The development of DDP-informed parenting groups for parents and carers of children looked after or adopted from care

Introduction

Nurturing Attachments and Foundations for Attachment are groupwork programmes devised to contribute to support interventions for the range of parents and carers parenting children living in or adopted from care (Golding, 2014; 2017). This population includes many children who have experienced abusive and/or neglectful early parenting. As a result, they often display a range of challenges including those stemming from the impact of trauma upon behaviour, attachment development and neurodevelopment (Tarren-Sweeney, 2013) and many are described as ‘developmentally traumatised’. This term ‘developmental trauma’ incorporates complex trauma that was continuous during the early months and years of a child’s life and was experienced from within the birth family. The term also acknowledges the damaging effects of the early familial experiences to which the children were exposed (van der Kolk, 2005). It is recognised that alternative parents via foster, residential and kinship care and adoption need to adapt their parenting approaches to meet these complex needs in order to counter the impact of this trauma and help the children to develop security of attachment (Dozier and Rutter, 2008). The Nurturing Attachments and Foundations for Attachment programmes were devised to support and guide the parents and carers in this endeavour.

Both programmes are informed by the Dyadic Developmental Psychotherapy (DDP) model. Parents are encouraged to adopt the attitude of PACE (Playfulness, Acceptance, Curiosity and Empathy) as a central part of a DDP-informed parenting approach (Hughes, Golding and Hudson, 2019). Nurturing Attachments and Foundations for Attachment, in common with DDP, are theoretically based on attachment theory (Bowlby, 1998) and have also been influenced by the work of colleagues on intersubjectivity (Trevarthen, 2001), mentalization-based therapies (Allen, 2013; Fonagy, et al., 2002; Luyten, et al., 2017) and polyvagal theory (Porges, 2011; 2017).

Nurturing Attachments is an 18-session group-based programme that provides psycho-education alongside practical advice and guidance to assist parents and carers to develop a parenting approach matched to the emotional and behavioural needs of their children. Group members are helped to support children’s behaviour within the context of encouraging them to build trust in adults and experience security. Traditional social learning theory-based parenting ideas are adapted to include attention to emotional connection and regulation. This is informed by attachment theory, intersubjectivity and an understanding of the impact of trauma on the children. This approach is visually presented as a ‘House Model of Parenting’ explained below.

The length of the programme provides scope for an experiential and developmental approach within which group members are encouraged to develop reflective function through a process of discussion, modelling, practice and the use of reflective diaries. Participants reflect on the meaning underlying the behaviours the child is displaying and the impact that this is having upon themselves. This reflection supports their own emotional regulation, allowing them to stay open and engaged to their children, even at the more challenging times, so that they can support their child to emotionally regulate and reflect. It is thought that increased parental reflective function can strengthen the relationship between parent and child, contributing to security for the child and the stability of the placement (Redfern, et al., 2018).

Foundations for Attachment is a briefer, complementary intervention delivered over three days or six sessions, organised around the model of the same name. It supports parents to adopt the same DDP-informed parenting approach as Nurturing Attachments but without the developmental possibilities of the longer programme. Group members can use Foundations for Attachment as a shorter introduction to the approach before committing to the full Nurturing Attachments programme, or it can be used as a stand-alone intervention.

This article provides an overview of the development of and current research base for both these approaches.

The Dyadic Developmental Psychotherapy (DDP) model

DDP was developed by Dan Hughes as a model of therapy to help children and young people who had experienced abuse and neglect in their families of origin but who were now living in secure foster and adoptive homes. At the time of its development, beginning at the end of the last century, there were no interventions designed specifically for this group of children and traditional therapies, such as cognitive behavioural approaches, were reported by clinicians to be ineffective. Additionally, foster carers and adoptive parents were noting that traditional and well-accepted parenting practices were proving unsuccessful in helping the children to adapt to their new families (Hughes, Golding and Hudson, 2019). While interventions based on cognitive behavioural and social learning theory are successful with children growing up in secure families, they are much less effective for those who have experienced traumatic early environments and are growing up in alternative families. This is likely to be because the interventions do not address the core difficulties of emotional regulation. David Howe (2005) concludes that effective interventions with older children (beyond infancy) need to be long term and require more costly professional inputs. He suggests that there is a key therapeutic challenge to help the children feel safe with sensitive and responsive carers (p. 260):

Not until they learn to ‘let go’ and connect, mind to mind, with an open and attuned caregiver can they begin to explore their own and other people’s mental states. This is the road to self-regulation and good mental health, but the older the child and the more profound the trauma, the longer and more difficult the journey.

