**3. Attachment-based intervention strategies and protocols designed for maltreated children and their parents**

Based on Bowlby's [34] work and empirical studies on the intergenerational transmission of attachment, Berlin et al. [35]suggest that interventions inspired by attachment theory should be guided by three major therapeutic principals. The first two relate to intervention targets and the way change is likely to occur. Attachment-informed interventions are concerned with the promotion of child attachment security because it constitutes an important protective factor in the development and well-being of the child. Therefore, key targets should be empirically associated with child attachment. Whether target of intervention is to change parents' representations of attachment or behaviors with the child, in both cases, emphasis is placed on the parent-child attachment which is used as the main intervention vehicule to promote child attachment security and optimize child development. The third principal refers to the intervention process in which a relationship of trust between parent and practitioner, the latter in the role of a secure base for the parent, is necessary to promote change.

For the past few years, several intervention protocols have been developed based on research in the area of parent-child relationships and attachment. Accordingly, two metaanalytic studies [33,36] have shown that short-term behavioral interventions aimed at changing parental behavior towards the child are more effective in improving parental sensitivity and child attachment security and reducing the incidence of disorganized attachment behaviors, than those aimed at changing parental representations or providing parental social support. However, none of the studies included in these meta-analyses exclusively examined maltreating parents and their children. Recently, three majorattachment-based intervention protocols have emerged as effective for improving child attachment security of maltreated children. These protocols, which are either shortterm (approximately 6-10 weeks) or long-term (approximately 20 weeks to 2 years), have been developed for mother-child dyads in infancy and preschool age, and usually involve weekly home visits. Long-term protocols aim mainly the modification of parents'

representational models, while short-term protocols focus on the modification of parental behaviors. In both models parent and child are present during intervention sessions, but in long-term protocols, parents may receive social support and participate in separate individual psychotherapy sessions.

Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 69

one to conclude that observed effects are due to the intervention and not simply explained by the passage of time, or other confounding variables. In this study, both intervention protocols involved mothers and their child (mean age=13 months), and dyads were met at a frequency of one session per week during one year. These two protocols were compared to two other groups: 1) a community standard control group, which received the usual community services available to maltreating families, and 2) a normative comparison group, which consisted of non-maltreating, high socioeconomic risk families from the community. Results of this study indicated a substantial increase in secure attachment and a substantial decrease in disorganized attachment for children in the IPP and Psychoeducational group compared to those in the community standard services and normative comparison groups. However, no intervention effect was observed regarding maternal sensitivity. Moreover, a second study with the same sample revealed significant differences in stress (cortisol) regulation trajectories over time as a function of intervention groups [42]. More specifically, children receiving community standard services showed more dysregulated trajectories of stress (cortisol) beginning mid-treatment, in comparison to children in the IPP and Psychoeducational Intervention groups, for whom trajectories remained similar to those of non-maltreated children across time. In another study, this team also examined the effect of CPP on preschool children's (4 years old) representations of self, mother and relationships [43]. Using a randomized control trial, mother-child dyads were assigned to CPP, a Psychoeducational Parenting Intervention, or a community standard services group. Children in the CPP group showed significant decreases in negative representations of self and mother, as well as increases in their positive mother-child relationship expectations. Results by this research team thus support the efficacy of the IPP and CPP as successful long-term interventions in altering the predominantly insecure attachment organizations of infants and preschoolers from maltreating families, which is not the case with typical intervention services. These results point to the importance of providing services early on in the child's development by working jointly with the parent-child dyad in order to promote child attachment security, remediate early developmental difficulties, and prevent the

Other studies by Lieberman et al. [44] assessed the efficacy of the CPP with mothers and their preschooler (3-5 years old). Using a randomized control trial, these researchersprovided dyads witha one-hourintervention session per week, for an average of 50 weeks. CPP, as a preschool version of the IPP, targeted changes in maladaptive behaviors through developmentally supported and appropriate interactions; and guided mother-child dyads in creating a joint narrative of traumatic events while working towardsa resolution. The efficacy of the CPP on variables such as child behavior problems, post-traumatic stress symptoms, and presence of life stressors, was compared with a regular case management group which included individual psychotherapy with mothers. Study results showed a decrease in behavioral problems and post-traumatic stress symptoms for children in the CPP group in comparison to the case management group. Ata 6-month follow-up of this sample, reductions in child behavior problem were maintained, showing that the effects of the CPP were stable across time [45]. According to the authors, CPP assisted parents in finding effective

development of later psychopathology.

