The feasibility of a randomised controlled trial of Dyadic Developmental Psychotherapy

Family-based psychological interventions for domestically adoptive families: a systematic review

Adopted children are often at a risk of experiencing several neurobiological and psychosocial difficulties. Adoptive parents must support these difficulties whilst managing their own idiosyncratic challenges. Family-based psychotherapeutic interventions which promote adoptive family functioning, environments and relationships can mediate these difficulties for adopted families. This review synthesises evidence exploring family-based psychological interventions for adoptive families, appraises the literature's strengths and weaknesses, and reports characteristics of promising interventions. Included studies recruited domestically adoptive families receiving psychotherapeutic interventions delivered to at least one adoptive parent and child. The authors searched seven electronic information databases, four grey literature databases, two journals and five relevant websites up to 12.12.2022. The quantitative Risk of Bias in Non-Randomised Studies of Interventions tool and the qualitative Critical Skills Appraisal Programme checklist assessed risk of bias. The narrative synthesis presents 20 papers detailing 18 studies involving at least 729 adopted children and 829 adoptive parents. Findings provide preliminary support for integrative interventions which include aspects of sensory activities, attachment-based play, Dyadic Developmental Psychotherapy and Eye Movement Desensitisation and Reprocessing with Therapeutic Input provided to adopted children and adoptive parents separately, alongside the adoptive family. However, risk of bias was high, limiting the conclusions. Future research should examine the feasibility, acceptability and efficacy of integrative therapeutic approaches for adoptive families to further direct clinical practice.

Online therapy with families - what can families tell us about how to do this well? A qualitative study assessing families' experience of remote Dyadic Developmental Psychotherapy compared to face-to-face therapy

Dyadic Developmental Psychotherapy (DDP) is a family-based therapy for adopted children aiming to achieve secure attachment between the child and parent. Due to restrictions under the COVID-19 pandemic, delivery of DDP transitioned from face-to-face to online methods. This study aimed to explore families experience of online DDP compared to face-to-face DDP, looking at the advantages and disadvantages of remote delivery methods and the implications this has on future service delivery for clinicians. Semi-structured interviews with 6 families were conducted online. Analysis of transcripts using Interpretative Phenomenological Analysis (IPA) revealed four superordinate themes: environment and child engagement, non-verbal communication, travel and familiarity with remote interactions. Parents recognised the influence the physical and online environment had on their child's engagement levels, however, varied in their experience and hence preference of delivery method. All families emphasised the importance of non-verbal communication within DDP sessions and majority highlighted this may be lost online. For families who travelled to face-to-face DDP, car journeys provided a unique opportunity to decompress and reflect after sessions. For families where travel is unfeasible, online DDP was a lifeline, demonstrating the ability of remote therapy to widen access to specialist healthcare. Familiarity with online work emerged as a strong indicator of positive attitudes towards remote DDP, especially if the previous experience is positive and the child is confident using technology. Overall, families differed greatly in their experience of remote and face-to-face DDP indicating a new approach must be undertaken with each family beginning therapy, ensuring it is unique and individual to their needs.

Differences in the diagnosis and treatment decisions for children in care compared to their peers: An experimental study on post-traumatic stress disorder

OBJECTIVES

Despite evidence of high rates of diagnosable mental health difficulties in children in care, there remains ongoing debate around the appropriateness of traditional diagnoses and treatments. The aim of this study was to quantitatively explore whether mental health diagnosis and treatment decision-making differed when a young person was identified as being in care, specifically focused on post-traumatic stress disorder (PTSD). PTSD is a trauma-specific mental health disorder with rates substantially higher in children in care versus their peers.

METHODS

Participants were 270 UK mental health professionals who completed an online survey. Participants were randomized to receive one of two vignettes, which were identical in their description of a teenage boy experiencing PTSD symptoms, except in one he was in foster care and in the other he lived with his mother. Participants were asked to select a primary diagnosis, treatment approach, and potential secondary diagnosis.

RESULTS

Professionals were twice as likely to choose a primary diagnosis of PTSD and a National Institute for Clinical Excellence (NICE)-recommended PTSD treatment when randomized to the mother vignette versus the foster carer vignette. Selecting PTSD as the primary diagnosis made clinicians three times more likely to select a NICE-recommended treatment for PTSD. Developmental trauma was the most common 'diagnosis' for both groups, although this led to different treatment decisions.

CONCLUSIONS

In the context of PTSD, we found children in care face diagnosis and treatment decision-making biases. Practice implications are discussed.

Nurturing attachments group: A virtual group intervention for adults caring for traumatised children in the context of COVID-19

Background: Evidence indicates that the more traditional and behavioural parenting strategies are ineffective when parenting a child who has experienced developmental trauma. Recognising the need to parent with an attachment focus, the current paper evaluates the effectiveness of running the [Enfys] Nurturing Attachments Group, virtually, within the context of the COVID-19 pandemic. Method: A pilot feasibility study evaluated eight bespoke groups. Consenting professionals and co-professionals completed the Brief Parental Self-Efficacy Scale (BFSS), Care Questionnaire (CQ) and the Parental Reflective Functioning Questionnaire (PRFQ). Results: One hundred forty individuals attended the groups, with 51 (36%) completing both pre-and post-measures. The results provide evidence that professionals and co-professionals reported statistically significant positive increases on both the BPSS (d = .55) and CQ (d = .62). For the PRFQ, the results showed a statistically significant decrease on the Pre-mentalising sub scale, a non-significant mid-range score for Certainty about Mental States and a non-significant increase for Parental Interest and Curiosity in Mental States. Conclusion: The study has demonstrated initial viability of effectively facilitating the [Enfys] Nurturing Attachments Group, virtually. Importantly, it has also shown that the group can be run with professionals alongside co-professionals.

Mental health services for children in care: investigation to elicit outcomes of direct and indirect interventions

AIMS AND METHOD

The aim of this study was to compare the efficacy of direct therapy and indirect consultation for treating mental health difficulties among looked after children (LAC), and also to identify any demographic or clinical predictor variables for outcomes in this cohort. A retrospective evaluation of mental health outcomes for 104 LAC was conducted. All children received network consultation in combination with or without direct therapeutic work. Outcomes were compared between the groups with and without direct therapeutic intervention.

RESULTS

Those receiving both treatments displayed significantly greater Strengths and Difficulties Questionnaire (SDQ)-rated improvements than those receiving just consultation. Nonetheless, improvements in scores for the latter group were significant relative to baseline. Treatment duration, younger age at referral and start SDQ were all correlated with positive outcomes, while number of address changes predicted higher start SDQ scores.

CLINICAL IMPLICATIONS

Despite the retrospective design of this study, its results can be considered as preliminary findings to guide treatment decisions in LAC.

Adoptive parents' experiences of dyadic developmental psychotherapy

Dyadic developmental psychotherapy (DDP) is an attachment-focused therapy frequently used with adoptive and foster families. While the evidence base for DDP is building, national guidance has called for further trials and qualitative evidence. This study aimed to understand the experience of adoptive parents who have completed DDP therapy. Semi-structured interviews with 12 adoptive parents were analysed using interpretative phenomenological analysis. Four superordinate themes were identified: (1) increased understanding, (2) 'It's a different method of parenting generally', (3) the DDP journey and (4) 'It's a shared kind of experience you go through and come out together'. Parents felt they had increased insight into their child's mind and how to better support their child. They felt DDP was a good fit to their unique situations and it appeared to promote acceptance. The DDP journey started with parents feeling uncertainty and questioning the effectiveness of DDP. However, generally parents became committed to the therapy once they saw change and expressed fear and sadness at ending. Parents acknowledged the dyadic nature of DDP, feeling it helped build trust and security and supported co-regulation. Parents also acknowledged the therapist's role in conveying the core DDP principles. Further implications for practice and research are highlighted.

A qualitative exploration of the experiences of adoptive parents attending 'Nurturing Attachments', a dyadic developmental psychotherapy informed group

Children who are adopted have frequently experienced a range of aversive experience which impact on their ability to form secure attachments. Dyadic Developmental Psychotherapy (DDP) is an intervention designed to develop and promote secure attachments with children who have experienced developmental trauma. Eight adoptive parents participated in semi-structured interviews regarding their experiences of attending the 'Nurturing Attachment' group informed by DDP. The transcripts of their interviews were explored using Interpretative Phenomenological Analysis. The analysis revealed five inter-connected superordinate themes which were as follows: A supportive group, A shift in perspective, 'Turning trauma into secure attachment', 'Am I doing it right?' and Continuing the adoption journey. Themes are considered in relation to the theoretical underpinnings and practice of DDP. Some further implications for clinical and research practice are also discussed.

