by M Dozier · 2019 · Cited by 217 — Biobehavioral Catch-Up (ABC) intervention through a program in her city that was intended to reduce the incidence of foster care placement. Following her

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514 Gloria was enrolled in the Attachment and Biobehavioral Catch-Up (ABC) intervention through a program in her city that was intended to reduce the incidence of foster care placement. Following her participation in the interven -tion, what is immediately striking about Gloria is that she lights up when interacting with her 2-year-old son, Nathan. When he pushes his toy truck under her feet, she says, fiThat truck is moving fast, Natie!fl Later, when he pricks his finger on a sharp edge of the truck, Gloria says, fiOh sweetie. I know that hurts,fl and hugs him. These types of interactions are very different from her interactions several months earlier. When she enrolled in the program, Gloria felt overwhelmed by the challenges of raising Na -than. As a single mother with few resources, she had lived in shelters, motel rooms, and friends™ living rooms since his birth. Her own upbringing had not prepared her to be a sensi -tive or responsive parent. Her birth mother had struggled with alcoholism and had been both distant and punitive. Her birth father seemed a bright memory, but he had died when Gloria was very young. Nathan had come to feel like a burden to her. She rarely commented on his play other than to tell him not to do something. When he was hurt or frightened, she told him not to be a baby. Sometimes without knowing it, she reacted strongly and in ways that fright -ened Nathan. She was an ideal match with ABC™s targets. Overview of ABC ABC is a 10-session parenting intervention de -livered in parents™ homes. It was originally de -veloped for parents of infants between ages 6 and 24 months. We have now also adapted the intervention for parents adopting children in -ternationally, and for parents of toddlers (24Œ36 months old). ABC focuses on three specific tar -gets: nurturing the distressed child, following the child™s lead with delight, and avoiding harsh or frightening behavior. Parent coaches present manualized intervention content in each of the 10 weekly sessions. Videos of other parents and children are used to illustrate concepts, espe -cially early in the intervention. The sessions are video-recorded, both for supervision purposes and to allow for presentation to parents. Brief video clips are used to illustrate strengths of parents relative to particular intervention tar -gets, and as time goes on, areas that need work. Key to the intervention are fiin-the-momentfl comments by parent coaches, which direct par -ents™ attention to the targeted behaviors. Parent coaches are expected to make comments at least once per minute, which, relative to most other interventions, represents a stunningly high rate. We think that providing parents feedback and practice in implementing targeted behaviors is key to helping them carry their learning into their everyday lives. CHAPTER 31 Attachment and Biobehavioral Catch-Up Mary Dozier Kristin Bernard

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31. Attachment and Biobehavioral Catch-Up 515 In this chapter, we first provide an account of how the intervention was developed. We de -scribe the intervention, then move on to present results of efficacy trials, and provide an over -view of our efforts to disseminate the interven -tion nationally and internationally. Intervention Targets The ABC intervention was developed to ad -dress issues that we identified through our re -search findings, as well as the research findings of others, as critical for young children who have experienced adversity, such as abuse or neglect and disruptions in care. The conceptual model is presented in Figure 31.1. Intervention Target 1: Importance of Nurturance The first issue we identified is how critical it is for children who have experienced adversity to have nurturing caregivers. When children have parents with autonomous states of mind, they typically develop secure attachments (Verhage et al., 2016). fiState of mindfl refers to parents™ way of thinking about and processing attach -ment-related memories and experiences, and is assessed through discourse analysis of a semi -structured interview (Main & Goldwyn, 1998). There are three types of nonautonomous states of mindŠdismissing, preoccupied, and unre -solvedŠbut only the unresolved state of mind predicts child disorganized attachment (Ver -hage et al., 2016). Disorganized attachment is particularly concerning because it is predictive of a range of problematic outcomes, including externalizing and dissociative symptoms (Carl -son, 1998; Fearon et al., 2010). Parents with un -resolved attachment may behave in frightening ways, which has been suggested as a possible mechanism for the development of disorganized attachment (Main & Hesse, 1990; Schuengel, Bakermans-Kranenburg, & van IJzendoorn, 1999). In a study conducted nearly 20 years ago, we found that many (55%) young foster chil -dren developed disorganized attachments when their foster parents had dismissing states of mind (Dozier, Stovall, Albus, & Bates, 