Relational Interventions for Maltreated Children

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Most interventions focus on mothers because mothers are usually identified as the maltreating parent, frequently parent alone, and fathers who are present tend to be minor caregivers.

“intervention efforts focus primarily on enhancing the mother-child relationship because mothers are most likely to be identified as perpetrators of maltreatment, often in single-parent roles, and because when fathers are present they tend to have a peripheral role in caregiving (Howes & Cicchetti, 1993; US DHHS 2015).”

• cites Howes & Cicchetti, 1993Not checked yet

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• cites US DHHS 2015Not checked yet

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When these key parenting behaviors are missing, secure attachment often fails to develop and insecurity tends to result.

“In the absence of these critical parenting behaviors, the development of a secure attachment relationship is often impeded, and attachment insecurity results.”

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Infants derive security from their main caregiver and use that bond as a base for environmental exploration.

“Infants rely on their primary caregivers, typically mothers, to derive a sense of security and they use this relationship as a base from which to explore the environment (Sroufe, 1979).”

• cites Sroufe, 1979 sourceNot checked yet

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An RCT found that after treatment, ABC children showed less disorganized attachment (d=.52) and more secure attachment (d=.38) than children in a developmental education condition, even though pretreatment insecurity was similar.

“Results indicated that children in the ABC treatment had lower rates of disorganized attachment (d = .52) and higher rates of secure attachment (d = .38) posttreatment relative to children in the other intervention despite having comparable rates of attachment insecurity pretreatment (Bernard et al., 2012).”

• cites Bernard et al., 2012 sourceNot checked yet

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These parenting mechanisms seem changeable, although the meta-analysis was not limited to maltreating families.

“although included studies were not exclusive to maltreating families, these important parenting mechanisms appear to be modifiable.”

• cites Bakermans-Kranenberg, van Ijzendoorn, & Juffer, 2003Not checked yet

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A meta-analysis of more than 80 studies showed that interventions reduce insensitive parenting (d=.33) and attachment insecurity (d=.20), with small-to-medium effect sizes.

“a meta-analysis of over 80 studies demonstrated that interventions are effective in improving insensitive parenting (d = .33; in general, values of .2, .5, and .8 represent small, medium, and large effect sizes respectively) and attachment insecurity (d = .20; Bakermans-Kranenberg, van Ijzendoorn, & Juffer, 2003) with small to medium effect sizes”

• cites Bakermans-Kranenberg, van Ijzendoorn, & Juffer, 2003Not checked yet

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Two core, changeable features of the parent-child bond for maltreated children are maternal sensitivity and attachment organization, which relational treatments can enhance.

“maternal sensitivity and attachment organization are highlighted as central components of the parent-child relationship that can be improved by relationally based interventions for maltreated children.”

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These brief models can be provided by paraprofessionals, potentially aiding broad dissemination.

“Moreover, these models can be provided by paraprofessionals, which may facilitate widespread dissemination and implementation.”

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One year after intervention, CPP children had more secure attachment (d=.33) and less disorganized attachment (d=.34) than PPI children.

“At one-year post intervention, children in the CPP condition had higher rates of secure attachment (d = .33) and lower rates of disorganized attachment (d = .34) than children in the PPI condition (Pickreign Stronach, Toth, Rogosch, & Cicchetti, 2013).”

• cites Pickreign Stronach, Toth, Rogosch, & Cicchetti, 2013 sourceNot checked yet

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Classified as probably not a substantial claim.

Since most relational intervention work has been developed and delivered with mothers, one cannot assume identical strategies will be equally effective with fathers.

“because the vast majority of the work on relational interventions has been developed and implemented with mothers, we cannot assume the same strategies will work as well with fathers.”

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Evidence for RET is preliminary and awaits an ongoing RCT.

“Support for RET is preliminary and pending the results of an ongoing RCT.”

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RPMG has been tested in two RCTs; attachment was not measured, but the program was linked to lower maltreatment risk and better child socio-emotional functioning.

“Another group relational intervention, Relational Psychotherapy Mother’s Group (RPMG; Luthar & Suchman, 2000; Luthar et al., 2007), has been evaluated in two RCTs. Although attachment was not assessed as a post-treatment outcome, RPMG was associated with other improvements including reduced risk for child maltreatment and improved child socio-emotional functioning”

• cites Luthar & Suchman, 2000 sourceNot checked yet

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• cites Luthar et al., 2007 sourceNot checked yet

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Short relational programs improve maternal sensitivity in maltreating families after brief treatment and also yield benefits such as child physiological regulation and emotional adjustment.

“Overall, brief relational models are effective in improving maternal sensitivity among maltreating families following a short duration of treatment, and are associated with additional positive effects including child physiological regulation and emotional adjustment.”

Probably not a substantial claim: may not pass S2 (checkable).

Because official child welfare determinations depend on local evidentiary standards, clear operational definitions of maltreatment subtype and severity are needed independent of those designations.

“Clear operational criteria for maltreatment subtypes and severity, independent of child welfare designations, are necessary because the determinations included in official child welfare records (i.e., substantiated physical abuse) are subject to evidentiary standards that vary across locales (Manly, 2005).”

• cites Manly, 2005 sourceNot checked yet

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A pilot RCT found that maltreating parents given RET engaged in more elaborative, emotion-rich reminiscing after treatment (d=.64-.97) than controls, and their children had better memory and emotion discussion skills (d=.94, 1.4).