DDP is influenced by the body of attachment theory and research (Cassidy and Shaver, 2016), alongside child development theory which describes how infants relate with healthy adults. The latter is influenced by Trevarthen’s theory of intersubjectivity and Stern’s ideas about attunement (Stern, 2000; Trevarthen, 2001; 2016). The research of notable psychologists and neuroscientists such as Peter Fonagy (Fonagy, et al., 2002; Fonagy, et al., 2016), Allan Schore (Schore and Schore, 2014), Dan Siegel (2012) and Stephen Porges (2011; 2017) provide the theoretical foundations for developing DDP interventions to mitigate the impact of developmental trauma (Cook, et al., 2005).

Because the foster and adopted children involved are highly likely to have been traumatised within their attachment relationships, DDP includes the active presence of new attachment relationships, offering a source of safety to help overcome the impact of previous traumas. As DDP-trained clinicians worked with the families, they increasingly became aware of the importance of the parenting the children were experiencing at home if they were to benefit from therapy. In addition, Mary Dozier’s research was highlighting how new parents can unwittingly be pulled into patterns of relating that reinforce their children’s expectations of parents from the past (Dozier, 2003; Dozier and Rutter, 2008). But despite this progress, there was a gap in the interventions offered to such children and their families. Therapy was not enough and parents needed support to parent the children differently, in line with the DDP principles, so that the children can discover that adults can be predictable and available to meet their needs. This helped the children to begin to trust in the current parenting. DDP as a parenting model was able to complement the therapy model in order to provide parents with the parenting advice they need and so filled a gap by offering an additional level of support for the children and their families (Golding, 2014; 2017).

While all the DDP principles have informed these groupwork programmes, three central tenets are evident in both the content of the programmes and the way in which they are delivered by the group facilitators:

The attitude of PACE. This provides children with a relationship which is appropriately playful (P) but also accepting (A), curious (C) and empathic (E) about their mental life. It provides a framework for connecting with the children in a way that increases feelings of trust and safety. Parents also need an attitude of PACE for themselves. It is, therefore, an organising stance for both the delivery and content of the groupwork programmes.

Development of the Nurturing Attachments Group intervention

The development of Nurturing Attachments has spanned almost two decades. The range of research studies over this time earned it the rating of research-based approach in a review of interventions for post-adoption support published by the UK Department for Education (Stock, Spielhofer and Gieve, 2016). The development of the group, in collaboration with the parents attending, and revisions made in response to early research studies are an important strength of the model as described below.

In 1999, the author had the privilege of taking on a new role working with colleagues from social care to set up and develop a new service for foster carers in the English county of Worcestershire. Interventions were sought which would be supportive for the carers but also cost effective and viable with small resources. A group intervention was considered ideal for meeting these aims. At the time, there were no group programmes tailored specifically for foster carers.

Having previously found Carolyn Webster-Stratton’s Incredible Years programme useful for birth families, it was decided to trial this over 12 weeks with a group of foster carers (Webster-Stratton and Hancock, 1998). The manual for the delivery of the programme was followed while the facilitators also provided opportunities for additional discussion about how the various ideas and strategies could be adapted for foster children. The carers were eager for knowledge and ideas for helping the children and desperate for support. The collaborative approach to group work, advocated by Webster-Stratton, worked well, allowing facilitators and foster carers to learn from one another.

The social learning theory that inspired the Incredible Years programme has a proven track record in helping families of children with conduct disorder, but something more was needed for those who are described as developmentally traumatised (Golding, 2007). The foster carers ‘lit up’ when trauma and attachment were discussed. Thus, the germ of an idea for a ‘Fostering Attachments’ group was born. At the time, Dan Hughes was in the UK providing training on his new model; the author attended and found that this approach, soon to be called DDP, offered a set of principles that could inform the development of this parenting group.

In 2001, another group of 14 experienced foster carers was recruited. They were given a four-week training in attachment theory, followed by monthly meetings to explore parenting. We did not know how long these meetings would continue but we invited the carers to attend for as long as they wished. Nine stayed the course and we developed the programme together over an 18-month period; this became a collaborative venture combining psychological and parenting expertise informed by the DDP model. What emerged was the 18-session Fostering Attachments Group (later renamed the Nurturing Attachments Group), built around the ‘House Model of Parenting’, a visual representation of the elements that would be explored within the group and the way in which they fitted together (Figure 1). The original model was revised and simplified as the programme developed, so that each session of Modules 2 and 3 was represented by a layer within the house (Golding, 2014).

OPEN IN VIEWER

Figure 1.

The House Model of Parenting (Golding, 2014). ¹

Nurturing Attachments was a unique approach at the time and has continued to deliver a rich experience that offers carers something different from other programmes.

Comparison with other parenting programmes

As Nurturing Attachments was being developed, the main parenting programmes available within the UK were the Incredible Years (Webster-Stratton and Hancock, 1998) and Triple P parenting programmes (Sanders, et al., 2018). These were proven to be effective in reducing antisocial behaviours and lasting effects were found for two-thirds of families and for up to four years (Dadds, 1995; Webster-Stratton, 1997). The programmes are based on a social learning model, drawing upon cognitive-behavioural parenting practices. The later Fostering Changes programme (Pallett, et al., 2002) provided an adaptation of Webster-Stratton’s Incredible Years approach for foster carers and has remained predominantly led by social learning theory, with some attention to the children’s attachment needs and recognising the importance of a positive relationship between child and carer.

In contrast, Nurturing Attachments is a programme based on attachment theory that directs attention to the significant needs of children affected by previous trauma and attachment difficulties, including separation from their birth family.

There are some areas of compatibility between all these programmes. For example, they provide guidance for parents to support children’s behaviour and recognise the importance of a positive parent‒child relationship. The differences lie in the methods employed. For example, the social learning theory-based programmes have a central focus on achieving behavioural change. To accomplish this, parents are helped to better manage environmental contingences in order to encourage the development of prosocial behaviours by the children. In addition, there is a focus on developing a positive relationship from parent to child and strengthening the communities within which the families live. Nurturing Attachments differs in that its central focus is on emotional connection. Parents are supported to increase mentalization and adopt the PACE attitude so that they can emotionally connect with the children, providing regulatory support, security and helping the children to develop capacity for regulation and reflective function. Thus, all the programmes include attention to supporting behavioural change but there are differences in how to achieve this, and whether to prioritise containment of behaviour or regulation and emotional connection.

The importance of support and self-care for the parents is also recognised in all the programmes but Nurturing Attachments further encourages carers to understand the impact the children can have on their ability to stay open to emotional connection, in the context of their own attachment and relationship history ‒ recognising when they become defensive and how to move out of this and repair relationship ruptures.

Nurturing Attachments was not the only programme that was moving away from a purely behavioural approach to parenting. The Solihull Approach (Douglas and Ginty, 2001) was being developed for birth families at around the same time. This focuses on containment, reciprocity and behaviour management. Later, this programme was further developed for foster carers with promising results (Harris-Waller, Bangerh and Douglas, 2018; Madigan, Paton and Mackett, 2017). The Secure Base Model was also emerging, with a focus on helping children to feel secure with foster carers or adopters (Schofield and Beek, 2014) and in the USA, the Circles of Security programme has been a highly successful attachment theory-based programme for birth families aimed at improving the attachment relationship offered by the parents (Cooper, et al., 2005). It has also been used with adoptive parents.

All these programmes have been well received by the recipients, with each offering something different. Nurturing Attachments offers a comprehensive parenting model informed by the DDP principles which fully complements the DDP therapy. It is delivered over 18 sessions. This enables facilitators to support parents over a reasonable time period that allows the group to have a developmental focus. Parents can develop increased capacity for mentalization and regulation, with the group supporting them as they facilitate a more secure relationship with their children. The use of a collaborative and experiential approach allows parents and facilitators to work together over time to fine-tune parenting to the needs of the children informed by a theoretical understanding of the difficulties the children and their families face. While the programme can stand alone, it is recognised that the children have complex difficulties and parents are likely to need continuing support. The advantage of the programme being developed from the DDP model is that this can inform continuing interventions for the parents and children that complement the benefits parents have gained from attending the group.

