Intervening with Attachment and Biobehavioral Catchup to Enhance

Intervening with Attachment and Biobehavioral Catch-up to Enhance Responsiveness among Parents in the Child Welfare System University of Maryland School of Social Work Strengthening Society through Stronger Parenting September 28, 2018 Mary Dozier University of Delaware

Attachment and Biobehavioral Catch-up (ABC) � 10 - session intervention � Targets key issues identified as problematic for children who have experienced early adversity � Implemented in home

Targets of Intervention Enhanced Parenting Nurture ABC Intervention In the Moment Comments Follow child’s lead Avoid harsh behavior Attachment quality Early selfregulation

Nurturance �Nurturance especially important for children who have experienced early adversity �Two things can get in the way Children may push away Nurturance does not come naturally to some parents

Children push parents away � Contingency analyses reveal that parents respond “in kind” Stovall-Mc. Clough & Dozier, 2004, Development and Psychopathology

Nurturance �Two things can get in the way Children may push away or may be hard to soothe Nurturance does not come naturally to some parents

Characteristic ways parents may be non-nurturing ▪ ▪ ▪ You’re ok. You’re not hurt. (dismissing) You’re a big boy. It’s not broken? (making fun of child) I told you! (fussing) Look outside. There’s a butterfly! (distraction) Ignore All of these – giving child message that he or she shouldn’t bring distress to parent

First target for intervention: Providing nurturance �Even when child doesn’t elicit it �Even when it doesn’t come naturally to parent

ABC intervention sessions Manualized content Sessions 1 -2: Providing nurturance Sessions 3 -4: Following child’s lead Sessions 5 -6: Avoiding intrusive and harsh behavior Sessions 7 -8: Over-riding “voices from the past” Sessions 9 -10: Consolidating

�Manualized content �In the moment comments

Comments can have 1 -3 components 1. Description of parent behavior “He’s crying and you’re holding him” 2. Link parent behavior to intervention target “Good job nurturing him” 3. Link parent behavior to child outcome “That lets him know you’re there for him”

Functions of in the moment comments �Support of parent, buy-in to intervention, connection to parent coach �In service (specifically) of intervention goals �Helps parent find parenting, intervention, parent coach rewarding

Targets of intervention Enhanced Parenting Nurture ABC Intervention In the Moment Comments Follow child’s lead Avoid harsh behavior Attachment quality Early selfregulation

Biological dysregulation Early adversity leads to biological dysregulation Non-human and rodent (as well as human) studies have shown effects of early experience on HPA system

HPA axis H - Hypothalamus P - Pituitary A – Adrenal Cortisol an end product Sensitive to effects of early experience

HPA axis: 2 orthogonal functions �Stress reactive function Body’s mounting a stress response �Diurnal function Organism functioning as diurnal (or nocturnal) creature

Typical diurnal pattern of cortisol e im dt be ft m id -a m -a in -m 30 m id W ak e- up mg/dl 0. 9 0. 8 0. 7 0. 6 0. 5 0. 4 0. 3 0. 2 0. 1 0

When we measure cortisol 0. 9 0. 8 0. 7 0. 6 0. 5 mg/dl 0. 4 0. 3 0. 2 0. 1 e im dt be ft m id -a m -a in -m 30 m id W ak e- up 0

Log-transformed Cortisol Value (in ug/dl) Early adversity and diurnal cortisol Low-risk (n = 96) -0. 5 Foster (n = 184) Neglected (n = 155) -0. 7 -0. 9 -1. 1 -1. 3 Wake-up Bernard et al. , 2010, Archives Ped Adol Med Bedtime

Dysregulation �Biological dysregulation: cortisol �Behavioral dysregulation: Behavior problems Inhibitory control

Second target for intervention: Helping children develop better regulatory capacities �Parents who follow child’s lead have children with better selfregulation (Raver, 1996)

ABC intervention sessions Sessions 1 -2: Providing nurturance Sessions 3 -4: Following child’s lead Sessions 5 -6: Avoiding intrusive and harsh behavior Sessions 7 -8: Over-riding “voices from the past” Sessions 9 -10: Consolidating

Comments can have 1 -3 components 1. Description of parent behavior “Like her reaching out and your giving it to her” 2. Link parent behavior to intervention target ----3. Link parent behavior to child outcome “That’s going to make her feel important and like she can have an effect on things around her”

Targets of intervention Enhanced Parenting Nurture ABC Intervention In the Moment Comments Follow child’s lead Avoid harsh behavior Attachment quality Early selfregulation

Harsh behavior �Harsh, frightening, and/or intrusive behavior Undermines child’s ability to regulate behavior and biology Bernard et al. , 2010

ABC intervention sessions Sessions 1 -2: Providing nurturance Sessions 3 -4: Following child’s lead Sessions 5 -6: Avoiding intrusive and frightening behavior Sessions 7 -8: Over-riding “voices from the past” Sessions 9 -10: Consolidating

Targets of intervention Enhanced Parenting Nurture ABC Intervention In the Moment Comments Follow child’s lead Avoid harsh behavior Attachment quality Early selfregulation

Assessing effectiveness Randomly assigned children and parents to Attachment and Biobehavioral Catch-up (ABC) or to an alternate intervention (DEF) Focus here on outcomes for neglected/CPS-involved sample Children 6 -24 months at start of intervention