2001). Ordinarily, one would expect children to have avoidant attachments (i.e., turning away from parents when distressed) if their parents had dismissing states of mind. We were surprised to find that they had developed disorganized attachments. What distinguishes parents with dismissing states of mind is that they tend to discount the need for nurturance (Hesse, 2016). The biological children of such parents can organize their attachments, though, showing avoidant attachments that although perhaps not optimal, are well suited to the parent. Foster children, however, seemed unable to organize their attachments, underscoring the importance FIGURE 31.1. Anticipated effects of ABC across developmental periods. ABC InterventionNurturance to distressFollowing theleadNonfrightening behaviorAttachment qualityEarly self-regulationEnhanced ParentingOngoing Enhanced ParentingInhibitory controlEmotion regulationPeer relations and aggressionPhysiological regulationdoohdlihC elddiMdoohdlihC ylraEycnafnI

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516 V. INTERVENTION of nurturing care following adversity. For this reason, we included parental nurturance as the first component of the ABC intervention. Our findings and the findings of others sug -gested two things that could interfere with parents providing nurturance. The first is that children who experience adversity often be -have in ways that fail to elicit nurturance from their parents. For example, when young foster children were hurt, they often acted as if they did not need their foster parents. What is strik -ing was that this led foster parents to respond in kindŠand fail to provide nurturance. Of course, young children living with birth parents would be likely to send similar signals if birth parents had previously been rejecting of their bids for reassurance, even if their parents had subsequently made changes and become nur -turing. The task for such parents is therefore not only to respond sensitively but also to be thera -peuticŠthat is, to provide nurturance even if it is not elicited. The second issue that can interfere with pro -viding nurturance is that nurturance does not ficome naturallyfl to some parents. When par -ents have autonomous states of mind, that is, states of mind in which they can freely evaluate earlier attachment experiences, they are likely to behave in ways that are nurturing. However, when parents have nonautonomous states of mind, that is, when they are either dismissing of the importance of earlier attachment expe -riences or are caught up and preoccupied with those experiences, they are often not nurturing in consistent ways when their children are dis -tressed. Therefore, the first intervention component is directed toward helping parents provide nur -turance to distressed children, even when chil -dren do not elicit nurturance or when nurtur -ance does not come naturally to parents. Intervention Target 2: Importance of Following the Child™s Lead with Delight We began studying children™s biological out -comes after becoming aware of nonhuman re -search findings that seemed relevant. Levine and colleagues (Wiener, Bayart, Faull, & Levine, 1990) found that nonhuman primate infants showed glucocorticoid reactions to sep -arations, and never habituated to these separa -tions. Glucocorticoids (cortisol in primates, and corticosterone in rodents) are an end product of the hypothalamicŒpituitaryŒadrenal (HPA) axis. When experiencing an uncontrollable stress, human adults and many other mammals show an increase in cortisol as the result of a sequence of reactions involving this axis. This stress reactivity is one of two key functions of the HPA axis: The second function is the main -tenance of a diurnal (in the case of humans) pat -tern. High levels of cortisol are secreted in the morning, reflecting greater metabolism of glu -cose and ready energy supply, and low levels at night. This diurnal patterning represents one of the contributors to helping humans function as diurnal creatures, awake when other members of the species are awake and asleep when other members of the species are asleep. Although human infants typically do not mount a cortisol response to threat, effects of challenging con -ditions can nonetheless be seen on the diurnal patterning of cortisol. We studied the diurnal production of corti -sol in children who had experienced adversity, examining children™s cortisol level at wake- up and bedtime over several days (Bernard, Butzin-Dozier, Rittenhouse, & Dozier, 2010). Young children who were living under low- risk conditions showed high morning cortisol values and low bedtime cortisol values. Young children living in foster homes showed a more blunted pattern of cortisol production than did low-risk children, with higher wake-up values. But children living with parents involved with child protective services (CPS) showed the flat -test slopes of all, with the highest wake-up val -ues. It seemed that the more adverse conditions children were living under, the more disrupted their production of diurnal cortisol. We reasoned that if adverse experiences can disrupt the functioning of the HPA axis in such a way, then remediation through enhanced par -enting should help normalize functioning. It was not immediately clear just what aspect of par -enting was most relevant, though. We searched the literature and found evidence that when par -ents are very responsive and well tuned to chil -dren™s signals, children develop better regula -tory capabilities (Raver, 1996). Although there was not yet evidence that such parenting would lead to more normative cortisol production, we thought it likely. Therefore, we incorporated parents™ becom -ing very responsive partners to their children as the second intervention target. More specifi -cally, we think of this as parents following their children™s lead. For example, when a child picks up a toy to show his mother, she might say, fiOh,