The Nurturing Attachments Group: development and research

The initial pilot evaluation was completed by seven of the foster carers. They expressed high satisfaction, increased understanding and confidence and rated their children as improved on the Strengths and Difficulties Questionnaire (SDQ). These SDQ changes were statistically significant (Golding and Picken, 2004).

A range of small outcome studies was then carried out between 2004 and 2011, with mixtures of foster carers and adopters (Green, 2011; Gurney-Smith, et al., 2010; Laybourne, Andersen and Sands, 2008). Satisfaction was consistently high and understanding and confidence increased. Stress levels and ability to mentalize changed variably between studies. One identified a statistically significant reduction in stress levels, but this effect has not been found across all studies. One of two studies exploring changes in mentalization demonstrated statistically significant increases in mentalization at points of rupture (Gurney-Smith, et al., 2010). Participants reported positive changes in the behaviours of the children, but this was not always reflected in SDQ scores.

In 2011, a larger evaluation studied 25 foster carers and adopters randomly assigned to Group 1 or a waiting list/Group 2. This demonstrated positive change attributed to the intervention, with statistically significant improvement in confidence, competence and self-efficacy in the parents, either by the end of the group or by the eight-month follow-up. Stress levels changed variably and remained high for several of the respondents. There was no change in mentalizing nor on child measures (Wassall, 2011).

In 2013, a manual was prepared for publication. With the increase of adopters joining, ‘Fostering Attachments Group’ no longer seemed a logical title so it was renamed ‘Nurturing Attachments’. The format and content of the group remained the same, but the writing of the manual provided an opportunity to strengthen the programme, informed by the experience of running the group over a number of years, together with feedback from participants and research findings.

This resulted in a more practical focus on parenting earlier in Module 1. Facilitators were given advice on how to explicitly help parents to develop their mentalization skills, with better use of reflective diaries and increased modelling during the delivery of the group sessions. The development of the parenting attitude of PACE was strengthened in the revised manual, complementing this focus on reflective function. This required facilitators to give more attention to PACE throughout the programme as well as in Module 3, Session 2. Again, modelling and practising this during the facilitation of the group were seen as central to helping carers develop their skill in adopting this attitude.

To date, two studies have evaluated the revised Nurturing Attachments programme. The first was a feasibility study with foster carers conducted in Northern Ireland (McAleese, 2015). This explored recruitment and retention, acceptability, initial outcomes and fidelity to the manual. The author concludes that the intervention is feasible and had a positive impact on the foster carers.

The second study is an independent evaluation across four geographical sites (Staines, Golding and Selwyn, 2019). This quantitative evaluation involved 36 adoptive parents (29 families) parenting 49 adopted children aged between 18 months and 17 years (mean 8 years). The parents completed a range of questionnaires pre-, post- and at seven to eight months follow-up. Over four-fifths of the parents reported that they had found the group to be valuable and effective. Goals set at the beginning of the group were met. While the challenges of parenting the children remained high, half the parents reported increased feelings of well-being and some felt less overwhelmed. They expressed feeling more confident in their parenting and demonstrated statistically significant increases in feelings of self-esteem and in improved reflective functioning (as manifest in increased curiosity on the Parental Reflective Functioning Questionnaire). With regard to the children, they reported statistically significant increases in total difficulties as measured by children's SDQ scores for emotional distress and peer problems but a reduction in conduct problems. This is likely to be due to parents becoming more aware of the emotional needs underlying their children’s behaviour and understanding behavioural challenges as linked to these. This new understanding that behaviour is not an outcome of their poor parenting but a consequence of emotional needs linked to past experience may explain why parents feel more effective in their parenting by the end of the group (Staines, Golding and Selwyn, 2019).

