Title: A feasibility study and pilot trial of a modified video-feedback intervention for children and foster carers to improve mental health outcomes of children with reactive attachment disorder.
Funder: Department of Health and Social Care

Abstract: DESIGN: The study will comprise 3 interlinked phases. We will adapt and manualise the proposed intervention (Phase 1), then train CAMHS professionals to deliver it to a case series of foster carers and children (Phase 2). In phase 2 we will also conduct a scoping study of key implementation parameters, including engagement of local authorities, recruitment and consenting strategies, and the utility and acceptability of a screening system for Reactive Attachment Disorder (RAD). Finally we will conduct a pilot RCT of the proposed intervention, assessing key outcome parameters, treatment acceptability and monitoring usual care (Phase 3). SETTING: Outpatient CAMHS in five NHS Trusts and their partner social services departments. Sites will include urban (Greater London) and rural (Yorkshire) areas. TARGET POPULATION: Foster carers with fostered children with symptoms of Reactive Attachment Disorder (RAD) aged 6 and under. EXCLUSION CRITERIA: Parental figure: (a) insufficient language or cognitive abilities to participate fully in trial procedures; (b) already engaged in similar parenting intervention. Child: (a) severe developmental disability. HEALTH TECHNOLOGIES: We will adapt and manualise a well-established attachment-focused intervention, Video Feedback to Promote Positive Parenting (VIPP) to meet the needs of fostered children with RAD, in order to (a) improve the sensitive responding of foster carers, (b) improve the consistent responding of foster carers to challenging child behaviour, c) improve RAD symptoms and child mental health outcomes. VIPP will be compared with usual care. CARE PATHWAYS: there are no established pathways for RAD. Provision in CAMHS and social care is mixed and limited. MEASUREMENT OF COSTS AND OUTCOMES: Costs: Child and Adolescent Service Use Schedule (CA-SUS) to measure use of all health, social care and preschool education based services and to support the description of usual care. Screening: Attachment Screening Assessment, DAWBA DSM-5 RAD module. Primary outcomes: 1) Disorders of Attachment Interview, RAD symptom scores. Secondary outcomes: Strange Situation Procedure, DAWBA, Child Behaviour Checklist, Observed sensitivity of parenting (Emotional Availability Scales), Alabama Parenting Questionnaire, Parenting Stress Index, Goal-based outcomes assessment. SAMPLE SIZE: In Phase 2, there will be 6 single case studies, complemented by detailed interviews with participants, therapists and carers. In Phase 3, N=40 will be randomised to VIPP-Foster Care or Treatment as Usual (TAU). ANALYSIS: Feasibility parameters (means, proportions, variance estimates) will be assessed using 95% confidence intervals. Mixed methods will be used to address questions regarding stakeholder and foster carer perceptions of treatment acceptability and delivery. TIMETABLE: The project will run for 30 months. Phase 1 (4 months) will adapt and produce intervention manuals. In Phase 2 (6 months) we will train therapists, undertake initial feasibility testing and further examine key implementation parameters. Phase 3 (20 months) will be a pilot RCT, with 12-months for recruitment, 4 months for treatment and outcome assessment and 4 months for final analysis and dissemination. TEAM EXPERTISE: Our strong team multidisciplinary team has expertise in parenting interventions, attachment disorders, child mental health, service user involvement, clinical trials, qualitative methods and health economics.

Lay abstract: Children in foster care have typically had a very difficult start in life, as a result of abuse and/or neglect within their family of origin. For these children it is often difficult to trust new adults, which may lead to difficulties in their relationships with new carers when they enter foster care - such as being unable to form a secure emotional bond with their carer (known as an ‘attachment’). Some children in foster care have such severe problems in this area that they may qualify for a clinical diagnosis of what is termed Reactive Attachment Disorder. Reactive attachment disorder refers to a pattern of behaviour among young children who have been exposed to extremely insufficient early care in which they fail to seek or respond to comfort from carers when hurt or distressed, and are highly socially and emotionally unresponsive and withdrawn. Having reactive attachment disorder can limit the benefits these children might otherwise experience from foster care; it also places them at risk of serious longer-term behavioural problems, emotional disturbance and placement breakdown. While there are a small number of promising treatments for improving some of the attachment difficulties that foster care children experience, unfortunately there are no evidence-based interventions available for treating reactive attachment disorder. Video feedback Intervention to Promote Positive Parenting (or 'VIPP') is a method that has been developed to promote secure attachments in young children and help parents deal with disturbed and difficult behaviour by increasing the sensitivity and responsiveness of their parenting. In light of its strong evidence base, VIPP is one of the treatments recommended by the UK’s National Institute for Health and Care Excellence for children showing signs of attachment problems who are adopted or in kinship or foster care. VIPP has recently been modified specifically for the foster care context by its developers in the Netherlands. This modified programme ('VIPP-Foster Care') pays particular attention to the need to help carers recognise signals that are specific to foster children--that may be quite challenging and difficult to understand--so that they are better equipped to respond sensitively, and to support the child’s secure attachment to them as their carer. In our research we will work with the developers, leading experts and experienced practitioners, to further modify VIPP-Foster Care to ensure that it appropriately addresses the needs of young children in foster care with reactive attachment disorder, and that it is suitable for use in a UK health and social care context. Our research will also involve foster carers in developing this adapted version of VIPP. We will then work with local authorities and Child and Adolescent Mental Health Services to develop a system for identifying young children in foster care in need of this intervention, train a small team of practitioners to deliver it, and conduct a small (pilot) study to gather information about the best way to provide VIPP-Foster Care for children with reactive attachment disorder in foster care. By rigorously studying and documenting the challenges and solutions at each stage of the process, we will obtain detailed information about how best to conduct a larger (full-scale) study to test how effective VIPP-Foster Care is for resolving symptoms of reactive attachment disorder in children in foster care, and if it offers good value for money.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH