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 behaviors, 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.
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.
'"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 depression 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 infants initiative. The idea is that it increases the mother 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.
"Manipulation of sensitive responsiveness", van den Boom (1994) 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.
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 care 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.
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 emotions, 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.
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