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An intervention aimed at helping parents with their emotional attunement to their child Introduction Brenda McLackland Dip Clin Psych Consultant Clinical Psychologist, Barnardo’s Sue Channon D Clin Psych Consultant Clinical Psychologist, South Wales Doctoral Programme in Clinical Psychology Kathryn Fowles D Clin Psych Independent Clinical Psychologist Laura Ashley Jones BSc PGE Volunteer Research Assistant, Barnardo’s Correspondence: ComfortZone@barnardos.org. uk Abstract Comfort Zone for Children is an intervention that practitioners in a range of settings can use in their work with parents, with the aim of enhancing parental emotional attunement to their child. This article describes the development and evaluation of the intervention using preliminary outcomes, focus groups and interviews with staff and parents. The ongoing development of the intervention in the light of the feedback and future development is discussed. Key words Attunement, attachment, parenting, infant mental health, early intervention Community Practitioner, 2013; 86(4): 24–27. No conflict of interest declared
The benefits for children and their caregivers of developing a secure relationship have been well documented, as have the difficulties that may ensue when insecure attachments develop (Allen, 2011). Emotional availability, a concept that refers to emotional responsiveness and attunement to another’s needs (Emde, 1980) is an essential component of helping infants regulate their own emotions and develop secure attachments (Easterbrooks and Biringen, 2000). As a consequence of these findings and the everincreasing understanding of the importance of the quality of early relationships, academics, practitioners and policy makers have become focused on the need to intervene early to promote secure attachments and reduce the potential for insecure patterns developing. Various interventions have been developed to help facilitate this process, eg, Family Nurse Partnership (Olds, 2006) the Solihull Approach (Douglas, 2001) and Brazelton (Brazelton, 1995). The rationale behind Comfort Zone for Children (CZ4C) was to develop an enabling model that, although informed by complex concepts of attachment and attunement, was relatively simple to engage
Child’s attachment behaviours Parent’s response Controlling Hostile Intrusive
Attuned Loving Available
Unresponsive Neglectful Unavailable
Red/hot
Yellow/warm
Blue/cold
Avoidant
Secure
Ambivalent
Disorganised
Figure 1. The hypothesised link between attachment patterns and Comfort Zone
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with and actively encouraged parents to take responsibility for attunement with their child. It requires that they rate their emotional responses to their child and change them, if necessary, with staff support. This may help develop skills and insights that could generalise across settings and time.
Background The development of the scale The CZ4C scale was developed in 2009 by the first author and is based on the ABC+D model of attachment (Main and Hesse, 1990). The nature of the attachment relationship can be arranged on a continuum from A(insecure/avoidant) when carers’ responses are intrusive and over-controlling; to B (secure attachment) when the carer is sensitive and responsive to the child’s needs; to C (ambivalent) when carers’ responses are unreliable and under-responsive. Disorganised (D) is spread out across the three previous categories as it is possible, as stated by Howe (2011: 48) that ‘when stress levels are lowered, otherwise disorganised children can, and do show some organisation in their attachment behaviour such that their strategies might be recognised as either avoidant, ambivalent or even secure.’ The new perspective brought by the CZ4C intervention is the application of colour and temperature to the ABC+D model (see Figure 1). It is hypothesised that the comfort zone for children is attained when carers are sensitively attuned and respond warmly to the child. This sensitive response provided by parents is given a warm temperature and coloured yellow. Parental responses that are too intrusive and overresponsive are characterised as ‘hot’ and assigned the colour red. Parental responses that are unavailable and under-responsive are given the temperature ‘cold’ and the colour blue.