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31. Attachment and Biobehavioral Catch-Up 517 you have your bus!fl Or if the child is pushing his car into a box, the mother could do the same. As we implemented this second component, we found it important to tweak it somewhat. Some parents began following their children™s lead, but they did so in rote ways. In previous work, we had found that foster parents with higher levels of commitment, or emotional investment, in their children showed greater delight during interactions with their children than did foster parents who expressed low levels of commitment (Bernard & Dozier, 2010). Fur -thermore, we observed that high-risk birth par -ents, who often felt overwhelmed by stressors or experienced elevated depression, struggled to enjoy their time with their children. Thus, we incorporated delight into expectations for fol -lowing the lead. Intervention Target 3: Importance of Avoiding Harsh and Frightening Behavior At an anecdotal level, we observed parents be -having in harsh or frightening ways for a va -riety of reasons. Sometimes parents™ harsh and frightening behaviors, such as glaring angrily, smacking or grabbing children, or threatening children verbally, appeared to be attempts to control children™s behavior. Sometimes parents responded harshly when they became over -whelmed by chaotic environments (e.g., chil -dren yelling, dogs barking). And other times parents behaved in frightening ways without being aware they were doing so. Indeed, par -ents™ own histories of trauma, especially when they have unresolved states of mind with regard to loss or abuse, are associated with frighten -ing behaviors (Jacobvitz, Hazen, Zaccagnino, Messina, & Beverung, 2011; Jacobvitz, Leon, & Hazen, 2006). We were aware of the consequences of such behavior from the research on frightening be -havior. When parents are frightening, children are at risk for developing disorganized attach -ments (Lyons-Ruth, Bronfman, & Parsons, 1999; Schuengel et al., 1999), and for having difficulty regulating physiology and behavior (Bernard & Dozier, 2010; Fearon et al., 2010; van IJzendoorn, Schuengel, & Bakermans- Kranenburg, 1999). We thought it likely that parents could make impressive progress with regard to our first two intervention targets (nurturing children and fol -lowing the lead), with this progress undermined by frightening behavior. Therefore, we included avoiding harsh and frightening behavior as our third intervention component. The ABC Approach Manualized ABC is a manualized intervention, which means that a manual guides the presentation of the in -tervention content. Parent coaches are expected to become very familiar with intervention con -tent so that they can discuss it comfortably with parents while attending to parentŒchild inter -action. We modified the order of presentation topics over time as it became apparent which topics could be introduced early on and which required more fibuy in.fl Sessions are described briefly below. Sessions 1 and 2 introduce parents to the im -portance of nurturing their child. In the first session, parents are asked to consider common -ly held ideas about parenting, such as whether one can spoil a baby, and that responding to ba -bies™ cries makes them cry more. Research evi -dence is presented that challenges these ideas. Although it is not expected that parents will change their ideas, this discussion gently opens a dialogue about the challenges of nurturing in response to children™s distress. Additionally, parents are helped to see how children™s signals may make it challenging to respond in nurturing ways. The key idea presented is that children™s behaviors elicit complementary, or fiin kind,fl behaviors from parents; that is, there is a powerful pull to re -spond in a nurturing way to a baby who is eas -ily soothed, but there also is a powerful pull to turn away from a baby who appears not to need the parent. Parents™ jobs are made harder if their children turn away from them (i.e., are avoidant) or are fussy and inconsolable (i.e., are resistant). Parents view video clips of chil -dren showing avoidant and resistant behaviors, and are helped to consider how these signals are confusing and may elicit non-nurturing re -sponses. The intervention is less threatening than it might otherwise be because the parent is presented (accurately) as having a challenging job. Parents are helped to see that nurturance is important for their child, even if the child fails to elicit it. Sessions 3 and 4 focus on the importance of following the child™s lead. Parents are given several activities (i.e., reading a book, building with blocks, and making pudding). The activi –

