An attachment-based parenting program for caregivers of severely conduct disordered adolescents
Marlene Moretti, Roy Holland, Ken Moore, Sue McKay
Abstract: Security of attachment is associated with healthy adjustment and successful transition to autonomy during adolescence. This paper reports on findings on an attachment- focused parenting group developed to enhance security in the relationships of parents (or other caregivers) with their severely conduct-disordered adolescents. This brief psycho-educational program focused on promoting enhanced parental-reflective capacity, attunement, and empathy. Preliminary findings show significant reductions in parental reports of externalizing and total behaviour problems, and high parental acceptance of the intervention. Limitations and future directions are discussed.
Although the vast majority of studies in the attachment field have focused on the significance of attachment for early childhood adjustment, or adjustment in adulthood, the past decade has witnessed a burgeoning interest in the application of attachment theory to understanding adolescent mental health. Recent studies indicate that, like younger children, adolescents who are securely attached to their parents experience less distress with the transition from primary to secondary school, experience less loneliness and depression, are less likely to experiment with substance use and risky sexual behaviour, and are more likely to feel confident and to have empathy for others (Doyle & Moretti, 2001; Papini & Roggman, 1992). In contrast, insecure attachment in adolescence is associated with a range of mental health problems (Allen & Land, 1999), including suicidality (Lessard & Moretti, 1998).
Although attachment to parents continues to be important during adolescence, the attachment functions that parents serve change. Physical proximity to caregivers becomes less important than in childhood, and adolescents rely increasingly on close friends and romantic relationshps for comfort when distressed. Nonetheless, adolescents continue to turn to their parents as a secure base from which to negotiate autonomy. Autonomy is facilitated by availability, engagement, and acceptance by parents, particularly in the face of conflict and identity differentiation, which is characteristic of this developmental period (Kobak & Sceery, 1988).
What can attachment theory offer to guide intervention with conduct disordered youth and their families? It is essential that any intervention program targeting severe conduct disorder or delinquency embody a multi-systemic perspective as such approaches have shown considerable promise in producing positive treatment effects (Henggeler, 1991; Fisher & Chamberlain, 2000; US Department of Health and Human Services, 2001). Attachment theory enhances a systemic perspective by elucidating the unique meaning of disruptive behaviour within the context of the child-parent relationship (Byng-Hall, 1991; Byng-Hall & Stevenson-Hinde, 1991).
Aggressive and disruptive behaviour may function to secure the attention of caregivers. In other instances, it reflects a reaction to perceived rejection from parents (Moretti & Holland, 2003; Moretti, DaSilva, & Holland, 2004). An attachment perspective provides researchers and clinicians with a pragmatic framework for differentiating motivations underlying aggressive behaviour. With this understanding in hand, interventions can be tailored so that they fit with the unique attachment dynamics that precipitate and maintain aggressive behaviour.
In British Columbia, attachment theory has provided the foundation of systemic programming for severely conduct disordered youth (Moore, Moretti, & Holland, 1998; Moretti, Holland, & Peterson, 1994; Moretti, Holland, & Moore, 2002). The "Response Program" provides a comprehensive evaluation of social-psychological factors related to adolescent mental health problems, and an attachment based model of care to support adolescents and their families toward healthy adjustment.
To achieve this goal, a multidisciplinary team works with each youth and his or her family--both on site and in the community--to gather information at each level of the ecology (cultural, community, family, and individual).
The multidisciplinary team, community, family, and the youth come together to share information and develop a "care plan", which provides an understanding of the attachment style of the youth and the attachment dynamics underlying interactions with parents and other important people within his or her ecology. Strategies are developed to support adaptive functioning within the home community. Outreach staff work with community teams to support the implementation of the care plan within the youth's home community. Respite care for up to two weeks is provided to ensure that the care-giving system remains intact over time.