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Implementation of CZ4C in practice
Aim
The CZ4C intervention follows a rapportbuilding phase wherein staff build a relationship with parents before introducing the ideas in Figure 1. Once staff are confident they have reached that point they will ask the parent to rate their emotional response to their child using the colour scale. This opens two opportunities: first, parents are asked to think about their emotional responses to their child, which they might never have done previously. Second, it gives staff ‘permission’ and a ‘language’ with which to talk to parents openly about their responses to their child. For example, it may be easier or more socially acceptable for a parent to say their responses are in the red zone than to say they were furious with their child. The skill of using the intervention is to help parents rate their emotional responses to their child. Are they generally toward the hot or cold zone? This requires staff sensitivity and skill as most parents tend to rate themselves at the centre in order to present their responses to their children in a positive light. Progress on this issue often occurs after it is explained that most parents will see elements of many of the colours in their responses to their child throughout each day. Parents then feel freer to acknowledge this in their own responses. To start the intervention the direction from the centre is more important than the actual colour chosen. Once parent and staff are in agreement about the direction of a parent’s response, the appropriate strategies that form the intervention can be offered and applied. Parents whose responses are in the hot/red zone are given a set of strategies to help them ‘cool down’ their responses. For example, breathe deeply, count to 10 and try to calm down before responding. In contrast, parents whose responses are in the cold/blue zone were given a set of strategies to help them ‘warm up’ their responses to their child. This may be as simple as sitting the child close and watching a film with them. An important feature of the intervention is to change a reaction into a response; a reaction being almost instinctive and a response being more controlled and considered. The latter has the potential to give parents more control, empowerment and confidence. In the on going work staff would review the parents’ use of the strategies and provide further advice as necessary.
The aim of the pilot project was to see if the use of CZ4C was feasible, acceptable and useful to both staff and parents.
Method Piloting the intervention The initial piloting of the Comfort Zone was conducted as a service development with a Barnardo’s Family Support Team in England who were working on an outreach basis from a children’s centre with parents who had at least one preschool child. The focus groups established to evaluate the service development followed ethical principles, including full explanation in advance, an ‘opt-in’ approach with participation as entirely optional, an external facilitator, informed consent and anonymity of participants. In autumn 2009 the staff received training that included the model of attachment theory and how to use the CZ4C intervention. They were given a training manual and a leaflet to help explain CZ4C to parents. From January 2010 staff were asked to consider using the intervention with all new referrals. Referral criteria at this point included any parent that might benefit from any children’s centre service even universal services, such as playgroups. Staff were asked to record the parents’ ratings of their response to their child before and after the intervention. Staff recorded this on the colour bar which, for ease of use, was included in Barnardo’s recording system. This allowed for an examination of pre and post intervention ratings. Staff received supervision of the work through monthly group supervision sessions with the first author in addition to their individual supervision with the team manager. The use of the intervention was monitored through this process and amended as necessary through the pilot year.
Evaluation The pre-post self-ratings of parents on CZ4C were collated. To quantify the changes made
R4
R3
R2 R1
0
B1
B2
B3
following the intervention numerical values were given to all the colours (see Figure 2). After the one-year pilot two focus groups, one with staff and one with parents, were arranged to explore participants’ experience of using the intervention. The facilitators (SC and KF) were independent of the development and intervention. The team manager was also interviewed for her views. All interviews were recorded, transcribed and themes emerging from the discussion were explored by the facilitators.
Results Pre-post intervention evaluation In the first instance staff were asked to use CZ4C with all new referrals to their service. However, it became apparent from the initial review of the data at six months that some data were included for parents who did not fit the pilot remit; ie, those being signposted elsewhere. These data were not included in the results and the criteria for using CZ4C altered so that it was only offered to parents who were referred for a Family Support Team intervention. Figure 3 is a summary of the parents’ scores before and after the intervention. Full data sets were available on 26 parents, all mothers. In the pre-intervention data 13 parents rated themselves toward the blue/cold zone and 13 toward the red/hot zone with no parents rating themselves in the Comfort Zone. Post intervention more parents rated themselves closer to the Comfort Zone with 10 parents ratings in the central Comfort Zone and 11 rating themselves just one point away (B1=6 and R1=5) at the end of the intervention. Figure 4 shows the direction and magnitude of change in more detail. It can be seen that for seven (three in red zone and four in blue zone) out of 26 parents the approach was not successful as there was no change. A total of 12 parents managed a one point change in the direction of the Comfort Zone (seven from the red and five from the blue zones) Five parents felt they had made a more substantial change of two points, (two from the red zone and three from the blue zone). One parent felt they had moved three points from the blue zone and one other rated themselves as having moved from the extreme red four points to the Comfort Zone.
B4
Staff feedback Figure 2. Numerical values assigned to the colours
In March 2011 a staff focus group was conducted with the Family Support team. In
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parent sometimes”. I think it is a really useful, easy to read, easy to understand, universal tool’.
Pre score 1
5
3
4
0
6
3
3
1
Post score 0
3
0
5
10
6
1
1
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Figure 3. Summary of pilot data. Number of parents rating their response to child at each colour pre- and post-intervention (n=26)
brief, the main areas explored in the discussion were the fit between CZ4C and their work, the strengths and weaknesses of the intervention, areas where they felt it could be useful and suggestions for improvement. The perceived strengths of CZ4C were most apparent when the key presenting difficulty was clearly identified as an issue between parent and child, eg the parent describing themselves as feeling cross with the child. They felt that CZ4C could best be seen as a way of thinking and encouraging parents to think about their feelings. They were particularly positive about the link between the colours and the list of strategies provided to enable parents to ‘warm-up’ or ‘cool-down’. One member of staff said: ‘I think it is a really useful universal tool for all parents. I’ve had colleagues sat in the office and seen it on my desk and said, “Phew, I could do with that on my fridge, I could do with it as a
One problem staff identified was not with CZ4C, but with the protocol that required them to use CZ4C with all parents. This seemed inappropriate as some parents merely needed signposting to other services. As previously stated the protocol was changed so that CZ4C was only used for parents referred for a Family Support Team intervention. Staff reported difficulties in explaining the relevance of CZ4C to some parents. They said that if a child was referred with a sleep problem the parent would expect a solution rather than a discussion about attachment. Indeed, there was some confusion in the staff group about whether CZ4C was about parental feelings or responses Staff said it was sometimes difficult helping parents with their ratings as sometimes the emotional issues which were raised by using CZ4C felt beyond their remit and training.
Feedback from the Family Support Team manager The Family Support Team manager reported the purpose of using CZ4C as being to provide ‘the building blocks of working with parents and looking at their relationship with their child’. She said it gave staff ‘a tool that they could use to enhance what they were already doing. To build relationships with parent and child before we entered into any kind of behaviour management’. As the pilot progressed she
Figure 4. Points change post-intervention in the red and blue zones (n=26)
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saw that the CZ4C could be used both before behavioural programmes and alongside them. She reported that in her judgement it enhanced the work of programmes such as Triple P (Saunders, 1999). The team manager acknowledged the timing of the pilot had been challenging with staff perceiving it as ‘another thing to do’. She suggested that for some staff the introduction of CZ4C had been a rollercoaster, while for others it had been more straightforward. Her view was that the more confident and experienced staff embedded it in their practice quickly while the newer less experienced staff struggled with this a bit more.
Parents’ feedback All 26 parents who had received the CZ4C were invited to take part. Nine parents took part in the interviews. There were two small groups and one parent opted to be interviewed separately. One parent commented that with regard to finding their zone, ‘the worker did not say anything, it was about me’. One parent said that it did not help and another said she could not remember it. Four parents reported the colour key as the most helpful aspect of the intervention – they found the colours made sense. The phrase ‘it is up to you’ was a turning point for one parent who said, ‘I realised only I could change my life’. The parents thought that the colours were good and represented moods well: ‘Red is an angry colour and blue is a down colour’, so they could see that it was about ‘how you feel from 1 to 10’. They understood that they had to ‘stay away from the red/blue bit’ as much as they could and to stay in the middle zone as much as possible. They thought that the colours related to mood, connected to how they were feeling, and made sense. They found it easy to rate themselves on the scales, although sometimes it was hard to visualise where they were on the scale. They thought the colours were ‘more than words’. Parents gave examples of strategies that had been given as part of the CZ4C work they used, ‘singing songs on the way to school ... if you are calm they are calm’ and taking ‘time out’ – removing themselves for a moment to reflect on behaviours of themselves and their children to decide which strategy would work best. Other positive reflections included that parents felt that CZ4C fitted with other
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Key points l The
concepts of colour and temperature are added to attachment theory to increase parental understanding l The aim of the pilot was to see if a tool to enhance parental attunement was acceptable l Although the study was limited, initial data were encouraging l Hypothesised links between attunement and attachment require further research
parenting interventions, such as Triple P. One parent said that, of all the interventions she had experienced, CZ4C had impacted most. One interviewee developed her own statement: ‘Just think yellow’. Another said she used it to reflect on what went wrong and how it could be put right. One parent said, ‘I would have loved it from day one’.