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518 V. INTERVENTION ties were selected because they often elicit par -ents fitaking chargefl or leading the interaction. Parents are challenged to follow the lead even though their tendency may be to do things such as turn the pages of the book in order, build a high tower, and direct the child through steps of making pudding. Before trying these activi -ties, parents see videos of parents who have fol -lowed their children™s lead effectively, and those that have not, with the specific behaviors high -lighted. Sessions 5 and 6 move from consideration of following the lead to intrusive behaviors and eventually to frightening behaviors. In Session 5, parents are asked to recall times when they experienced intrusive behaviors when they were children. Most adults report that they did not like to be tickled as children, with this provid -ing a useful fiin.fl We talk with them about how, as adults, we often assume children enjoy such behaviors, but to children these behaviors are often overwhelming and dysregulating. Parents are shown videos of a mother overwhelming her child with a puppet, then a parent responding to her child™s cues that he was frightened of the puppet. Parents then are asked to play with pup -pets and other such toys with their own child, while being mindful to follow the child™s lead rather than be intrusive. Session 6 is concerned with behaviors that are frightening. The parent coach tailors the session to issues observed in the first five sessions. Par -ents are asked to think of times in their lives when caregivers were frightening, and to con -sider how these behaviors affected them as chil -dren. They are then gently asked to think about conditions that elicit frightening behaviors from themselves, and to think about how they are sometimes able to avoid behaving in frightening ways. Video examples of times when they were able to avoid behaving in frightening ways, and times when they behaved in frightening ways are often presented. Parents are helped to see that frightening behaviors, even if infrequent, have the potential to undo all of their efforts to be nurturing in response to their child™s distress and to follow their child™s lead. Sessions 7 and 8 are intended to help parents think about how issues from their past can affect their current parenting. We talk about this with parents, about how fivoices from the pastfl affect how they parent. Whereas it might be tempting to think of fivoices from the pastfl as a weak -ness, we encourage parents to recognize that everyone has fivoices,fl and that recognizing the voices allows parents to override these voices and to behave in nurturing, sensitive ways. For example, when a mother™s child cries, her auto -matic response is to say, fiHop up, you™re okay.fl She recognizes through this discussion, though, that this automatic response is consistent with her own mother™s voice, saying to her when she was little, fiYou™re not hurt. Get upŠyou™re not a baby.fl When she can recognize this, instead of quickly urging her child to move on when hurt, she can stop herself and recognize that she is hearing her fivoice from the pastflŠand that she can choose to behave in a different (more nur -turing) way. The discussion is these sessions is based on our observations of which targets are challeng -ing for the parent. Parent coaches approach the sessions quite prepared, with a good sense of where the parent struggles most (with nurtur -ing, following the lead, and/or avoiding fright -ening behavior). They consider comments the parent may have made or other suggestions for connections between earlier challenges and current parenting. One video is typically shown in which the parent behaved in a nurturing or sensitive way, followed by a video in which the parent did not behave with nurturance or sensitivity. Attention can first be given to the nurturing or sensitive video, with a focus on the parent™s ability to override fivoices from the past.fl Then, when considering the other video, the parent is asked to consider what fivoice from the pastfl interfered, and, moving forward, how to override his or her automatic response. Sessions 9 and 10 help consolidate gains from previous sessions, and continue to work on issues that remain problematic. In Session 10, parents receive a montage of brief video clips highlighting moments throughout the sessions when they provided nurturance and followed the child™s lead. In the Home We consider it very important that ABC is im -plemented in the home. We invite everyone who is in the home (e.g., boyfriend, grandmother, other children) to join in the sessions. Our inter -est is in changing parents™ behavior in the con -text in which they live, which includes challeng -es of multiple children to attend to, commentary by other family members, and other sources of distraction. Changes to parents™ behavior are expected to be more sustainable when practice occurs in the environment in which they live.