A focused ethnography of a Child and Adolescent Mental Health Service: factors relevant to the implementation of a depression trial

BACKGROUND

Prior to commencing a randomised controlled trial, we conducted a focused ethnography to ensure that the trial was well suited to the proposed setting.

METHODS

A six-month observation of a Child and Adolescent Mental Health Service site in the North-East of England was undertaken to observe the site procedures, staff culture and patient care pathways. During this period, documentary data were collected and interviews were conducted with key informants to provide insight into staff perceptions of the proposed trial. The data were coded using thematic analysis and the resulting themes were verified by a second coder.

RESULTS

Seventeen documents were collected, 158 h of observation and six formal staff interviews were undertaken. Four themes emerged from the data; non-clinically orientated variation in practice, diagnosis, capacity and staff economy. Non-clinically orientated variation in practice occurred when staff decisions were based upon resource availability rather than on clinical judgement. Diagnosis demonstrated differing staff confidence in making diagnoses and in the treatment of patients who had received a diagnosis. Capacity consisted of the time to attend training and the psychological capacity to consider or incorporate learning into practice. Staff economy was characterised by staff changes and shortages. There was significant interaction between the themes, with staff economy emerging as a central barrier to research. The results directly informed adaptations to the trial protocol.

CONCLUSIONS

An ethnographic approach has provided important insights into the individual, practical and organisational boundaries into which a trial would need to be implemented.

Evidence-Based Parenting Interventions to Promote Secure Attachment: Findings From a Systematic Review and Meta-Analysis

Various interventions are used in clinical practice to address insecure or disorganized attachment patterns and attachment disorders. The most common of these are parenting interventions, but not all have a robust empirical evidence base. We undertook a systematic review of randomized trials comparing a parenting intervention with a control, where these used a validated attachment instrument, in order to evaluate the clinical and cost-effectiveness of interventions aiming to improve attachment in children with severe attachment problems (mean age <13 years). This article aims to inform clinicians about the parenting interventions included in our systematic review that were clinically effective in promoting secure attachment. For completeness, we also briefly discuss other interventions without randomized controlled trial evidence, identified in Patient Public Involvement workshops and expert groups at the point our review was completed as being used or recommended. We outline the key implications of our findings for clinical practice and future research.

Examining the feasibility of an economic analysis of dyadic developmental psychotherapy for children with maltreatment associated psychiatric problems in the United Kingdom

BACKGROUND

Children with maltreatment associated psychiatric problems are at increased risk of developing behavioural or mental health disorders. Dyadic Developmental Psychotherapy (DDP) was proposed as treatment for children with maltreatment histories in the USA, however, being new to the UK little is known of its effectiveness or cost-effectiveness. As part of an exploratory study, this paper explores the feasibility of undertaking economic analysis of DDP in the UK.

METHODS

Feasibility for economic analysis was determined by ensuring such analysis could meet key criteria for economic evaluation. Phone interviews were conducted with professionals (therapists trained and accredited or in the process of becoming accredited DDP practitioners). Three models were developed to represent alternative methods of DDP service delivery. Once appropriate comparators were determined, economic scenarios were constructed. Cost analyses were undertaken from a societal perspective. Finally, appropriate outcome measurement was explored through clinical opinion, literature and further discussions with clinical experts.

RESULTS

Three DDP models were constructed: DDP Full-Basic, DDP Home-Based and DDP Long-Term. Two potential comparator interventions were identified and defined as Consultation with Carers and Individual Psychotherapy. Costs of intervention completion per case were estimated to be: £6,700 (DDP Full-Basic), £7,100 (Consultations with Carers), £7,200 (DDP Home-Based), £11,400 (Individual Psychotherapy) and £14,500 (DDP Long-Term). None of the models of service delivery were found to currently measure effectiveness consistently. The Strengths and Difficulties Questionnaire (SDQ) was deemed an appropriate primary outcome measure, however, it does not cover all disorders DDP intends to treat and the SDQ is not a direct measure of health gain. Inclusion of quality of life measurement is required for comprehensive economic analysis.

CONCLUSIONS

Economic analysis of DDP in the UK is feasible if vital next steps are taken to measure intervention outcomes consistently, ideally with a quality of life measurement. An economic analysis using the models constructed could determine the potential cost-effectiveness of DDP in the UK and identify the most efficient mode of service delivery.