DEF (Developmental Education for Families) Control intervention focused on cognitive and motor development Structure same as for ABC 10 weekly sessions in home

Intervention effects on parental sensitivity � Parents who received ABC more sensitive at post- intervention than DEF parents (medium to large effect) � These gains sustained 3 years later Bick & Dozier, 2013; Raby et al. in prep; Yarger et al. , 2016

Intervention effects on parental brain activity Brain activity of neglecting mothers indicated failure to discriminate faces (Rodrigo et al. , 2011)

Intervention effects on mothers’ neural activity � Looked at through event related potentials (ERPs) � Compared 3 groups: Low-risk comparison DEF (high-risk control) ABC (high-risk experimental) Kristin Bernard dissertation Bernard et al. , 2015, Child Development

Results- N 170 � Low-risk comparison group -5 -4 -3 -2 -1 0 1 Crying Neutral Laughing 2 3 4 5 -200 0 200 400 Bernard, Simons, & Dozier, 2015, Child Development 600 800

Results- N 170 � DEF (High-risk control group) -5 -4 -3 -2 -1 0 1 Crying 2 Laughing 3 Neutral 4 -200 0 200 400 600 800

Results- N 170 � ABC -5 Crying Neutral Laughing -4 -3 -2 -1 0 1 2 3 4 -200 0 200 400 600 800

Targets of intervention Enhanced Parenting Nurture ABC Intervention In the Moment Comments Follow child’s lead Avoid harsh behavior Attachment quality Early selfregulation

Intervention effects on child attachment security �Assessed in Strange Situation �Parents involved in child welfare system �N=120 Secure Insecure

Percent of Children with Secure vs. Insecure Attachmnent Classifications Intervention effects on child attachment security 100% 80% Insecure (48%) Insecure (67%) Secure (52%) Secure (33%) ABC Control 60% 40% 20% 0% ABCIntervention Group. DEF Bernard, Dozier et al. , Child Development, 2012

Intervention effects on diurnal cortisol production �Assessed at wake-up and bedtime post- intervention over 3 days

Log-transformed Cortisol Value (in ug/dl) Early adversity and diurnal cortisol Low-risk (n = 96) -0. 5 Foster (n = 184) Neglected (n = 155) -0. 7 -0. 9 -1. 1 -1. 3 Wake-up Bedtime Bernard, Butzin-Dozier, Rittenhouse, & Dozier, 2010

Log-transformed Cortisol (in ug/dl) Intervention effects on diurnal cortisol 1 month post-intervention -0. 6 -0. 7 ABC -0. 8 DEF -0. 9 -1 -1. 2 AM PM Bernard, Dozier, et al. , 2015, Development and Psychopathology

Log-transformed Cortisol Value (ug/d. L) Intervention effects on diurnal cortisol 3 years post-intervention -0. 6 -0. 7 ABC -0. 8 DEF -0. 9 -1 -1. 2 -1. 3 AM Bernard, Hostinar, & Dozier, 2015, JAMA - Peds PM

Inhibitory control • Being able to sit quietly in school key to success • Doing what one is supposed to do • Inhibiting urge to do what one wants to do

Assessment of inhibitory control �Put attractive toys in front of child �Tell him or her not to play with them, instead play with crayons (boring in this context)

Intervention effects on inhibitory control 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 34% Touched 53% Touched ABC DEF 0% Lind, et al. , 2017

Attachment security in middle childhood • Kerns Security Scale • Self-report questionnaire • 15 items Kerns, Klepac, & Cole, 1996

Child attachment security (Kerns) 4 3. 5 3. 2 3 2. 5 AB DEF 2 1. 5 1 Category 1 Zajac et al. , in prep ABC

f. MRI research �Study differences in brain functioning among children �N=75 (25 ABC, 25 DEF, 25 low-risk) �In collaboration with Nim Tottenham

Attention to threat task Neutral Fear Butterfly (target) Neutral Time Push button when you see butterfly Fear

Attention to threat task �Fear faces (High Risk minus Low Risk) R • High risk (ABC + control) greater activation of occipital cortices and fusiform gyrus than low risk High Risk greater attention to threat

Attention to threat task �Fear faces (ABC minus DEF) R • ABC children had greater activation in • R orbitofrontal cortex • R Insular cortex • Anterior cingulate cortex than control children while viewing fear faces ABC greater regulation to threat

Mother/Stranger Task Happy (target) Neutral mom stranger Time Neutral mom Happy (target) stranger Push button when you see happy face.

Mother/Stranger Task • ABC group had greater activation in… • Posterior cingulate gyrus • Middle/inferior temporal gyrus during viewing of mother faces relative to stranger faces Z = 2. 3 ABC greater salience of mother faces ABC n = 22, DEF n = 24

Effective intervention � Parent: Sensitivity (3 years post-intervention) Neural activity/ERP (3 years post-intervention) (Bernard) Attachment script knowledge (Raby) � Child: Attachment DNA Methylation (whole genome analyses (Hoye and Roth) Emotion expression (2 years post-intervention) (Lind) Language development (2 years post-intervention) (Raby) Cortisol production (3 years post-intervention) Executive functioning (3 years post-intervention) ▪ Inhibitory control (Lind) ▪ Set-shifting (Lewis-Morrarty) Security (9 -years-old) (Zajac) ANS regulation (9 -years-old) (Tabachnick) Brain activation (9 -years-old) (Valadez & Tottenham)