Consistent with research supporting the efficacy of systemic intervention, significant reductions in problem behaviour (e.g., aggressive and delinquent behaviour, anxiety, depression) from both caregiver and youth perspectives have been documented in youth served through the Response Program. These findings have been documented for up to 18 month's follow-up (Moretti, et al., 1994). Reductions were noted for even the most highly aggressive youth in this study. Recently, the centre has developed an intensive non-residential program which integrates interventions targeted at family, school, vocational, and peer group functioning. A central component of the program is a 10-week psychoeducational parenting group on attachment as it pertains to adolescent development and issues of conflict and autonomy. "Connect" introduces parents to attachment concepts, promotes the development of attunement and empathy, and encourages parents to reframe their adolescent's behaviour from an attachment perspective. Attachment principles are introduced each week, accompanied by handouts to help parents review concepts and to reflect on how these apply to their relationship with their child (see Appendix 1). Group leaders employ role-plays and case examples to illustrate the attachment issues that are often disguised by aggressive behaviour. Parents are assisted in identifying anxiety-related aspects of their adolescent's behaviour so they can better respond to initial signals from their child and pre-empt negative interaction cycles. A manual was developed detailing the central principle and learning goals for each session and providing a template of the session formats, educational materials, and illustrative role-plays. Group leaders were closely supervised through observation and supervision meetings to ensure compliance with the manual and guidance in acheving therapeutic goals.
At the heart of the attachment parenting groups is the goal of enhancing parental attunement and reflective capacity (Fonagy & Target, 1997).
Increasing the capacity of parents to identify and reflect on attachment issues in their relationships with their adolescents assists them in reframing conflict and increasing the effectiveness of parental communication and limit-setting. In the current paper, we describe a preliminary evaluation of the Connect program, with particular emphasis on assessing the impact on parent reports of youth behaviour problems, and parents' perceptions of the significance and helpfulness of the intervention.
Participants in the pilot project included 16 adolescents (8 male; 8 female), between the ages of 13 to 16 years (M=14.80, SD=1.03), and their caregivers (13 biological mothers, 1 stepmother, 2 foster mothers, 5 biological fathers, 3 foster fathers). Twenty-one of 24 (87.5%) parents attended 50% or more of the parent group sessions. Parents attending fewer than 50% of sessions were not included in the current analysis.
Youth were included in the program via their referral Maples Adolescent Treatment Centre, a provincial facility that serves the needs of severely conduct-disordered youth. Adolescents included in the program were known to have a history of very severe behaviour problems, as indicated by the following characteristics documented withn six months prior to their admission: 44% were not attending school primarily due to their decision to drop out (5 of 7); 68% had been placed outside their home for some time; 47% had been criminally charged; 31% had been incarcerated; 60% had been on probation; 65% were reported to have threatened to kill or seriously harm someone; and 53% had threatened to kill or seriously harm themselves.
Parents completed a number of measures on admission and upon termination. For the purposes of this paper, we have focused on parent reports of child behaviour as assessed by the Child Behavior Checklist (CBCL) (Achenbach & Edelbrock, 1981). The CBCL is a widely used measure of emotional and behavioural problems that has been shown to possess strong psychometric properties. Three scales were used for the purpose of this evaluation: externalizing behaviour problems; internalizing behaviour problems; and total behaviour problems. Parents also completed a questionnaire designed to assess their perceptions of the parenting group. Parents utilized a four point rating scale, ranging from 1 (not at all) to 4 (very), to assess how helpful they found education on attachment: whether the group increased their understanding of their child, themselves, and their family; whether they applied information discussed in the group to parenting their child; and whether they felt more efficacious in parenting. Parents also provided written feedback summarizing their experience of the group.
Pre-Post Changes in Parent Ratings of
Results revealed that parent scores dropped sigruficantly on externahzing, F(1,18) =6.62, p=.02 (es = .25), and total behaviour problems, F(1,19) = 7.04, p=.02 (es = .27). No difference was found on the internalizing problem scale.
Parent Feedback on the Group
The majority of parents rated the educational focus on attachment in the group as helpful (46%) or very helpful (38%). Parents also rated the group as helpful (50%) or very helpful (38%) in enhancing their understanding of their child, and helpful (33%) or very helpful (46%) in enhancing their understanding of themselves as parents. Similarly, most parents felt the group was helpful (50%) or very helpful (21%) in understanding their family. The majority of parents (87%) also indicated that they applied ideas discussed in the group to parenting their child, and 48% indicated that their relationship with their child had changed at least somewhat, while 22% reported major changes in their relationship. Perceived efficacy of parenting was also rated by parents to have improved somewhat (64%) or greatly (14%) as a function of the group. Finally, virtually all parents (96%) felt respected in the group, and most (80%) felt safe and welcomed.
