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Group Attachment-Based Intervention

Group Attachment-Based Intervention (GABI) is a trauma-informed attachment-based intervention designed to increase mother-child attachment security in families where the caregiver has a history of trauma.

The overarching purpose of GABI is to break the intergenerational cycle of abuse by restoring functioning in families with children ages 0-3. To do so, clinicians attempt to increase mother-child attachment by promoting reflective functioning. There are three unique modalities to each GABI session, beginning with supervised parent-child play sessions. After, separate group parent-only and child-only therapeutic sessions take place. Lastly, the is the reunion in which mother-child interaction becomes the focal point. The core of GABI is the 'REARING framework' which specifies the key targets for therapeutic action and informs clinician supervision. The intervention was created and is delivered in The Bronx, New York, one of the poorest urban counties in the United States of America. GABI started at Rose F. Kennedy Children’s Evaluation and Rehabilitation Centre as an open-enrollment model before being developed into an Randomised Controlled Trial (RCT). The ongoing RCT was developed and is continuously refined by the clinical team at Montifire Medical, lead by Anne Murphy, and the research group at New School’s Centre for Attachment Research, lead by Miriam and Howard Steele. The available RCT data suggests that GABI is considered to be an effective, evidence-based intervention.

Theoretical Underpinning

GABI is based on the idea, rooted in attachment theory, that attachment security is fluid and permeable to influences throughout the lifespan. In addition, GABI is informed by research on childhood trauma which suggests that individuals with four or more adverse childhood experiences (ACEs) are venerable to developing multiple physical and mental health problems later in life. GABI also recognises that individuals who have been maltreated in their childhood and have reduced reflective functioning abilities, are at a greater risk of problematic parenting later in life. Together, these theories imply that it is possible, through intervention, to ameliorate parent-child attachment security which has been negatively affected by early adversity.

Intergenerational Cycle of Abuse

A drawing by Mary Cassatt of a mother holding a child who is looking into a mirror. This image can be considered a visual representation of the ways the intergenerational cycle of abuse can manifest in families through a parent's attachment history reflecting onto their child's attachment, self-concept and future parenting abilities.

Maltreatment is a pervasive social problem which has devastating effects on a child's social, emotional and cognitive development. Maltreatment is associated with child cognitive deficits, behavioural issues and dysfunction in parent-child attachment. During adolescence, maltreated children are at a greater risk of dropping out of school, delinquency, substance abuse and relational difficulties. In adulthood, individuals who have been maltreated are at a greater risk of problematic parenting and perpetuating the intergenerational cycle of abuse.

Reflective Functioning

Attachment-based parenting interventions aim to increase attachment security for the caregiver and their child, referred to as a dyad, based on the concepts of attachment theory. This is often done by working to improve a parent's reflective functioning abilities, also referred to as mentalization. Parental reflective function is the ability for a parent to recognise the mental states of their children and act appropriately to help regulate their child's behaviour. Reflective function is a crucial element of caregiver-child attachment security.

Disorganised Attachment

Maternal sensitivity is important in determining dyad security. Yet, to create long-lasting changes in caregiver-child attachment, interventions must also target parent's mental representations of attachment. These representations are based on the parent's attachment to their own caregivers Histories of insecure attachment in mothers has been shown to be associated with insensitive responses to an infant's attachment signals, impacting dyad attachment. Mental health disorders, potentially related to adverse childhood experiences (ACEs), also impact the quality of parental care an individual is able to offer.

Disorganised attachment is the type of insecure attachment most closely related to maltreatment. To the child in a maltreating family, the parent represents a paradox where they are the child's only source of comfort yet also a figure which acts in frightening, unpredictable or abuse ways. Maltreated children with disorganised attachment often develop behavioural problems around age 5, develop symptoms of PTSD around age 8 and display externalising symptoms in preschool which extend through adolescence. Together, parent insecure mental representations have the potential to impact dyad attachment security, and perpetuate the intergenerational cycle of abuse.

Child Self-Concept

Childhood maltreatment has implications for children's self-concept. Maltreated children have a limited chance to explore their own identities outside of their parent's hostility. It is suggested that these children may even integrate their parent's antagonism with their own identity and may begin to identify with the aggressor. Parents with limited reflective function may also limit the their ability to mentalize. Children exposed to extreme abuse may also feel too fearful to explore the mental states of others and may have reduced reflective functioning capacity. During adolescence, children who have experienced childhood trauma may experience identity diffusion, negative expectations about themselves and the future, self-blame, and social difficulties, all of which may further impact self-concept. In adulthood, a damaged self-concept, stemming from childhood maltreatment, is the cornerstone of personality pathology. Together, childhood maltreatment, not only, alters caregiver-child attachment, but also, may impact the child's self-concept which, left unresolved, has the capacity to contribute to the intergenerational cycle of abuse.

Randomised Control Trial

Parents and children are referred to the GABI program by professionals such as paediatricians or corporate bodies including the Administration for Children's Services. Of the 60 mother-child dyads participating in the original GABI RCT, 77% of the mothers in the sample had a high amount of, four or more, ACEs. 28% of children had ACEs. The demographics of sample was considered to be representative of the community in The Bronx.

