: 1) Parental Capacity Assessments (PCA) to orient child placement decisions and 2) Intervention services to protect the child, promote child development, and rehabilitate the parent. Intervention encompasses various types of services that may range, depending on the severity of cases and the court’s decisions, from providing services directly in the families' homes to out-of-home childcare. In the former, family services seek to enhance parental capacities and reduce the recurrence of maltreatment. Whether children remain with their parents or are removed, the overarching goal of CPS is to preserve or reunify families, unless the child’s safety under parental care is not possible.²

In the past years, many studies were conducted to examine the effects of support and treatment protocols for maltreating parents and their children; and results of attachment-based interventions have shown positive effects on parents and children’s well-being.³ However, less can be said of attachment-based PCA protocols, given the early stages of this research. Nevertheless, recent advances in the field of attachment underscore attachment theory’s framework as valuable at both the assessment and intervention levels.⁴ In this commentary, we briefly review the results of past attachment research in these two specific domains (PCA and intervention), outline important research questions for future studies, and underscore what we believe is one crucial key ingredient to the success of attachment-based practices in the context of child maltreatment.

Attachment-Based Intervention

A significant number of studies have tested long- and short-term attachment-based intervention protocols with maltreating parents and their children.³ Thus far, all protocols show significant changes in parents' and children's functioning. For example, using the Attachment and Biobehavioral Catch-up (ABC) with maltreating parent-child dyads and relying on a randomized control trial (RCT) design, researchers found that children in the ABC intervention group expressed lower levels of negative affect during a challenging task. Also, a higher proportion of children were securely attached at post-test in comparison to children of the control group.^5,6 Testing the Attachment Video-feedback Intervention (AVI; RCT), our work with maltreating parent-child dyads showed increases in maternal sensitivity, child attachment security, and child mental and motor development, and decreases in child attachment disorganization and behavior problems for families of the AVI group.^7,8 Using the Video feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD; RCT), mothers at very high risk of maltreatment with the highest parenting stress levels at intake showed greater decreases in harsh discipline than other parents.⁹ As for the Video Interaction Guidance intervention (VIG; no-RCT), it was delivered to parents in a residential treatment center who were at high risk of having their child removed.¹⁰ This small-scale study revealed that parental care and sensitivity increased for parents of the intervention group, but diminished for those of the control group.  

All of these protocols have in common their focus on the parent-child relationship and the inclusion of both the parent and child during intervention sessions. As well, all protocols are strength-based, relying on the assumption that individualized positive comments to the parent (whether positive video- or in-the-moment feedback) enhances parental sensitivity and child functioning. However, thus far, there is still a lot to learn about the mechanisms through which treatment effects are observed and the conditions under which they are most successful. Furthermore, regarding intervention outcomes specific to the context of maltreatment, more studies should consider examining the risk of child placement and recurrence of maltreatment. 

Best conditions of treatment success. A small set of attachment-based studies recently suggested that specific parent and child characteristics or difficulties may impede treatment efficacy. In particular, maltreating parents are likely to suffer from psychopathology, have experienced maltreatment and trauma during their childhood, and show higher stress levels or lower social support.^11,12 Tarabulsy et al. found that mothers with the highest levels of psychiatric symptoms, in comparison to those with the lowest levels at intake, benefited more from the AVI.¹³ Steele et al. found that the Group Attachment-Based Intervention (GABI; RCT), implemented with mothers at very high risk of maltreatment, was less effective in improving dyadic coordination for mothers with high levels of adverse childhood experiences (ACE) in comparison to mothers with low levels of ACE.¹⁴ Similarly, we recently showed, for a sample of parents with substantiated reports of maltreatment, that those of the AVI group with more severe childhood trauma levels showed fewer improvements in parent-child interaction than AVI parents with less severe childhood trauma.¹⁵

In short, results suggest that attachment-based interventions are successful with maltreating parents; however, some protocol adjustments would be warranted for some parents, particularly those who have experienced more severe trauma. Do these parents need more intensive interventions? Would a focus on trauma be a valuable approach? More research is needed to identify other potential moderators of intervention effects and develop tailored intervention strategies for those families with specific needs. 