Parents' written responses also indicated that they found the group helpful. In particular, parents noted the usefulness of the group in helping them to gain a new perspective on their relationship with their adolescent and their own behaviour, suggesting that it provoked increased reflective capacity. For example, one parent noted that the group "taught me to be more empathic, and to remove myself from my child's anger, and look at the underlying cause." Another stated: "I was able to look at how I reacted to my child's behaviour and to look at changing my own behaviour to his behaviour."
The findings from this preliminary evaluation support the utility of a psycho-educational group on attachment for parents of adolescents with severe behaviour problems. Parents' ratings of their adolescents' behaviour problems dropped significantly over the course of the program, and their ratings of the attachment parenting group were very positive. From an attachment perspective, interventions are most likely to be successful when they enhance a secure base and a safe haven within relationships.
Our findings suggest that the group helped to improve the quality of the parent-adolescent relationship, thereby providing the foundation for positive change in the post-therapy period.
Our findings must be viewed with caution given their preliminary nature and lack of a comparison group. As well, it is essential to demonstrate that change persists beyond termination. These issues will be addressed in the next stage of our research. It is also important to note that, although parent ratings of behavioural problems were significantly reduced over the duration of the program, on average, symptoms still remain in the clinical range. Intensification of the intervention to produce more substantial reductions is desirable. Finally, the group intervention took place within the context of a systemic program that addressed multiple aspects of family and adolescent functioning. Thus, change noted over the course of the program is likely a function of multiple program components and not of the attachment parenting group alone. Identifying the specific effects of components within this systemic approach is an important step in program evaluation as we look to the future.
Attachment theory has been increasingly applied to the development of new intervention programs for infants and young children, and adults (Johnson & Whiffen, 2003). Surprisingly few programs have advocated attachment-focused approaches for adolescents. Our preliminary findings support the growing recognition that attachment provides a viable framework for developing efficacious intervention programs for individuals across the lifespan.
See Appendix 1 (below)
Achenbach, T. M. (1995). Youth self-report. Burlington: University of Vermont, Department of Psychiatry.
Achenbach, R.M., & Edelbrock, C.S., (1981). Behavioural problems and competencies by parents of normal and disturbed children aged four through sixteen. Monographs of the Society for Research in Child Development, 46, 1-78.
Allen, J. P., & Land, D. (1999). Attachment in adolescence. In J. Cassidy, & P. R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp. 319-335). New York: Guilford.
Byng-Hall, J. (1991). The application of attachment theory to understanding and treatment in family therapy. In C. M. Parkes, J. Stevenson-Hinde, & P. Harris (Eds.), Attachment across the lIfe cycle. New York: Routledge.
Byng-Hall, J., & Stevenson-Hinde, J. (1991). Attachment relationships within a family system. Infant Mental Health Journal, 12,187-200.
Doyle, A. B., & Moretti, M. M. (2001). Attachment to parents and adjustment to adolescence: Literature review and policy implications. Health Canada, Child and Family Division. File number 032~~.H5219-9-CYH7/001/SS.
Fisher, P.A., & Chamberlain, P. (2000). Multidimensional treatment foster care: A program for intensive parenting, family support, and skill building. Journal of Emotional and Behavioural Disorders, 8,155-164.
Fonagy, P., & Target, M. (1996). Playing with reality: I. Theory of mind and the normal development of psychc reality. International Journal of Psycho-Analysis, 77,217-233.
Henggeler, S.W. (1991). Multidimensional causal models of delinquent behaviour and their implications for treatment. In R. Cohen, & A. W. Siege1 (Eds.), Context and development. (pp. 211-231). Hillsdale, NJ: Lawrence Erlbaum.
Johnson, S., & Whiffen, V. (2003). Clinical applications of attachment theory. New York: Guildford.
Kobak, R., & Sceery, A. (1988). Attachment in late adolescence: Working models, affect regulation, and representations of self and others. Child Development, 59(1), 135-146.
Lessard, J. C., & Moretti, M. M. (1998). Suicidal ideation in an adolescent clinical sample: Attachment patterns and clinical implications. Journal of Adolescence, 21, 383-395.
Moore, K., Moretti, M. M., & Holland, R. (1998). A new perspective on youth care programs: Using attachment theory to guide interventions with troubled youth. Residential Treatment for Children and Youth, 15, 1-24.