Eighteen parents (62%) who were parenting 29 adopted children returned the questionnaire at the follow-up point. The results suggest that the adopted children had high levels of difficulties that continued, despite the parents being supported to adopt a therapeutic parenting model. Twelve families reported sustaining the gains made at the end of the intervention, with nine of these describing some ongoing small improvements. Six parents reported difficulties continuing the same or worse compared to the start of the intervention. This is a reminder that although the group intervention was reported as beneficial for the majority of participants, these children pose challenges that will persist. A group intervention can only meet a part of the support needs of those parenting traumatised children. Individual support and therapy, where appropriate, are also an important part of the wrap-around support needs of these families.

A qualitative evaluation was also included as part of this evaluation (Hewitt, Gurney-Smith and Golding, 2018). Eight adoptive parents participated in semi-structured interviews regarding their experiences of attending the group. The transcripts of their interviews were explored using Interpretative Phenomenological Analysis (IPA), identifying five inter-connected superordinate themes. These highlighted the respondents’ experience of ‘a supportive group’, which provided ‘a shift in perspective’, allowing them to ‘turn trauma into secure attachment’. There was a preoccupation with whether the parents were ‘doing it right’ and some thoughts and concerns about the ‘continuing adoption journey’.

The strengths of Nurturing Attachments are its development over a long period in collaboration with the carers and parents receiving the intervention, the foundation of a theoretically informed parenting model and the underpinning of the well-respected DDP intervention model which continues to develop in line with the latest research, informing both therapy and parenting. A range of research studies of Nurturing Attachments highlights the challenges faced by the parents of this population of children, their extensive support needs and the efficacy of this intervention as part of meeting this need. DDP therapy for the children requires preliminary work with the parents, one of the aims of which is to introduce the parents to a DDP-informed parenting approach. Attendance at the Nurturing Attachments Group provides such preparation in a supportive environment. As a group intervention, it therefore appears to be a cost-effective part of meeting the longer-term needs of these families, although further research is required to confirm this.

The Foundations for Attachment Group

As Nurturing Attachments became more widely known, facilitators began to shorten its length and adapt it for a broader range of parents, including residential and birth parents. It was also being used pre-placement with foster carers and adopters. As the programme has a developmental focus, involving the parents reflecting on their parenting throughout the programme, this was thought unlikely to be helpful. The Foundations for Attachment programme was therefore developed to meet the need for a shorter and more broadly applicable programme based on the same theory and DDP principles, and with the same format of group delivery as Nurturing Attachments.

Foundations for Attachment is a standalone programme that also provides a platform for the intensive Nurturing Attachments Group for those who want to go further. I have also heard that it has been used successfully in the form of top-up sessions following attendance at Nurturing Attachments. The initial pilot work is reported in the manual (Golding, 2017). In brief, the programme has been piloted across eight sites with around 100 participants, including foster carers, adopters, birth parents and residential carers. The children ranged in age from one to 19 years and their average age of being parented within a family was seven, although those living in residential care were generally older (85% aged between 12 and 16). A range of questionnaires revealed that post-group attendees had statistically significant increases in knowledge, feelings of well-being, reflective functioning and in self-reported skills and understanding. Satisfaction and achievement of goals are high, but feelings of self-efficacy did not change. Many parents who engaged with Foundations for Attachment continue to Nurturing Attachments. Further research is needed but the pilot work suggests that Foundations for Attachment has promise.

Conclusion

Nurturing Attachments was one of the first attempts at developing a groupwork programme for foster carers and adopters within the UK. It has had a long development period informed by feedback from group members, facilitators’ experiences of delivering the programme over many years and outcome evidence; Nurturing Attachments is complemented by Foundations for Attachment. Between these two programmes, group members can receive 25 three-hour sessions of education, support and immersive experience of the DDP model, which helps them to develop their parenting tailored to the needs of children who have experienced developmental trauma.

A range of research studies evaluating Nurturing Attachments has demonstrated satisfaction with the group interventions, alongside improved feelings of efficacy and parenting competence. There is evidence that reflective functioning increases as parents develop their use of the PACE attitude. However, in the face of continuing challenges from the children, parenting stress can remain high and feelings of well-being can stay low. Whatever the merits of specific programmes, these carers are parenting some of the most challenging and hurt children in our society and deserve group interventions as part of a wraparound package of support on offer for as long as necessary.