“A pilot study randomizing dyads to receive RET or a wait-list control condition indicated that maltreating parents who received RET demonstrated greater elaborative and emotion-rich reminiscing at post-test than did parents in the control condition (d = .64–.97, respectively), and their children showed enhanced memory and ability to discuss emotions (d = .94, 1.4).”

• cites Valentino et al., 2013 sourceNot checked yet

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Moss's program produced larger increases than control in the share of insecure children becoming secure (r=.36) and disorganized children becoming organized (r=.37).

“The intervention also facilitated attachment security, as a greater proportion of insecure children in the intervention group became secure (effect size r = .36, small effect), and a greater proportion of children with disorganized attachment in the intervention group became organized (r = .37) in comparison with the control group.”

• cites Moss et al., 2011 sourceNot checked yet

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After intervention, CPP and PPI children showed significant gains in secure attachment and reductions in disorganized attachment (d=.84-1.13), whereas community standard and nonmaltreatment comparison groups did not improve.

“At post-intervention children in the CPP and PPI groups showed significant increases in secure attachment, and decreases in disorganized attachment (d = .84–1.13) whereas attachment in infants in the community standard and nonmaltreatment comparison groups did not improve.”

• cites Cicchetti, Rogosch, and Toth (2006)Not checked yet

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Compared with wait-list controls, ABC families reported less child abuse potential and parenting stress, and their children had fewer internalizing and externalizing behaviors.

“families who participated in ABC had lower child abuse potential scores (parent reported), less parenting stress and children had lower internalizing and externalizing behaviors compared to families in a wait-list control condition (Sprang, 2009).”

• cites Sprang, 2009 sourceNot checked yet

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Classified as probably not a substantial claim.

It remains unknown whether brief relational models lower later child welfare involvement.

“despite reductions in (self-reported) parent child abuse potential, there are no data regarding whether these models reduce reinvolvement with the child welfare system.”

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The group program Circle of Security has improved attachment security in at-risk families, though it has not yet been tested in RCTs.

“Group relational interventions, such as Circle of Security (Hoffman, Marvin, Cooper & Powell, 2008), have demonstrated improvements in attachment security among at-risk families, but have not yet been examined in RCTs.”

• cites Hoffman, Marvin, Cooper & Powell, 2008Not checked yet

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Almost all reviewed relational interventions were tested with mothers; apart from PCIT, which included 35% male caregivers, fathers made up under 5% of caregivers in every other reviewed intervention study.

“nearly all of the relational interventions reviewed were evaluated with mothers. With the exception PCIT, which has been evaluated in a RCT with 35% male caregivers (Chaffin et al., 2004), fathers represented less than 5% of participating caregivers in all other intervention studies reviewed.”

• cites Chaffin et al., 2004 sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

The absence of new maltreatment reports during treatment does not by itself prove treatment effectiveness.

“a lack of new reports during treatment is not a sufficient marker of treatment effectiveness.”

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Longer-term relational models have increased secure attachment and other positive outcomes and have been tested in diverse samples resembling child welfare populations.

“Overall, long term relational models have demonstrated success in promoting secure attachment among several other positive outcomes and they have been evaluated among diverse samples representative of those involved in the child welfare system.”

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Interventions that improve maternal sensitivity and attachment security are essential for breaking negative developmental cascades and fostering resilience in maltreated children.

“Intervening to enhance components of the mother-child relationship, including maternal sensitivity and attachment security, is critical for interrupting negative developmental cascades and for promoting resilience among maltreated children (Toth et al. 2013).”

• cites Toth et al. 2013 sourceNot checked yet

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Evaluations up to one or two years after treatment show effects maintained, including less subsequent child welfare involvement.

“Post-treatment evaluations (limited to 1–2 years) have revealed maintenance of effects, including decreased re-involvement with the child welfare system.”

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Biobehavioral regulation is another pathway by which maltreatment causes dysfunction, and restoring children's regulatory capacity is an important indicator of treatment success.

“Biobehavioral regulation is an additional mechanism through which child maltreatment leads to dysfunction, and the ability to restore children’s regulatory capacity is an important measure of effective treatments (Toth et al., 2013).”

• cites Toth et al., 2013 sourceNot checked yet

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Maltreating mothers show deficits in elaborative and emotionally supportive communication, which acts as a pathway from maltreatment to cognitive, emotional, and physiological problems in preschool-aged children.

“Deficiencies in this behavior have been documented among maltreating mothers and serve as a mechanism through which maltreatment is associated with cognitive, emotional, and physiological dysfunction among maltreated preschool aged children (Valentino et al., 2015).”

• cites Valentino et al., 2015 sourceNot checked yet

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Maltreating families commonly confront multiple problems like poverty, unstable housing, and joblessness, and those with the greatest basic-needs struggles are often hardest to engage and keep in treatment.

“maltreating families are often facing multiple problems (i.e. poverty, housing instability, unemployment, etc.), and those struggling most with basic needs are often the most difficult to engage and retain in treatment (Thompson, 2015).”

• cites Thompson, 2015 sourceNot checked yet

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RPMG is a brief relational program suitable beyond early childhood and has been used with children as old as 18.

“RPMG (Luthar & Suchman, 2000; Luthar et al., 2007), is another brief relational intervention that is appropriate beyond early childhood and has been used with children up to age 18.”

• cites Luthar & Suchman, 2000 sourceNot checked yet

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• cites Luthar et al., 2007 sourceNot checked yet

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