Moretti, M. M., DaSilva, K., & Holland, R. (2004). Aggression in adolescent girls from an attachment perspective: Research findings and therapeutic implications. In Moretti, M. M., Odgers, C., & Jackson, M. (Eds.), Girls and aggression: Contributing factors and intervention principles (pp. 41-56). Boston:Kluwer
Moretti, M. M., & Holland, R. (2003). The journey of adolescence: Transitions in self within the context of attachment relationships. In S. Johnson, & V. Whiffen (Eds.), Clinical Applications of Attachment Theory (pp. 234-257). New York: Guilford.
Moretti, M. M., Holland, R., & Moore, K. (2002). Youth at risk: Systemic intervention from an attachment perspective (pp. 233-252). In M. V. Hayes, & L. T. Foster (Eds.), Too small to see, too big to ignore. Victoria: Western Geographic Series, University of Victoria.
Moretti, M. M., Holland, R., & Peterson, S. (1994). Long term efficacy of an attachment-based program for conduct disorder. Canadian Journal of Psychiatry, 39,360-370.
Papini, D. R., & Roggman, L. A.(1992). Adolescent perceived attachment to parents in relation to competence, depression, and anxiety: A longitudinal study. Journal of Early Adolescence, 12,420-440.
U.S. Department of Health and Human Services. (2001). Youth violence: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; and National Institutes of Health, National Institute of Mental Health.
“CONNECT” GROUP SESSIONS:
ATTACHMENT PRINCIPLES AND DISCUSSION FOCUS
|Session||Attachment Principle||Group Focus|
|1||All behavior has meaning
Attachment needs often underlie behavior, even though these needs may sometimes be difficult to identify.
|What are attachment needs?
How does your child's behavior express attachment needs?
How would understanding the attachment needs underlying your child's behavior change how you respond in the relationship?
|2||Attachment is for life
Attachment remains important across development, but attachment needs are expressed differently in infants, children, and adolescents
|How did your child express his/her attachment needs when he-
she was were little?
How does your child connect and separate from you now?
What do you anticipate for the future?
|3||Attachment underlies our
thoughts, feelings and behaviors
Attachment is expressed in how we think about others and ourselves; in our feelings; and in our behaviors.
|Think about the different ways you and your
teenager communicate attachment needs - is it always in words?
What other forms of communication take place?
Think of times when your teenager communicated one message and you interpreted it as another. How about vice versa?
|4||Conflict is part of attachment
Conflict often feels threatening but it can be an opportunity for healthy change.
|What does conflict in a relationship mean
How do your feelings about conflict influence how you respond to your child?
How can you remain emotionally available to your teenager, and maintain boundaries while you are involved in resolving conflict?
|5||Autonomy includes connection
Autonomy does not mean disconnection and separation. Healthy autonomy develops through support, structure and respect for differentiation.
|How have you maintained closeness in the
relationship as your child becomes more autonomous?
How has your child maintained closeness as he or she becomes more autonomous?
What challenges have you overcome?
|6||Change involves moving forward
while understanding the past
Change takes place step by step, moving from what we know from past experience to new ways of seeing ourselves in the world.
|What type of 'map' do you think your child
has of him/herself and the world? What type of map do you have?
Think of times that you have tried to change important things about yourself. How did your relationships with others help or hinder the process?
What obstacles does your child face in making changes?
|7||Maintaining relationships is key
Focusing on the attachment meaning of issues and problems for your relationship with your child is important. The content is often irrelevant.
|Do you and your adolescent get stuck
arguing about small things? When you step back and think about
it, do these small things really mean something more about the
Does keeping the relationship front and center mean saying 'yes' to all requests, or is it possible to say 'no' and still maintain a healthy relationship?
|8||Understanding and change begin with
It's difficult to express empathy for your adolescent when you're upset, but doing so helps both of you to move on.
|How does it feel when someone expresses
their understanding of your position, even if they don't see
things the same way?
Is it possible to express understanding your adolescent's point of view but still hold firm boundaries for what is acceptable behaviour?
This feature: Moretti, M, Holland, R., Moore, K. and McKay, S (2004) An attachment-based parenting program for caregivers of severely conduct disordered adolescents: Preliminary findings. Journal of Child and Youth Care Work, Vol.19, pp. 170-178