#### *Long-term protocols: The modification of representational models*

Changing representational models refers to the modification of representations of the self, others, and attachment relationships developed by the parent throughout the years. The therapeutic objective is to bring the parent to understand how their representations of their child and of their relationship can be inadequate, distorted, and linked to insecure representations of past childhood relationships. According to Bowlby [34], the parent's capacity to give new meaning to attachment representations is possible through open dialogue, in which the therapist supports the parent in the reinterpretation of past childhood experiences and the recognition that these experiences may affect the actual quality of caregiving towards the child. According to this model, it is this reflective process that promotes parental responsiveness, sensitivity, and availability, which in turns foster child attachment security and development.

#### *The Infant/Child-Parent Psychotherapy (IPP or CPP)*

The intervention model developed by Fraiberg et al. [37] with parents and infants, and later extended by Lieberman and Van Horn[38]to parents and preschoolers, is centered on the modification of representations. CPP has its origin in attachment theory, developmental psychopathology, and trauma theory [38].The principal assumption of the IPP/CPP is that difficulties in the parent-child relationship (parental insensitive behaviors) are not only due to deficits in parenting knowledge and skills, but also, and most importantly, to insecure internal representational models developed by the parent in response to past childhood experiences. In particular, this intervention involves dyadic therapy sessions in which the therapist uses the child's naturally occurring play behaviors with the parent as a way to translate the developmental and emotional meaning of the child's behavior towards her parent and improve mother-child interactive quality [39,40].This approach is mostly supportive, nondirective, and non-didactic, and includes developmental guidance based on the parent's concerns, or other strategies like role modeling, emotional support or insightoriented techniques to promote, through a trusting therapeutic relationship, the parent's understanding and empathy towards the child [39,41].

Several studies have assessed the efficacy of CPP and IPP for maltreated children and their mothers. For example, the study conducted by Cicchetti et al. [41], noteworthy for its randomized control trial, compared the IPP to a Psychoeducational Parenting Intervention protocol in which mothers were giving didactic training in child development, parenting skills, coping strategies, and assistance in developing social networks in order to promote overall parenting skills. A randomized control trial, which involves random assignment of participants to an experimental group (receiving the intervention) and a control group (without intervention, or receiving an intervention having different targets and objectives from those of the experimental group), constitutes an extremely rigorous method that allows one to conclude that observed effects are due to the intervention and not simply explained by the passage of time, or other confounding variables. In this study, both intervention protocols involved mothers and their child (mean age=13 months), and dyads were met at a frequency of one session per week during one year. These two protocols were compared to two other groups: 1) a community standard control group, which received the usual community services available to maltreating families, and 2) a normative comparison group, which consisted of non-maltreating, high socioeconomic risk families from the community.

68 Child Abuse and Neglect – A Multidimensional Approach

child attachment security and development.

*The Infant/Child-Parent Psychotherapy (IPP or CPP)* 

understanding and empathy towards the child [39,41].

*Long-term protocols: The modification of representational models* 

individual psychotherapy sessions.

representational models, while short-term protocols focus on the modification of parental behaviors. In both models parent and child are present during intervention sessions, but in long-term protocols, parents may receive social support and participate in separate

Changing representational models refers to the modification of representations of the self, others, and attachment relationships developed by the parent throughout the years. The therapeutic objective is to bring the parent to understand how their representations of their child and of their relationship can be inadequate, distorted, and linked to insecure representations of past childhood relationships. According to Bowlby [34], the parent's capacity to give new meaning to attachment representations is possible through open dialogue, in which the therapist supports the parent in the reinterpretation of past childhood experiences and the recognition that these experiences may affect the actual quality of caregiving towards the child. According to this model, it is this reflective process that promotes parental responsiveness, sensitivity, and availability, which in turns foster

The intervention model developed by Fraiberg et al. [37] with parents and infants, and later extended by Lieberman and Van Horn[38]to parents and preschoolers, is centered on the modification of representations. CPP has its origin in attachment theory, developmental psychopathology, and trauma theory [38].The principal assumption of the IPP/CPP is that difficulties in the parent-child relationship (parental insensitive behaviors) are not only due to deficits in parenting knowledge and skills, but also, and most importantly, to insecure internal representational models developed by the parent in response to past childhood experiences. In particular, this intervention involves dyadic therapy sessions in which the therapist uses the child's naturally occurring play behaviors with the parent as a way to translate the developmental and emotional meaning of the child's behavior towards her parent and improve mother-child interactive quality [39,40].This approach is mostly supportive, nondirective, and non-didactic, and includes developmental guidance based on the parent's concerns, or other strategies like role modeling, emotional support or insightoriented techniques to promote, through a trusting therapeutic relationship, the parent's