Discussion The aim of this study was to see if CZ4C was feasible, acceptable and useful for parents and staff. Although there are several limitations to the study, the initial findings are encouraging. The limitations include lack of time to train staff, the absence of a control group and objective measures. There was also potential for bias in terms of confounding variables affecting parents’ ratings and parents who were self-selected for the focus groups. However, parents reported that CZ4C was simple, visual and easy to understand. The focus on colours functioned really well in conveying an idea, without getting caught up in language. They found the intervention strategies helpful and seemed to have grasped that they were to ‘warm-up’ or ‘cool-down’ to spend as much time as possible in the central zone. The Family Support Team Manager was also positive about the intervention, particularly its usefulness preceding and alongside a behavioural programme. CZ4C focuses on emotional attunement, which may complement behavioural interventions. Perhaps they are useful together, reflecting the tasks of parenting to provide both nurture and discipline. She acknowledged that some staff felt they did not have enough training; however, the importance of staff experience and confidence was also mentioned. Indeed, the range of issues that might be raised as parents consider their emotional responses needs experienced staff to recognise and signpost elsewhere as necessary. The staff team valued CZ4C as an easy to understand universal tool with helpful
strategies for discussions about parent–child relationships. However, there was clearly some ambivalence, particularly where the nature of the relationship was not articulated by parents as a focus for help. Nevertheless, it is acknowledged that whatever parents may initially expect, insight into their responses may assist them to address behavioural difficulties. Other interventions also stipulate the importance of the parent–child relationship as being fundamental and in need of attention before behavioural work is undertaken (eg, Solihull Approach) (Douglas, 2001). CZ4C may be worth assessing as a preventive early intervention tool to educate parents about the importance of their emotional responses both antenatally or early postnatally. Staff were concerned about the accuracy of their ratings as they might only have an hour a week to observe parental responses. This difficulty might be addressed through more intensive training. However, over the year of the pilot the parental ratings of their responses were increasingly toward the extremes of the scale, perhaps indicating in part staff members’ increased capacity to have difficult conversations with parents. There was some confusion about whether ratings should reflect parents’ feelings (internal) or responses (external). Again, further training might help clarify that ratings should be based on parents’ emotional responses to their child. It was intended that parents use the colours to reflect on and change responses through the use of strategies so that they were more attuned to the child. It is hypothesised that this may help promote secure attachments.
Conclusion More work is needed on the impact of CZ4C, but pre- and post-intervention scores indicate progress is heading in the desired direction. In addition to its use in preventive work the CZ4C scale could help increase the skills of practitioners working alongside parents. The intervention is based on an emotional
rather than behavioural approach, providing practitioners with a wider variety of skills to use with parents. If further research indicates that CZ4C is robust and clinically useful, the focus groups suggested it may be of use in health visiting, CAMHS, schools, Surestart centres and children’s services. Further work is needed on these options as well as the relationship of CZ4C to attunement and attachment.
Acknowledgements The authors are grateful for the support of staff and parents who took part in this service evaluation. In particular, we would like to thank Julie McVeigh (Assistant Director), the Family Support Team Manager and the Family Support Teams. We would also like to thank Dr Mike Robling (Associate Director South East Wales Trials Unit) for his guidance and advice.
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