Community implementation outcomes of Attachment and Biobehavioral Catch-up

Abstract

Bringing evidence-based treatments to community practice is a critical challenge for the field. When implemented in the community, evidence-based treatments often fail to provide the benefits shown in laboratory settings. Therefore, when evidence-based treatments are transported to the community, it is essential to investigate implementation process and outcomes. The present study assessed whether Attachment and Biobehavioral Catch-up (ABC), an intervention for high-risk parents that has been shown to be efficacious in randomized clinical trials (RCTs), changed parent behavior in a community-based setting. This study examined data collected from 78 cases by 9 parent coaches in a diverse community setting in Hawaii, and compared data to benchmarks from RCTs. Parent coach fidelity was coded from intervention session video clips, and was also compared with benchmarks. Caregivers participating in ABC were primarily birth parents, and most were referred through Child Protective Services involvement or for reasons of harsh parenting or neglect. Parental behavior was assessed before and after intervention using a semi-structured play task. Increases in parental following the lead and delight, and decreases in parental intrusiveness, were observed; these changes were comparable to effect sizes observed in RCTs. Intent to treat analyses were conducted using behavioral data from videotaped sessions, and suggested that ABC also improved following the lead in parents who subsequently dropped out of treatment. These results support the viability of ABC for enhancing parenting behavior among parents at high risk for maltreatment, and demonstrate that parent coaches in community agencies can successfully implement ABC.

Introduction

In 2013, approximately 6.4 million children were involved in Child Protective Services (CPS) referrals (USDHHS, 2015). Children under age 3 made up 27.3% of all victims of child abuse and neglect in 2013, and children under 1 year had the highest rate of victimization, at 23.1 children per 1,000 (USDHHS, 2015). Early childhood maltreatment has been linked to negative outcomes such as disorganized attachment (Cyr et al., 2010, van IJzendoorn et al., 1999) and physiological and behavioral dysregulation (Bernard et al., 2010, Bruce et al., 2009, Cicchetti et al., 2010). In early childhood, when children's social and physiological systems are developing rapidly, consequences of maltreatment may be particularly detrimental. Thus, provision of high quality services is critical for children during this developmental period, in order to prevent long-term consequences of abuse and neglect.

To this point, evidence-based interventions have not been used frequently in community settings (National Advisory Mental Health Council, 2001, President's New Freedom Commission on Mental Health, 2004). The services offered in child welfare settings typically lack strong research evidence to support their effectiveness, and rarely include evidence-supported interventions (Barth et al., 2005, Hurlburt et al., 2007). However, recent implementation studies have provided encouraging findings regarding the potential effectiveness and transportability of evidence-based parenting programs in community welfare settings. For example, SafeCare and an adaptation of Parent–Child Interaction Therapy (PCIT) have been shown to reduce child maltreatment recidivism when implemented in community settings (Chaffin et al., 2011, Chaffin et al., 2012).

The Attachment and Biobehavioral Catch-up (ABC) intervention targets a specific niche within the child welfare population. Specifically, ABC was designed for maltreated infants and their parents, and addresses infants’ attachment and regulatory problems. ABC uses an active coaching approach to support parents in developing behaviors that promote these outcomes in children. ABC targets three critical parent behaviors: nurturance, following the lead with delight, and frightening/intrusive behavior. First, parents are encouraged to respond in nurturing ways when their children are distressed. Nurturance is especially important in helping children develop secure and organized attachments (Leerkes, 2011, McElwain and Booth-LaForce, 2006). The second target includes two components: following the lead and delight. When children are not distressed, parents are encouraged to interact synchronously, following their children's lead in play and everyday activities. Following the child's lead, or parent–child synchrony, has been linked with children developing adequate regulatory capabilities (Bornstein and Tamis-Lemonda, 1997, Feldman et al., 1999). Parents are also supported in taking delight in their children, or responding to their children with genuine positive affect and enjoyment, for example, smiling and laughing in response to children's behavior. Although data are more limited in linking delight to child outcomes, research on similar constructs, such as shared positive affect (e.g., Kochanska & Aksan, 1995) and maternal responsiveness to child positive affect (e.g., Feng, Shaw, Skuban, & Lane, 2007), suggest that delight may also play a role in children's development of behavioral and emotional regulation. Finally, parents are helped to recognize and inhibit intrusive or threatening behaviors that could be frightening to their children. Intrusive behaviors include overwhelming physical interactions, like tickling or squeaking a toy in the child's face, in which the parent ignores the child's attempts to disengage; more overtly frightening behaviors include using a harsh tone or yelling when setting limits, and physical discipline. Parental frightening and intrusive behavior interferes with children's ability to regulate and organize their physiology and behavior (e.g., Hane and Fox, 2006, van IJzendoorn et al., 1999).

ABC is conducted by clinicians referred to as “parent coaches” in 10 in-home sessions with families. During hour-long sessions, parent coaches discuss manualized content with caregivers, use structured practice activities, and present video feedback to highlight parents’ intervention-targeted behaviors. The key active ingredient of intervention is thought to be in the moment feedback, which is used to support parents’ in-session practice of behaviors targeted by ABC. Parent coaches make in the moment comments to point out when parents engage in intervention-targeted behaviors. Importantly, these comments draw attention to the specific behaviors of the parent (so that the parent understands what behavior is being addressed), link behaviors to the intervention targets (so that the parent can see how a specific behavior relates to intervention targets), and discuss the effects of the parent's behaviors on the child (so that the parent can see how the behavior will influence long-term outcomes for the child). Research from a randomized clinical trial of ABC found that more frequent in the moment feedback in an early session of intervention predicted higher frequency of parent following the lead in a later session, even when controlling for the parent's prior level of following the lead (Meade & Dozier, 2012).

ABC has been shown to decrease rates of disorganized attachment, and increase rates of secure attachment, among infants living with their CPS-involved birth parents (Bernard et al., 2012). ABC has also been found to normalize diurnal cortisol production of children living with high-risk birth parents, leading to higher morning values and steeper slopes across the day, when compared with children enrolled in a control intervention (Bernard, Dozier, Bick, & Gordon, 2015). Such differences in cortisol production are not only observed soon after intervention, but are also sustained 2 to 3 years following intervention (Bernard, Hostinar, & Dozier, 2015). Other long-term outcomes that have been observed among children include enhanced executive functioning (Lewis-Morrarty, Dozier, Bernard, Terraciano, & Moore, 2012) and emotion expression (Lind, Bernard, Ross, & Dozier, 2014). With regard to parenting outcomes, ABC has been found to increase maternal following the lead, and result in different patterns of parental brain activity than seen among parents in a control intervention condition (Bernard, Simons, & Dozier, 2015). Enhanced parenting following participation in ABC has also been found among mothers living with their infants in residential substance abuse treatment facilities (Berlin, Shanahan, & Appleyard Carmody, 2014). These final results are notable because they come from a study conducted outside ABC's laboratory of origin, providing preliminary support for the success of ABC implementation in new sites.