The ongoing RCT of GABI compares the intervention against the systematic Training for Effective Parenting (STEP) program, which is the standard intervention in the New York City, Bronx county. STEP was implemented before RCTs became a standard in psychological research. The primary goal of STEP is to promote parent's positive perceptions of their children for families with children aged two to eighteen. STEP is suitable for a larger age range than GABI. Parents attend STEP once a week for 10 to 12 weeks. A notable difference between the interventions is that while GABI clinicians have specific parts of each session for children and mothers, STEP focus entirely on the parents.

Evidence Base

The preliminary results of the RCT indicate that mothers who participated in GABI showed increased supportive presence and decreased hostility, both of which are proxy measures of maltreatment risk. In comparison, those that attended STEP showed no significant changes. This change has been attributed to the parent-child play sessions at the start of each GABI session which allow dyads to practice bonding activities. Dyad's scores for other proxy measures of maltreatment, emotional expressiveness and reciprocity during interaction, also changed for the better during GABI. Those enrolled in STEP showed no changes or a change for the worse. Unlike STEP, the use of video feedback in GABI may allow parents to more accurately and critically reflect on their interactions with their child. However, the effectiveness of GABI in changing these proxy measures lessened when mothers had experienced a high amount of ACEs, exemplifying the difficulty in breaking intergenerational cycles for highly traumatised families. In comparison, dyads participating in STEP with high amounts of ACEs, showed no change in these measures. In addition, mothers who had experienced a low amount of ACEs displayed a worrying change for the worse. A six month follow-up study suggests that mother and child dyads in GABI showed significantly increased attachment security than 6 months prior. Conversely, dyads enrolled in STEP showed no change. Follow-up research also confirms that GABI is able to increase parent sensitivity in every day interactions and decrease coercive and harsh parenting techniques.

Intervention Structure

Each session of GABI is 120 minutes long. The sessions run six times a week. Parents are expected to come to at least one session a week. At each session, there are two to five graduate students and two clinicians present. Clients are able to text clinicians twenty-four hours a day, seven days a week. When parents have finished the intervention they are still able to attend the sessions to prevent potential negative consequences of removing a place of community and routine for high risk families. The clinicians also have connections to programs, such as psychiatric treatment programs for caregivers or therapeutic nurseries for children, which they can refer families who have completed the intervention to for extra support.

Modalities

Each GABI session has three distinct phases. The session begins with clinician supervised parent-child play sessions. This allows parents to practice attachment-enhancing activities with reduced caregiving responsibilities which are assumed by supervising clinicians. Next are separate parent and child therapeutic sessions lasting one hour. In the parent-only sessions, the group of caregivers discuss their past and its impact on their caregiving. The group setting promotes community, empathy and may reduce stress for caregivers. In the child-only session, child socio-emotional development is fostered through guided peer interaction. Group video feedback is offered twice within the first six months of treatment for each family. In these sessions, parents are encouraged to lead discussions reflecting on footage of interactions with their children. Lastly, the parent and child are reunited. This phase is important for clinicians because, as demonstrated by Mary Ainsworth's Strange Situation studies, the reunion of a mother and child is a gold-standard measure of a dyad's attachment security.

Trauma-Informed Approach

GABI is designed with a trauma-informed approach. Trauma informed practices do not target the acute symptoms of trauma but strive to prevent retraumatization and are sensitive to the effects of trauma on individual's lives. The clinic is intentionally filled with neutral stimuli and non-commercial toys as to not evoke negative associations for caregivers. When a parent experiences retraumatization, this becomes the focus of the session. Research from 2020 suggests that in comparison to STEP, parents who attended GABI with high amounts of ACEs and low protective factors attended more sessions. This difference is attributed to the trauma-informed approach which may be especially important and nurturing for severely traumatised families.

Therapeutic Action

Referred to as the REARING framework, the identified key areas for therapeutic action at the core of GABI are:

• Reflective functioning: This is the main objective for clinicians.
• Emotional attachment: Clinicians try to motivate parents to explore their children's emotions.
• Affect Regulation: Clinicians must maintain flattened-affect while also teaching parents regulate their own emotions.
• Reticence: Clinicians must allow parents to explore their own feelings and come to conclusions in their own time.
• Intergenerational Patterns: Clinicians must be aware of the effects of the intergenerational cycle of maltreatment.
• Nurturance: Clinicians must be sensitive to the needs of the dyads to support and empower parents in caring for their children.
• Group Context: The group delivery of GABI allows clinicians to attend to multiple dyads at once. The group based approach also helps combat social isolation experienced by many families enrolled in the program.

Competency Measures

The REARING coding scale (RCS) was developed as a supervision tool to ensure that clinicians adhere to the framework and refine their abilities. Clinicians code and submit ten-minute videos which reviewed by expert raters. Scores of zero to five are given to clinicians for each item. A score of three is assigned to interactions that meet expectations. Literature published in 2021 highlights how during supervision sessions, clinicians that are more reflective about their own mental states towards the videos, are also more willing to explore the mental states of clients during GABI sessions. These clinicians often achieve higher RCS scores. This suggests that RCS is an effective measure of clinician competency, not just for the specific demands of the interaction but for general abilities, such as mentalization, necessary for good clinical practice. Moreover, requiring clinicians exhibit and practice skills which they expect parents to learn exemplifies the beneficence of the intervention.