Several studies have assessed the efficacy of CPP and IPP for maltreated children and their mothers. For example, the study conducted by Cicchetti et al. [41], noteworthy for its randomized control trial, compared the IPP to a Psychoeducational Parenting Intervention protocol in which mothers were giving didactic training in child development, parenting skills, coping strategies, and assistance in developing social networks in order to promote overall parenting skills. A randomized control trial, which involves random assignment of participants to an experimental group (receiving the intervention) and a control group (without intervention, or receiving an intervention having different targets and objectives from those of the experimental group), constitutes an extremely rigorous method that allows Results of this study indicated a substantial increase in secure attachment and a substantial decrease in disorganized attachment for children in the IPP and Psychoeducational group compared to those in the community standard services and normative comparison groups. However, no intervention effect was observed regarding maternal sensitivity. Moreover, a second study with the same sample revealed significant differences in stress (cortisol) regulation trajectories over time as a function of intervention groups [42]. More specifically, children receiving community standard services showed more dysregulated trajectories of stress (cortisol) beginning mid-treatment, in comparison to children in the IPP and Psychoeducational Intervention groups, for whom trajectories remained similar to those of non-maltreated children across time. In another study, this team also examined the effect of CPP on preschool children's (4 years old) representations of self, mother and relationships [43]. Using a randomized control trial, mother-child dyads were assigned to CPP, a Psychoeducational Parenting Intervention, or a community standard services group. Children in the CPP group showed significant decreases in negative representations of self and mother, as well as increases in their positive mother-child relationship expectations. Results by this research team thus support the efficacy of the IPP and CPP as successful long-term interventions in altering the predominantly insecure attachment organizations of infants and preschoolers from maltreating families, which is not the case with typical intervention services. These results point to the importance of providing services early on in the child's development by working jointly with the parent-child dyad in order to promote child attachment security, remediate early developmental difficulties, and prevent the development of later psychopathology.

Other studies by Lieberman et al. [44] assessed the efficacy of the CPP with mothers and their preschooler (3-5 years old). Using a randomized control trial, these researchersprovided dyads witha one-hourintervention session per week, for an average of 50 weeks. CPP, as a preschool version of the IPP, targeted changes in maladaptive behaviors through developmentally supported and appropriate interactions; and guided mother-child dyads in creating a joint narrative of traumatic events while working towardsa resolution. The efficacy of the CPP on variables such as child behavior problems, post-traumatic stress symptoms, and presence of life stressors, was compared with a regular case management group which included individual psychotherapy with mothers. Study results showed a decrease in behavioral problems and post-traumatic stress symptoms for children in the CPP group in comparison to the case management group. Ata 6-month follow-up of this sample, reductions in child behavior problem were maintained, showing that the effects of the CPP were stable across time [45]. According to the authors, CPP assisted parents in finding effective

ways to processtheir own traumatic stress, which in turn improved child emotion regulation and aided in the correction of child cognitive distortions. However, while this study presents excellent methodological qualities, it did not measure parental sensitivity or child attachment.

Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 71

shows signs of distress. Parents are also encouraged to be sensitive to child needs despite the fact that some children may show rejecting behaviors (session 1 and 2). The practitioner's goal is therefore to help parents reinterpret their child's behavior, as well as their own personal issues, which may stem from past childhood attachment experiences and interfere with their present ability to provide sensitive care (session 7 and 8). In situations when the child is not in distress, parents are encouraged to support the child's exploration and feelings of competency. This is accomplished by following the child's lead with delight during moments of play (session 3 and 4). Parents are also asked to monitor their own overwhelming or intrusive behaviors towards their child during play activities (session 5 and 6). The practitioner thus uses structured activities to help parents enact particular skills. The practitioner also comments on parents' behaviors during these activities, as well as through video-feedback sessions in order to reinforce their positive parental behaviors, strengths, and understanding of the session content. The last two sessions are used to consolidate gains acquired during the first 8 weeks of intervention. Finally, weekly homework is assigned so that parents can practice the use of their newly developed skills

and record their own behaviors and those of their child throughout the week.

psychopathology in high-risk samples.

*The Attachment Videofeedback Intervention (AVI)* 

Bernard et al. [48] tested the efficacy of the ABC with parents and children (1-2 years old) reported to child protection services. Using a randomized control trial design, dyads were assigned to the ABC or a control intervention group, i.e., the Developmental Education for families (DEF), which aims the enhancement of cognitive and linguistic development of the child. Although child attachment was not assessed before the intervention, results from the 1-month post-intervention follow-up revealed a higher proportion of securely attached children and a lower proportion of disorganized children in the ABC group than in the DEF intervention group. These results support the efficacy of short-term attachment-based interventions for improving attachment security and decreasing later incidence of

The Attachment Video feedback Intervention, developed by Moss et al. [47] is a short-term attachment-based intervention for parents and their children consisting of 8-weekly home visits. The fundamental strategy of this approach is to focus on parental positive behavior to help the parent witness personal strengths and promote change. More specifically, during each intervention session of approximately 90 minutes, the practitioner reinforces the parent's sensitive behavior through a video-feedback discussion with the parent following a filmed parent-child interactive sequence. At each session, activities and toys are proposed to the dyad according to child age and parental behaviors to be modified. For this 10 to 15 minute filmed activity, the parent is given only one instruction targeting specific aspects of parental sensitivity to be improved (e.g. follow your child's lead, describe what your child is doing, describe your child's feelings during the activity). For younger children, caregiving activities such as breastfeeding or bath time can be used as filmed interactions. Following this activity, a video-feedback discussion of approximately 20 minutes is conducted by the practitioner who watches the interaction sequence with the parent. At first, the practitioner intentionally stops the film during positive moments in order to reinforce the parent's sensi-

CPP has also proven its' feasibility and effectiveness in a community and clinical setting as part of the Florida's infant and Young Child Mental Health Pilot Program designed for maltreating parents and their children (0-5 years old) [39]. Osofsky et al. [39] found improvements in parental sensitivity and responsiveness, and positive parental discipline. In addition, children showed improvements in positive affect, problem-solving or motor development, and mother-child dyads showed more reciprocal exchanges. This study did not however include a comparison or control group with random assignment.

#### *Short-term protocols: Modification of parental behaviors*

Changing parental behaviors refers to the modification of inadequate, insensitive, and frightening parental behavior into more sensitive caregiving behaviors. The therapeutic objective is therefore to bring parents to recognize, interpret, and properly respond to child distress and exploration signals. Video feedback has been considered as avaluable strategy to attain this objective. After filming a parent-child interaction, the therapist views video sequences with the parent in order to reinforce the latter's positive and sensitive behaviors towards the child. Video feedback allows the parent to witness personal positive behaviors, appropriate parenting skills, and most importantly their positive effect on child behaviors. Also, by highlighting the parent's strengths, this approach allows both the parent and the child to experience a new and pleasant relational exchange. According to this model, it is through these positive experiences that parents give new meaning to their relationship and increase their responsiveness, sensitivity, and availability towards their child, which in turn foster child attachment security and development. Although some parents may present limited strengths at the start of the intervention, emphasizing even simple positive behaviors such as saying "good job" to the child, can help the parent reconsider negative selfperceptions and discover hidden strengths, which can then lead to an increase in parental sensitivity. Once this is possible, positive behaviors may be consolidated and applied to other parent-child interactive situations [46].

To date, however, only two research teams have assessed short-term protocols based on attachment theory for maltreated children and their parents: the Moss, Dubois-Comtois, Cyr, Tarabulsy, St-Laurent, and Bernier (2011) research team [47] and the Bernard, Dozier, Bick, Lewis-Morrarty, Lindhiem, and Carlson (2012) research team [48].

#### *The Attachment and Behavioral Catch-up protocol (ABC).*

The ABC is a short-term attachment-based intervention consisting of 10-weekly home visits for which both the parent and the child are present. The main objective of the ABC [48] is to enhance sensitive, nurturing care among parents and to decrease frightening behaviors towards the child. While each session has a specific focus, the intervention aims mainly at helping parents become more nurturing towards their child especially when the latter shows signs of distress. Parents are also encouraged to be sensitive to child needs despite the fact that some children may show rejecting behaviors (session 1 and 2). The practitioner's goal is therefore to help parents reinterpret their child's behavior, as well as their own personal issues, which may stem from past childhood attachment experiences and interfere with their present ability to provide sensitive care (session 7 and 8). In situations when the child is not in distress, parents are encouraged to support the child's exploration and feelings of competency. This is accomplished by following the child's lead with delight during moments of play (session 3 and 4). Parents are also asked to monitor their own overwhelming or intrusive behaviors towards their child during play activities (session 5 and 6). The practitioner thus uses structured activities to help parents enact particular skills. The practitioner also comments on parents' behaviors during these activities, as well as through video-feedback sessions in order to reinforce their positive parental behaviors, strengths, and understanding of the session content. The last two sessions are used to consolidate gains acquired during the first 8 weeks of intervention. Finally, weekly homework is assigned so that parents can practice the use of their newly developed skills and record their own behaviors and those of their child throughout the week.