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31. Attachment and Biobehavioral Catch-Up 519 In-the-Moment Comments In-the-moment comments are a key part of the intervention. These comments provide feed -back to parents regarding how their behaviors fit with intervention targets, and the importance of the behaviors for the child™s development. The comments provide the parent extensive practice behaviorally with intervention targets throughout the 60-minute intervention session. Parent coaches are expected to make comments at a very high rate (about once per minute) re -garding parental nurturance and following the lead. Anytime the parent has an opportunity to behave in a nurturing way or in a responsive way, regardless of whether the parent does or does not behave in such a way, the parent coach then has the opportunity to comment. For ex -ample, if the child bumps his head and the par -ent says, fiOh, do you need a hug, honey?fl the parent coach has an opportunity to comment on the parent™s nurturance. In response, the par -ent coach might say, fiHe bumped his head and you asked him if he needed a hug. That™s such a great example of your nurturing him. That is the kind of thing that will let him know you™re there for him.fl If the child hands a toy to the parent, and the parent says, fiThanks for the truck,fl the parent coach has the opportunity to comment on the parent™s following the lead. Such a comment may similarly describe the parent™s behavior, label the intervention target, and link the behavior to outcomes of following the lead, such as the child™s sense of self-esteem or ability to attend. In early sessions, we expect parent coaches to make only positive comments, so that par -ents feel supported. These comments are pow -erful in engaging parents in the intervention. As time goes on, parent coaches are helped to make comments that scaffold or shape behavior, such as, fiHe might need you to hold him right now,fl when the parent does not behave in a nurturing way, for example. Even in later sessions, parent coaches maintain a higher ratio of comments that focus on positive behaviors of nurturance or following the lead than comments that focus on times when parents fail to behave in these ways. Efficacy of ABC The ABC intervention has now been tested in three large randomized clinical trials, and sev -eral smaller trials. The results of these trials have supported the intervention™s efficacy in enhancing attachment quality, cortisol produc -tion, and executive functioning, as described below. For our larger randomized clinical trials, parents were randomly assigned to either the ABC intervention or to a control intervention (Developmental Education for Families [DEF]) that focused on motor and cognitive develop -ment. The interventions were structurally very similar, with 10 weekly sessions conducted in the homes with parents and children included in sessions. Most of the results described below are for CPS-involved parents and their infants. These families had been referred as part of a program intended to reduce the incidence of foster care placement in a large city in the mid- Atlantic region. Attachment A key outcome of the intervention was im -proved child attachment quality. We were aware that children who experience adversity are at risk for developing insecure and disorganized attachments; therefore, a key goal was enhanc -ing attachment outcomes. To test whether the ABC intervention could affect attachment quality, we examined chil -dren™s attachment quality in the Strange Situ -ation at postintervention among 120 CPS-in -volved children (Bernard et al., 2012). All the parents had been referred to CPS because of concerns regarding maltreatment (primarily neglect), but the concerns were not considered sufficiently serious to lead to children™s removal from their homes. Nonetheless, all were eligible for services through the city™s diversion from foster care program. In the ABC condition, 52% of the children were classified as having secure attachments to their mothers, as contrasted with 33% of children in the DEF condition. Similarly, only 32% of children in the ABC in -tervention condition were classified as having disorganized attachments, in contrast with 57% of children in the DEF condition. Both of these effects represent statistically significant differ -ences. Thus, children in the ABC intervention were more likely than control children to seek out their mothers and to be soothed readily (i.e., to show secure attachments) than children in the control condition. They were less likely to show anomalous behaviors when distressed, such as freeze or stay still, turn in circles, or wander aimlessly (i.e., show disorganized at –

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31. Attachment and Biobehavioral Catch-Up 521 Children™s Behavioral Regulation A key task for children as they go into preschool and kindergarten is being able to control their behavior. More specifically, being able to in -hibit the urge to do things that one should not do, and to do things that one is supposed to do, is more important to success in school than knowing numbers and letters (Blair & Razza, 2007; Viterbori, Usai, Traverso, & De Franchis, 2015). We tested children™s fiinhibitory controlfl by presenting children of CPS-involved par -ents with an array of attractive toys that they were instructed not to touch. While parents completed questionnaires, children were given crayons and a coloring book (i.e., a boring task compared with playing with the toys). During this fiwaitfl task, fewer of the children in the ABC condition touched the toys than did chil -dren in the DEF condition (34 vs. 56%, respec -tively) (Lind, Bernard, Yarger, & Dozier, 2016). They also touched the toys a smaller percentage of the time, and even among the subgroup that touched the toys, had a longer latency to touch the toys, than did children in the DEF condition. Again, this outcome was assessed several years after the intervention was implemented. Table 31.1 describes other outcomes as a result of ABC, across the different samples, including reduced expression of negative affect (assessed behaviorally in a frustrating task) and improved cognitive flexibility (assessed through the Di -mensional Change Card Sort; Zelazo, 2006). For effects to be seen on child outcomes, such as at -tachment, inhibitory control, and cortisol regu -lation, and to be seen over time, one would think that parental behaviors would have to change in sustained ways. We have assessed parental sen -sitivity and parental brain activity, with findings that suggest this to be the case. Sensitivity We have examined parental sensitivity by as -sessing whether parents followed children™s lead in play. Foster parents who received the ABC intervention showed greater increases in sensitivity during play interactions from pre- to postintervention than did foster parents in the DEF group (Bick & Dozier, 2013). Furthermore, when assessing session-by-session changes in parenting, CPS-involved mothers who received ABC showed greater increases in sensitivity and decreases in intrusiveness than did moth -ers who received DEF, with most change in these parenting behaviors occurring in the first five sessions (Yarger, Hoye, & Dozier, 2016). Among a subset of CPS-involved mothers as -sessed approximately 3 years postintervention, ABC mothers still showed higher sensitivity (i.e., following the lead) than did DEF mothers; furthermore, ABC mothers were indistinguish -able from a low-risk comparison group (Ber -nard, Simons, & Dozier, 2015). Parental Brain Activity Rodrigo and colleagues (2011) found that ne -glecting mothers failed to show differentiated neural processing of crying, laughing, and neutral child facial expressions, as assessed via event-related potentials (ERPs), which are changes in the brain™s electrical activity in re -sponse to a stimulus, such as seeing a picture. Whereas control mothers showed larger ERP responses, particularly the N170 (negative de -flection occurring at approximately 170 ms poststimulus), to crying faces than neutral faces, neglectful mothers showed similar responses across conditions (Rodrigo et al., 2011). Using a similar facial viewing task, we found that ABC mothers showed larger ERP responses, includ -ing the N170 and late positive potential (LPP, a prolonged positive deflection that reflects sus -tained attention to emotional stimuli), to emo -tional faces than to neutral faces. ABC mothers™ ERP responses were similar to those of a low- risk comparison group, whereas DEF mothers failed to show this differentiated processing of emotional faces, similar to neglectful mothers in the Rodrigo and colleagues study. Taken to -gether, these behavioral and neural data from parents suggest that the ABC intervention is affecting parenting at multiple levels, likely serving as a mechanism by which key child out -comes are improved. Dissemination Having developed an efficacious intervention, we recognized the importance of making the intervention available to agencies nationally and internationally. When interventions are dis -seminated, however, effect sizes are often much smaller than in the original setting (Durlak & DuPre, 2008). One explanation for the drop-off in effect sizes seems to be fidelity to the model (Fairburn & Cooper, 2011; Hulleman & Cor -dray, 2009).

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522 TABLE 31.1. Overview of Key Child and Parent Outcomes Reference Intervention sample Outcome Mean child age at time of assessment Description of finding (ABC compared to DEF) Bick & Dozier (2013) Infants in foster care Foster parent sensitivity 11.1 months Greater improvements in pre- to postintervention parent sensitivity Yarger et al. (2016) CPS-involved infants living with birth parents Biological parent sensitivity 14.1 months Increase in parent sensitivity (following the lead) and decrease in parent intrusiveness across 10 sessions Bernard, Dozier, et al. (2015) CPS-involved infants living with birth parents Diurnal cortisol 17.6 months Higher wake-up cortisol and steeper decline in cortisol from wake-up time to bedtime Bernard et al. (2012) CPS-involved infants living with birth parents Attachment quality 19.1 months Increased likelihood of secure attachment and reduced likelihood of disorganized attachment Lind et al. (2014) CPS-involved infants living with birth parents Negative affect expression 28.2 months Lower expression of anger, anger at parent, and global negative affect during a problem-solving task Lind et al. (2016) CPS-involved infants living with birth parents Inhibitory control 38.4 months Fewer children touched prohibited toys, less time spent touching, and longer latency to first touch Bernard et al. (2017) Infants in foster care Receptive vocabulary 39.5 months Higher receptive vocabulary scores on Peabody Picture Vocabulary Test Lind et al. (2017) Toddlers in foster care Cognitive flexibility; attentional problems 47.6 months Higher cognitive flexibility and lower parent-reported attention problems, with ABC children scoring similarly to a non-foster-care group Bernard, Hostinar, et al. (2015) CPS-involved infants living with birth parents Diurnal cortisol 50.7 months Higher wake-up cortisol and steeper decline in cortisol from wake-up time to bedtime Bernard, Simons, et al. (2015) CPS-involved infants living with birth parents Parent brain activity; parent sensitivity 58.6 months Larger ERP responses to emotional child faces than neutral child faces; higher parent sensitivity Lewis-Morrarty et al. (2012) Infants in foster care Cognitive flexibility 60.3 months Higher cognitive flexibility, with ABC children performing similarly to a non-foster-care group