Recurrence of Maltreatment and Child Placements as Treatment Outcomes. Though the rates of re-reports of maltreatment and child placement are important indicators of intervention success in the context of maltreatment, there are very few attachment-based studies examining treatment effects on these outcomes, and those that have yielded mixed results. For instance, Cyr et al. (RCT) did not show any changes in the rates of these two indicators immediately following the AVI and up to one year later.¹⁶ Yet, in their study, Tarabulsy et al. (no-RCT) reported lower rates of child placements for children whose parents had been exposed to the AVI.¹³ To better inform CPS and help protect children, there is a pressing need for the attachment research community to provide more precise information on the re-reports of maltreatment and child placement rates in the months/years following an attachment-based intervention. Further long-term attachment-based intervention research is needed in this area.

Attachment-Based Assessments of Parenting Capacities to Orient Placement Decisions

When CPS substantiates maltreatment, caseworkers first ask whether parents can provide minimal standards of child care. The answer to this question is critical as children with unfit parents are to be placed in out-of-home care to ensure their safety. Hence, to answer this question, particularly in cases of children for whom the risks associated with placement may outweigh the risks of remaining in the care of their parents, caseworkers request a parenting capacity assessment (PCA). PCAs help document parents’ competence to ensure children's physical and emotional safety, and parents' potential for enhanced parenting.^17,18 Then, relying on the results of PCAs, caseworkers can formulate recommendations that assist judges in their decision-making process about child placement. PCAs, which reveal parental strengths and difficulties, further help with the planning of intervention in cases of children remaining in their parents' care.

It has been argued that good quality PCAs should focus on the evaluation of several risk and protective factors associated with parenting and child placement. Such factors relate to the parent’s cultural values, community, financial and psychological resources, as well as their history of maltreatment and the quality of their social support network.^19,20 Another important information to gather from PCAs is the parent’s potential for enhanced parenting. To this end, adding a short attachment intervention to a PCA protocol would be much suited. 

Two recent studies, the first by van der Asdonk and her colleagues²¹ in the Netherlands and the second by our group in Canada (Cyr et al.),¹⁶ have tested the value of a PCA protocol with a video-feedback parent-child training as an embedded intervention component to assess the potential for enhanced parenting. However, mixed results were shown. The RCT study of van der Asdonk et al. revealed that the quality of child placement decisions was not improved by implementing an attachment-based intervention (VIPP) component to a PCA.²¹ Precisely, following their PCA-VIPP protocol, practitioners of the target group did not feel more confident about their child placement recommendations. Authors argued that the evaluators involved in their study, given that they were part of different clinics, could not rely on a standardized evaluation protocol. As a result, although all evaluators used the VIPP, they may not have assessed and weighted other risk and protective factors in a similar fashion. These family system factors are likely to influence the parents’ capacity to care and change, and in turn, the evaluators’ perception of the parent. In the Cyr et al.’s RCT study,¹⁶ we looked at different outcomes. We found that conclusions drawn by AVI practitioners, as to whether the parent showed a minimal capacity to care for their child following the PCA-AVI protocol, were predictive of child re-reports of maltreatment in the year following PCA, while those of the control group were not. We concluded that relying on short attachment-based interventions to assess parenting improvements – combined with a standardized evaluation of other parental risk and protective factors –, are promising tools to orient child placement decisions. Given the paucity of research in this area, much research is needed to confirm these results and better inform CPS on the acceptable use and misuse of attachment tools in the context of maltreatment.

Conclusions

Training in attachment theory and observation as a key ingredient for success

Based on our work with the AVI, we advocate for the importance of training in attachment theory and observation. In our view, practitioners’ training to develop sharpened observational skills through an attachment theory lens represents a key ingredient to a more refined understanding of the positive and negative dynamics of parent-child interaction, a fundamental condition for successful assessments and interventions with maltreating samples. In addition, we believe that adequate training should always involve regular supervision with practitioners. Supervision is central for the appropriation of new practices by professionals and should remain (at a variable frequency) once training is over. As such, we have developed, in collaboration with other researchers and clinical experts in the field, a community of practice for professionals trained in attachment theory and the AVI. The CARE, the Montreal’s Community of practice on Attachment and Relational intervention, offers professionals monthly group supervision to promote and ensure continuous training. In the specific context of CPS, by increasing caseworkers’ abilities to identify parents’ good enough parenting and potential for positive change, our hope is that recommendations for placement in the child's best interest are enhanced.