Bernard et al. [48] tested the efficacy of the ABC with parents and children (1-2 years old) reported to child protection services. Using a randomized control trial design, dyads were assigned to the ABC or a control intervention group, i.e., the Developmental Education for families (DEF), which aims the enhancement of cognitive and linguistic development of the child. Although child attachment was not assessed before the intervention, results from the 1-month post-intervention follow-up revealed a higher proportion of securely attached children and a lower proportion of disorganized children in the ABC group than in the DEF intervention group. These results support the efficacy of short-term attachment-based interventions for improving attachment security and decreasing later incidence of psychopathology in high-risk samples.

#### *The Attachment Videofeedback Intervention (AVI)*

70 Child Abuse and Neglect – A Multidimensional Approach

*Short-term protocols: Modification of parental behaviors* 

other parent-child interactive situations [46].

*The Attachment and Behavioral Catch-up protocol (ABC).* 

attachment.

ways to processtheir own traumatic stress, which in turn improved child emotion regulation and aided in the correction of child cognitive distortions. However, while this study presents excellent methodological qualities, it did not measure parental sensitivity or child

CPP has also proven its' feasibility and effectiveness in a community and clinical setting as part of the Florida's infant and Young Child Mental Health Pilot Program designed for maltreating parents and their children (0-5 years old) [39]. Osofsky et al. [39] found improvements in parental sensitivity and responsiveness, and positive parental discipline. In addition, children showed improvements in positive affect, problem-solving or motor development, and mother-child dyads showed more reciprocal exchanges. This study did

Changing parental behaviors refers to the modification of inadequate, insensitive, and frightening parental behavior into more sensitive caregiving behaviors. The therapeutic objective is therefore to bring parents to recognize, interpret, and properly respond to child distress and exploration signals. Video feedback has been considered as avaluable strategy to attain this objective. After filming a parent-child interaction, the therapist views video sequences with the parent in order to reinforce the latter's positive and sensitive behaviors towards the child. Video feedback allows the parent to witness personal positive behaviors, appropriate parenting skills, and most importantly their positive effect on child behaviors. Also, by highlighting the parent's strengths, this approach allows both the parent and the child to experience a new and pleasant relational exchange. According to this model, it is through these positive experiences that parents give new meaning to their relationship and increase their responsiveness, sensitivity, and availability towards their child, which in turn foster child attachment security and development. Although some parents may present limited strengths at the start of the intervention, emphasizing even simple positive behaviors such as saying "good job" to the child, can help the parent reconsider negative selfperceptions and discover hidden strengths, which can then lead to an increase in parental sensitivity. Once this is possible, positive behaviors may be consolidated and applied to

To date, however, only two research teams have assessed short-term protocols based on attachment theory for maltreated children and their parents: the Moss, Dubois-Comtois, Cyr, Tarabulsy, St-Laurent, and Bernier (2011) research team [47] and the Bernard, Dozier,

The ABC is a short-term attachment-based intervention consisting of 10-weekly home visits for which both the parent and the child are present. The main objective of the ABC [48] is to enhance sensitive, nurturing care among parents and to decrease frightening behaviors towards the child. While each session has a specific focus, the intervention aims mainly at helping parents become more nurturing towards their child especially when the latter

Bick, Lewis-Morrarty, Lindhiem, and Carlson (2012) research team [48].

not however include a comparison or control group with random assignment.

The Attachment Video feedback Intervention, developed by Moss et al. [47] is a short-term attachment-based intervention for parents and their children consisting of 8-weekly home visits. The fundamental strategy of this approach is to focus on parental positive behavior to help the parent witness personal strengths and promote change. More specifically, during each intervention session of approximately 90 minutes, the practitioner reinforces the parent's sensitive behavior through a video-feedback discussion with the parent following a filmed parent-child interactive sequence. At each session, activities and toys are proposed to the dyad according to child age and parental behaviors to be modified. For this 10 to 15 minute filmed activity, the parent is given only one instruction targeting specific aspects of parental sensitivity to be improved (e.g. follow your child's lead, describe what your child is doing, describe your child's feelings during the activity). For younger children, caregiving activities such as breastfeeding or bath time can be used as filmed interactions. Following this activity, a video-feedback discussion of approximately 20 minutes is conducted by the practitioner who watches the interaction sequence with the parent. At first, the practitioner intentionally stops the film during positive moments in order to reinforce the parent's sensi-

tive behaviors towards the child, reciprocal interactions, and moments when the parent had a positive impact on the child. The practitioner also inquires about the parent's feelings and thoughts during specific moments. The parent is also invited to share observations relating to the self and the child (see Table 1 for a description of a typical session).Intervention sessions also include a discussion with the parent regarding attachment related themes, emotion regulation, and concerns regarding the child (e.g. anger, discipline). While the first video feedback session emphasizes child behaviors (e.g. proximity seeking, exploration, meaning of distress signals), the focus is gradually shifted on to parents' behaviors (e.g. interpretation of signals, adequate and nurturing responses).

Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 73

integrated into the intervention protocol, and for which child attachment disorganization decreased and child attachment security improved. However, this study did not examined intervention effects on parental sensitivity. In addition, while the Moss and al. study [47] did not specifically target parental frightening behaviors during video-feedback sessions, they attributed part of their success to the training received by clinicians working with the families. Not only were clinicians trained by attachment researchers (experts) in the recognition of children's distress signals and parental sensitive/insensitive behaviors, but they were also trained in the identification of parental frightening, extremely intrusive, and helpless behaviors. As suggested by Bakermans-Kranenburg et al. [33], to reduce child disorganization and its correlates, interventions should focus on both improving parental sensitivity and reducing parental

According to Bowlby [34], in order for intervention strategies to be effective, it is essential that the therapist be perceived as a secure attachment figure by the parent. By listening, being available and consistent, the therapist can be viewed as a sensitive personwho can help the parent find new meaning to past and current attachment representations or behaviors towards the child. By accompanying the parent in the re-interpretation of childhood experiences and by having the parent discover personal strengths, the therapist helps the parent experience a significant and gratifyingrelationship with another adult. The parent canthen refer to this new sensitive attachment figure to better interpret and appease their own distress as well as that of their child. The practitioner's empathy and ability to proceed with therapy in a progressive manner, respecting the parent's rhythm, are key elements for the development of a relationship of trust and the promotion of changes in the parent-child relationship. The more the parent learns to rely on this relationship of trust, the more the

Beyond these qualities, practitioner training and supervision are essential aspects of successful intervention protocols with parents. Research has shown that clinicians who intend to apply intervention strategies based on the principles of attachment theory must acquire indepth knowledge of the theory and of child developmental processes, and must develop excellent observational skills with respect to parent-child interactions [51]. For example, in the Moss et al. [47] study, the training, which included the presentation of multiple video case-studies, focused on the teaching of attachment theory concepts as well as associated intervention techniques. In addition, the appropriate attitudes to be adopted by clinicians partaking in the intervention protocol were clearly written out in the intervention manual received by clinicians during the training. Moreover, clinicians learned to be flexible and to make appropriate judgments in order to adequately adjust themselves to the particular needs of each family, the age of the child, and the complex problems surrounding families. In order to ensure the integrity of the intervention, regular supervision was also offered to clinicians. Supervision was carried out by a psychologist, whom also was an expert in attachment and the application of the AVI. As indicated by Olds [52] and Goodson, Layzer, St-Pierre, Bernstein, and Lopez [53], the absence of extensive training makes prevention or intervention efforts ineffective, and can even exacerbate the difficulties already present in

frightening behaviors.

the parent.

*The clinician as a secure base for the parent* 

parent learns to become his or her own security base.

Moss et al. [47] tested the efficacy of the AVI with parents and children (0-5 years old) reported to child protection services. Using a randomized control trial, dyads were either assigned to the AVI or to a case management control group receiving regular child protection services. Results revealed that parents exposed to the AVI were more sensitive after the intervention than those who received the usual servicesof the child protection services. Substantial increases in attachment security and decreases in attachment disorganization were also found for children of the AVI group. In addition, a decrease in behavior problems was observed for older children of the intervention group. Results of this study clearly support the value of short-term attachment-based interventions as a costeffective means for improving child attachment security as well as for promoting sensitive caregiving behaviors in parents identified as neglectful and/or abusive, and at-risk of having their parental rights terminated.

Overall, attachment-based intervention protocols represent promising and valuable intervention strategies for maltreated children and their parents.Given the relatively limited number of studies on intervention strategies for maltreated children and their parents, determining whether one type of protocol is more effective than another is premature. It is also difficult to determine the distinct benefits of short versus long-term programs, or best-suited intervention target (parental representations and/or parental behaviors). We can only deplore the rarity of studies that have evaluated the medium to long-term effects of these interventions. Accordingly, greater research is needed in order to examine whether the beneficial effects of these seemingly promising interventions are maintained over time.