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31. Attachment and Biobehavioral Catch-Up 523 Fidelity is critical, but often challenging to define and to measure in a way that is not sub -ject to reporting bias. Over the years, we came to see making in-the-moment comments as the critical aspect of fidelity. Nearly every parent coach was able to learn the intervention man -ual content; delivering this content is not what distinguished strong parent coaches from weak parent coaches. What did distinguish coaches, though, was whether they made in-the-moment comments. There were many obstacles to making com -ments, including the difficulty of attending to two things (i.e., manualized content and ongo -ing parentŒchild interactions) at the same time, feeling as though they might interrupt the inter -action, feeling unsure about what comments to make, and so on. Without clear rules for mak -ing comments and a system for ensuring that parent coaches were making such comments, it was clear that we would not succeed in getting parent coaches to make comments, especially when implemented outside of our own team. We have developed a system for quantifying these parent coach behaviors, which provides weekly feedback to parent coaches as they learn to implement the intervention, and provides quantifiable fidelity criteria. A 5-minute video clip from one of each parent coach™s sessions is identified for coding each week. The parent coach and a coding supervisor then code this same clip. The supervisor works with the parent coach to ensure that the parent coach is coding behaviors in a way consistent with our criteria, and then to provide suggestions and practice in other types of comments that could be made. This ongoing fidelity monitoring not only serves as a valuable tool for supervision but also results in rich data that can be used to examine mechanisms of parent change. Using fidelity data collected in the context of community- based implementation efforts, we found that the frequency and quality of parent coaches™ commenting predicted the magnitude of change in parent sensitivity and parent intrusiveness at postintervention, as well as the likelihood of parents completing ABC (Caron, Bernard, & Dozier, 2016). These data provide strong evidence of in-the-moment commenting as an active ingredient of change, and further high -lighted the importance of focusing training, su -pervision, and certification around this critical component. Although no randomized clinical trials have yet been conducted at dissemination sites, we have collected pre- and postintervention data regarding parental sensitivity. We have found large effects (e.g., d = 0.83Œ0.89) at these dis -semination sites (Caron, Weston-Lee, Hagger -ty, Dozier, 2016; Roben, Dozier, Caron, & Ber -nard, 2017), effects that are as large as those in clinical trials. This is exciting, suggesting that the ABC intervention can be disseminated with little drop-off in effectiveness. We attribute this to the strong fidelity assessment tool that allows monitoring of fidelity with regular feedback to parent coaches. Case Examples Brenda Brenda lived in a motel room with her two children, 3-year-old Darin and 8-month-old Sarah. When we first met the family, the baby was emotionally flat and interacted little with her environment. Instructed to play with her child fias she normally would,fl Brenda moved toys around in front of the baby and put Sarah™s hands on the toys to direct her, but Sarah ap -peared more like a doll than an infant. It was disturbing to see a child of this age so disen -gaged. It seemed likely that she interacted very little with others. Brenda responded openly and quickly to the intervention. In the first session, even before defining the ABC targets, the parent coach said, fiShe handed you that and you took it right from her. That may not seem like a big deal, but you™re following the lead when you do that. That™s so important for helping her develop a sense of confidence. We™ll be talking more about that in the next several weeks.fl Brenda beamedŠand right away, she started becom -ing more engaged with Sarah and with Darin. When Brenda then commented on a toy that Sarah put in her mouth, the parent coach again commented. The shift in Brenda was dramatic. She figot itfl and found the new interactions with her children and the feedback from the parent coach so rewarding that she was able to change the way she interacted with her children relatively quickly. When the parent coach ar -rived for the third session, Sarah seemed like a different childŠshe was alert, active, and in -teractive. What was easy about Brenda was that she did not resist the intervention or the parent coach, and she found changes in her interactions with her children rewarding. She had more work to

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