Innovations in attachment-based interventions in pandemic times: feasibility of online attachment-based interventions

KEYWORDS:

• COVID-19 pandemic
• attachment
• intervention
• online
• Vrtual VIPP
• mABC
• eCONNECT
• mentalization

Preface

In the midst of the COVID-19 pandemic Howard Steele decided to organize a mini-conference of the Society for Emotion regulation and Attachment Studies (SEAS) on the highly urgent but equally highly challenging topic: “Innovations in attachment-based interventions for pandemic times.” On the 2nd and 3rd of December 2021 this conference took place, of course online, and it attracted more than 250 participants. In this special section we present four papers emerging from this conference, covering online family support across the age range from infancy to adolescence. Various labels are used for online parenting support interventions (virtual, digital, online, hybrid, eHealth type, etc.), but they all share a common goal, that is, reaching families in need of support at distant places or during extraordinarily stressful times that make face-to-face coaching less feasible or even impossible.

The COVID-19 pandemic seems to have affected both the physical and mental health of parents and children. The “Stress in America” pandemic survey found large weight gains in the population, with parents being among those who gained the most weight during lockdowns. Many parents reported increased stress and sleeping problems and some turned to drinking more alcohol. The pandemic has also impacted children’s school achievements. Severe learning losses were observed, with those from lower socio-economic families suffering most. Interactions between parents and children were less smooth during the pandemic. Numbers of online searches for terms related to abuse increased steeply during the pandemic, suggesting more frequent child maltreatment (Riem et al., 2021).

Unfortunately, the growing need for support and treatment of mental health issues in parents and children during pandemic lockdowns was met with less instead of more family support. Home visits or group sessions became impossible as in-person interactions with families or groups were disrupted by the pandemic. With lockdowns making in-person support difficult if not impossible, it became ever more important to develop online parenting interventions. In spite of the intractable collateral damage to parents and children, the accelerated development of online family support might be called a collateral benefit of the pandemic. Even when a pandemic like COVID-19 would not return – which we all hope for – online parenting programs may have large benefits for difficult-to-reach families in low to middle income regions or countries, and the cost-utility balance (Van IJzendoorn & Bakermans-Kranenburg, 2020) of expensive home-visit programs might become significantly more favorable if (partly) delivered online. Online interventions may have broader reach, better documentation, and positive cost-effectiveness. Their efficacy however needs further testing before being brought to scale.

In the first paper, “Feasibility of Virtual VIPP: Development of Virtual VIPP for online training and delivery,” Marinus van IJzendoorn, Eloise Stevens, and Marian Bakermans-Kranenburg (2023, this issue), report on the development of the Virtual-VIPP, which is an online version of Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD). Eloise Stevens (2021) initiated an informal feasibility evaluation with eight pioneering interveners delivering Virtual-VIPP during the pandemic, which documented the positive impact as well as some challenges of Virtual-VIPP. Grounding these preliminary results in a wider literature, the authors conducted a systematic review of 17 published trials with online parenting programs, including 8 RCTs. The results show that such online program are feasible, well-received and have equivalent effects to in-person approaches. Having said that, preparing the technicalities and monitoring protocol fidelity are necessary steps in these interventions.

In the second paper, Madelyn Labella, Marta Benito-Gomez, Emma Margolis, Jingchen Zhang, and Mary Dozier (2023, this issue), present a randomized controlled trial on “Telehealth Delivery of Modified Attachment and Biobehavioral Catch-Up: Feasibility, Acceptability, and Lessons Learned.” They evaluate the efficacy of this modified version of the widely used ABC parent coaching program (mABC) for pregnant women with opioid use disorders pivoted to telehealth. Of 61 mothers in the pilot, 30 participated in telehealth and completed an average of 4.7 remote sessions each. Telehealth delivery of mABC was found to be feasible and acceptable, with advantages in terms of scheduling sessions and efficient use of intervener time. More than half of the randomized cases completed their intervention, comparable to pre-pandemic in-person intervention rates. Two case studies illustrate opportunities as well as challenges of mABC and crucial lessons learned for future telehealth implementation are discussed.

Parental support of children’s learning can impact their motivation and success, but many parents struggle with homework support. Naama Gershy, Racheli Cohen and Naama Atzaba Poria (Gershy et al., 2023), took on the challenge to develop and examine a brief online mentalization-based intervention to improve the quality of homework support by having parents dedicate the first 5 minutes to observation of the child behavior and parent’s own mental state. In their paper on “Parental Mentalization Goes to School: A Brief Online Mentalization-Based Intervention to Improve Parental Academic Support” the authors report a pilot study with 37 Israeli parents of elementary school pupils who showed high engagement and implementation rates of the mentalization-based observation technique. Statistically non-significant but promising medium-sized reductions in parental hostility and improved behavioral regulation, parental mentalization, and autonomy support were seen after the intervention.

In their paper on “eConnect: Implementation and Preliminary Evaluation of a Virtually Delivered Attachment-Based Parenting Intervention During COVID-19,” Lin Bao and Marlene Moretti (2023, this issue) adapted Connect, a widely-used attachment-based parenting group intervention, for online delivery and implemented eConnect Online with 164 Canadian parents of adolescent youth during the COVID-19 pandemic. The study found significant reductions in parent-reported youth internalizing and externalizing problems and attachment anxiety/avoidance, as well as reduced caregiver strain and parent-youth aggression. Parental depression did not significantly decrease. Program completion was high (84.7%) with positive feedback from facilitators and high satisfaction as reported by parents. Technical challenges were surprisingly limited, suggesting strong potential for sustainability after the pandemic. The study has limitations such as the lack of a control group, thus further research with randomized groups and interveners is needed.

In sum, the COVID-19 pandemic has accelerated the growth of online parenting interventions, which aim to support families in lockdown or otherwise difficult-to-reach settings. The work presented in this special issue has led to the surprising discovery that even attachment-based, relationship-focused methods when delivered online show promise as being acceptable, feasible, and potentially effective compared to face-to-face methods. In the transition to the context of justification we need rigorous randomized trials to determine whether short-term gains translate into persistent changes in parenting and child development, and whether online parenting support can be brought to scale.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The work of MHVIJ is supported by the Netherlands Organization for Scientific Research, Spinoza Award 2004. MJB-K is supported by the European Research Council (ERC AdG). MHVIJ and MJB-K are additionally supported by the Gravitation award of the Netherlands Organization for Scientific Research [NWO grant number 024.001.003].