Studies must also consider the potential influence of variables that can moderate the efficacy of intervention protocols (e.g. parental mental health, parental attachment state of mind, domestic violence). For example, some variables may influence the ability of some parents and children to benefit from specific types of intervention. In particular, studies have shown that mothers who have experienced trauma during their own childhood or have unresolved attachment representations in response to loss or past experiences of physical or sexual abuse, do not profit from a behaviourally-driven attachment-based intervention aiming the improvement of parental sensitivity [49,50]. Perhaps, sensitivity is more likely to improve if parents are able to witness their inappropriate, and sometimes frightening, behaviors in relation to their child. This hypothesis is supported by results from the Bernard et al. [48] study in which sessions specifically aiming the identification of parental frightening behaviors were integrated into the intervention protocol, and for which child attachment disorganization decreased and child attachment security improved. However, this study did not examined intervention effects on parental sensitivity. In addition, while the Moss and al. study [47] did not specifically target parental frightening behaviors during video-feedback sessions, they attributed part of their success to the training received by clinicians working with the families. Not only were clinicians trained by attachment researchers (experts) in the recognition of children's distress signals and parental sensitive/insensitive behaviors, but they were also trained in the identification of parental frightening, extremely intrusive, and helpless behaviors. As suggested by Bakermans-Kranenburg et al. [33], to reduce child disorganization and its correlates, interventions should focus on both improving parental sensitivity and reducing parental frightening behaviors.

#### *The clinician as a secure base for the parent*

72 Child Abuse and Neglect – A Multidimensional Approach

their parental rights terminated.

maintained over time.

interpretation of signals, adequate and nurturing responses).

tive behaviors towards the child, reciprocal interactions, and moments when the parent had a positive impact on the child. The practitioner also inquires about the parent's feelings and thoughts during specific moments. The parent is also invited to share observations relating to the self and the child (see Table 1 for a description of a typical session).Intervention sessions also include a discussion with the parent regarding attachment related themes, emotion regulation, and concerns regarding the child (e.g. anger, discipline). While the first video feedback session emphasizes child behaviors (e.g. proximity seeking, exploration, meaning of distress signals), the focus is gradually shifted on to parents' behaviors (e.g.

Moss et al. [47] tested the efficacy of the AVI with parents and children (0-5 years old) reported to child protection services. Using a randomized control trial, dyads were either assigned to the AVI or to a case management control group receiving regular child protection services. Results revealed that parents exposed to the AVI were more sensitive after the intervention than those who received the usual servicesof the child protection services. Substantial increases in attachment security and decreases in attachment disorganization were also found for children of the AVI group. In addition, a decrease in behavior problems was observed for older children of the intervention group. Results of this study clearly support the value of short-term attachment-based interventions as a costeffective means for improving child attachment security as well as for promoting sensitive caregiving behaviors in parents identified as neglectful and/or abusive, and at-risk of having

Overall, attachment-based intervention protocols represent promising and valuable intervention strategies for maltreated children and their parents.Given the relatively limited number of studies on intervention strategies for maltreated children and their parents, determining whether one type of protocol is more effective than another is premature. It is also difficult to determine the distinct benefits of short versus long-term programs, or best-suited intervention target (parental representations and/or parental behaviors). We can only deplore the rarity of studies that have evaluated the medium to long-term effects of these interventions. Accordingly, greater research is needed in order to examine whether the beneficial effects of these seemingly promising interventions are

Studies must also consider the potential influence of variables that can moderate the efficacy of intervention protocols (e.g. parental mental health, parental attachment state of mind, domestic violence). For example, some variables may influence the ability of some parents and children to benefit from specific types of intervention. In particular, studies have shown that mothers who have experienced trauma during their own childhood or have unresolved attachment representations in response to loss or past experiences of physical or sexual abuse, do not profit from a behaviourally-driven attachment-based intervention aiming the improvement of parental sensitivity [49,50]. Perhaps, sensitivity is more likely to improve if parents are able to witness their inappropriate, and sometimes frightening, behaviors in relation to their child. This hypothesis is supported by results from the Bernard et al. [48] study in which sessions specifically aiming the identification of parental frightening behaviors were According to Bowlby [34], in order for intervention strategies to be effective, it is essential that the therapist be perceived as a secure attachment figure by the parent. By listening, being available and consistent, the therapist can be viewed as a sensitive personwho can help the parent find new meaning to past and current attachment representations or behaviors towards the child. By accompanying the parent in the re-interpretation of childhood experiences and by having the parent discover personal strengths, the therapist helps the parent experience a significant and gratifyingrelationship with another adult. The parent canthen refer to this new sensitive attachment figure to better interpret and appease their own distress as well as that of their child. The practitioner's empathy and ability to proceed with therapy in a progressive manner, respecting the parent's rhythm, are key elements for the development of a relationship of trust and the promotion of changes in the parent-child relationship. The more the parent learns to rely on this relationship of trust, the more the parent learns to become his or her own security base.