References

1. Bakermans-Kranenburg MJ, van IJzendoorn MH. Attachment Security and Disorganization in Maltreating Families and in Institutionalized Care. In: Tremblay RE, Boivin M, Peters RDeV, eds. van IJzendoorn MH, topic ed. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/attachment/according-experts/attachment-security-and-disorganization-maltreating-families-and. Updated July 2020. Accessed September 18, 2020. 
2. Hélie S, Turcotte D, Trocmé N, Tourigny M. Étude d’incidence québécoise sur les signalements évalués en protection de la jeunesse en 2008. Rapport final. Montréal, Centre jeunesse de Montréal-Institut universitaire, 2012.
3. Steele H, Steele M, eds. Handbook of attachment-based interventions. New York, NY: Guilford Publications; 2018.
4. Cyr C, Alink LR. Child maltreatment: the central roles of parenting capacities and attachment. Current Opinion in Psychology 2017;15:81-86.
5. Bernard K, Dozier M, Bick J, Lewis‐Morrarty E, Lindhiem O, Carlson E. Enhancing attachment organization among maltreated children: Results of a randomized clinical trial. Child Development 2012;83(2):623-636.
6. Lind T, Bernard K, Ross E, Dozier M. Intervention effects on negative affect of CPS-referred children: Results of a randomized clinical trial. Child Abuse & Neglect 2014;38:1459-1467
7. Moss E, Dubois-Comtois K, Cyr C, Tarabulsy GM, St-Laurent D, Bernier A. Efficacy of a home-visiting intervention aimed at improving maternal sensitivity, child attachment, and behavioral outcomes for maltreated children: A randomized control trial. Development and Psychopathology 2011;23:195-210.
8. Dubois-Comtois K, Cyr C, Tarabulsy GM, St-Laurent D, Bernier A, Moss E. Testing the limits: Extending attachment-based intervention effects to infant cognitive outcome and parental stress. Development and Psychopathology 2017;29:565-574.
9. Pereira M, Negrão M, Soares I, Mesman J. Decreasing harsh discipline in mothers at risk for maltreatment: a randomized control trial. Infant Mental Health Journal 2014;35(6):604-613.
10. Kennedy H, Landor M, Todd L. Video Interaction Guidance as a method to promote secure attachment. Educational and Child Psychology 2010;27:59-72.
11. Stith SM, Liu T, Davies LC, Boykin EL, Alder MC, Harris JM, Som A, McPherson M, Dees JEMEG. Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Violent Behavior 2009;14:13-29.
12. Madigan S, Cyr C, Eirich R, Fearon RMP, Ly A, Rash C, Poole JC, Alink LRA. Testing the cycle of maltreatment hypothesis: Meta-analytic evidence of the intergenerational transmission of child maltreatment. Development and Psychopathology 2019;31(1):23-51. 
13. Tarabulsy GM, Baudry C, Pearson J, Milot T, Cyr C, Provost MA, Lemelin. Implementation and effectiveness evaluation of the Attachment Video-Feedback Intervention strategy in five child protection settings in Quebec. Symposium presented at the International Attachment Conference, July 20, 2019; Vancouver, BC, Canada
14. Steele H, Murphy A, Bonuck K, Meissner P, Steele M. Randomized control trial report on the effectiveness of Group Attachment-Based Intervention (GABI©): Improvements in the parent–child relationship not seen in the control group. Development and psychopathology 2019;31(1):203-217.
15. van der Asdonk S, Cyr C, Alink L. Improving parent–child interactions in maltreating families with the Attachment Video-feedback Intervention: Parental childhood trauma as a moderator of treatment effects. Attachment & Human Development 2020;1-21.
16. Cyr C, Dubois-Comtois K, Paquette D, Lopez L, Bigras M. An Attachment-Based Parental Capacity Assessment to Orient Decision-making in Child Protection Cases. Child Maltreatment. 2020. Accepted manuscript.
17. Budd KS. Assessing parenting competence in child protection cases: A clinical practice model. Clinical Child and Family Psychology Review 2001;4(1):1-18.
18. Harnett PH. A procedure for assessing parents' capacity for change in child protection cases. Children and Youth Services Review 2007;29(9):1179-1188.
19. Houston S. Assessing parenting capacity in child protection: towards a knowledge‐based model. Child & Family Social Work 2016;21(3):347-357.
20. Steinhauer PD, Leitenberger M, Manglicas E, Pauker JD, Smith R, Goncalves L. Assessing Parenting Capacity: Manual. The Institute for the Prevention of Child Abuse, Toronto. 1995.
21. van der Asdonk S, de Haan WD, van Berkel SR, van IJzendoorn MH, Rippe RC, Schuengel C, Kuiper C, Lindauer RJL, Overbeek M, Alink LRA. Effectiveness of an attachment‐based intervention for the assessment of parenting capacities in maltreating families: A randomized controlled trial. Infant Mental Health Journal. 2020;41(6):821-835.