Beyond these qualities, practitioner training and supervision are essential aspects of successful intervention protocols with parents. Research has shown that clinicians who intend to apply intervention strategies based on the principles of attachment theory must acquire indepth knowledge of the theory and of child developmental processes, and must develop excellent observational skills with respect to parent-child interactions [51]. For example, in the Moss et al. [47] study, the training, which included the presentation of multiple video case-studies, focused on the teaching of attachment theory concepts as well as associated intervention techniques. In addition, the appropriate attitudes to be adopted by clinicians partaking in the intervention protocol were clearly written out in the intervention manual received by clinicians during the training. Moreover, clinicians learned to be flexible and to make appropriate judgments in order to adequately adjust themselves to the particular needs of each family, the age of the child, and the complex problems surrounding families. In order to ensure the integrity of the intervention, regular supervision was also offered to clinicians. Supervision was carried out by a psychologist, whom also was an expert in attachment and the application of the AVI. As indicated by Olds [52] and Goodson, Layzer, St-Pierre, Bernstein, and Lopez [53], the absence of extensive training makes prevention or intervention efforts ineffective, and can even exacerbate the difficulties already present in the parent.


Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 75

**Figure 1.** Development of the maltreated child and attachment-based intervention targets to promote

Figure 1 presents the intergenerational transmission of child attachment disorganization and the compromised development of maltreated children. It also illustrates how the different therapeutic principals can guide and act as important elements in the process of change and

While the contribution of attachment theory in the assessment of parental capacity in child protection cases has been proposed by many researchers [54-57], key concepts of this theory have rarely been integrated intoassessment protocols. This is surprising given that attachment theory is closely linked to the concept of parental capacity, i.e., the parent's capacity to care for their child, to protect from potential threats, and to offer an environment that promotes child emotional, cognitive, and physical development [58].A competent parent, in terms of parenting capacity, is able to adapt to the inherent developmental changes of their child: not only is the parent sufficiently competent in responding to the child's needs while adjusting to the child's changing developmental capacities, but the parent is also able to find solutions to the daily struggles encountered as a parent [54,58]. It is through a high-quality relationship, in which the parent demonstrates interest, respect, and sensitivity towards the child that a parent's competency becomes apparent [59]. The concept of parental competency is therefore closely related to the concept of parental sensitivity, as defined by attachment

The assessment of parental capacity in cases of children reported for abuse or neglect is particularly important, in that it often informs the court of the child's best interest. Specifically, it

**4. Applying attachment-based intervention in a new context: The** 

**assessment of parental capacity in child protection cases** 

child development

theory.

modification of the parent-child relationship.

**Table 1.** Progress of an Attachment Video feedback Intervention session according to a protocol by Moss and Colleagues

#### Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 75

74 Child Abuse and Neglect – A Multidimensional Approach

 10-15 min.

1. Arrival at the home

3. Filmed playtime

4. Video feedback

5. End of session

Moss and Colleagues

Phases Duration Relational intervention session

signals, etc.)

merely an observer

sequence with the parent

herself and her child

**Table 1.** Progress of an Attachment Video feedback Intervention session according to a protocol by

2. Discussion 20 min. Theme chosen by the parent

the last encounter

10 min. Brief review of events which affected the parent and child since

relationship (e.g. bedtime, discipline, etc.)

Theme related to parent-child relationship, emotional

regulation or parent's preoccupations concerning parent-child

 Allows practitioner to develop relationship of trust with parent and helps the latter to make links between her present parental

preoccupations and how she interacts with her child

 Parent-child interaction filmed during playtime activity Activity and toys supplied by practitioner in accordance to the child's age and dyadic aspects to be worked at (e.g. physical proximity, child's need to explore, interpreting child's distress

 A single instruction is given to the parent (e.g. to act as usual, follow her child's rhythm, imitate her child, etc.) No intervention is made during interaction; the practitioner is

Practitioner asks parent how she feels and what she notices of

 Practitioner intentionally pauses at positive moments where he reinforces parental sensitivity, reciprocity and moments when

20 min. Video feedback done by practitioner who views the interaction

the parent has a positive impact on her child

 10 min. Homework: Practitioner encourages the parent to reproduce an activity with her child during the week

**Figure 1.** Development of the maltreated child and attachment-based intervention targets to promote child development

Figure 1 presents the intergenerational transmission of child attachment disorganization and the compromised development of maltreated children. It also illustrates how the different therapeutic principals can guide and act as important elements in the process of change and modification of the parent-child relationship.
