An intervention- based diagnostic instrument to assess parenting potential in child protection cases: improving the quality of decision making.

Decisions about families.
Decisions about out- of- home placement of the child, custody, or termination
of parental rights have enormous consequences for both parents and children.
These decisions are often based on clinical evaluations of parenting
capacities. It is crucial for both the child and the parents that a careful
evaluation of the parents* capacities to take care of the children is
performed. Unfortunately, most assessments of parenting capacities are not
evidence-based. This is also true for the Netherlands. In addition, substantial
limitations of diagnostic evaluations in child abuse cases have been reported,
such as using only a single session, no home visit, little use of behavioral
observations, and no description of the parent*s caregiving qualities or the
child*s relationship with the parent. In addition, it has been shown that
professionals can be reluctant to revise their initial judgments despite
evidence against these judgments.

To be able to empirically test the effectiveness of parenting capacity
assessments in order to have evidence-based methods for diagnosis, a framework
for conceptualizing parenting capacity assessments is needed. Budd (2001; 2004)
lists three core characteristics of these assessments: focus on parenting and
the parent-child relationship, functional competence (emphasizing behaviors and
skills in everyday performance), and a minimal, or good-enough, parenting
standard. Additionally, the American Psychological Association has developed
guidelines for psychologists conducting evaluations in child protection cases.
One of the recommendations listed in these APA Guidelines for Evaluations in
Child Protection Cases is: *In evaluating parental capacity to care for a
particular child or assessing the child-parent interaction, psychologists make
efforts to observe the child together with the parent in natural settings as
well as structured settings.* It is also recommended that *the current and
potential functional abilities of the parent(s) to meet the needs of the child*
should be assessed. Taken together, it is proposed that parenting capacity
assessments should include observations of the parent-child relationship in
everyday situations in order to assess whether a minimal parenting standard is
met and whether the parent has the potential to meet this minimal parenting
standard.

Harnett (2007) has proposed a procedure to assess these potential functional
abilities. He lists four steps in the assessment of the parents* capacity to
change: 1) carrying out a cross-sectional assessment of the parents* current
functioning, 2) specifying operationally defined targets for change, 3)
implementing an intervention with proven efficacy for the client group with a
focus on achieving identified targets for change, and 4) the objective
measurement of progress over time including evaluation of the parents*
willingness to engage and cooperate with the intervention and the extent to
which targets were achieved.

Good-enough parenting.
Another important question is what constitutes good-enough parenting. In
addition to physical safety, research has shown that one of the most important
core components of parenting is the ability to provide emotional safety or
security. Based on attachment theory, one of the most influential theories in
the area of child development, a competent parent is able to respond to the
child*s emotional and physical needs and adapt to the child*s developing
capacities in a changing environment (Ainsworth et al., 1974) also defined as a
sensitive parent. Parental sensitivity to the child*s emotional and physical
needs fosters the development of a secure relationship between the child and
the parent, which is predictive of a large number of positive developmental
outcomes (Sroufe et al., 2005). In line with this, Juffer argues that the
quality of the parent-child relationship and the parent*s capability of
responding sensitively to the child should be an essential factor in child
protection decisions.

Evidence-based interventions
To be able to assess improvement in the parent*s capacity to provide security
for the child, evidence-based interventions are needed. Unfortunately, the
number of evidence-based parenting interventions in the Netherlands is
alarmingly low. The Video-feedback Intervention to promote Positive Parenting
and Sensitive Discipline (VIPP-SD) is one of the few evidence-based
interventions in the Netherlands. This program aims at improving the parents*
sensitivity and sensitive discipline in order for the parent to be able to
provide emotional security for the child. VIPP-SD consists of six home visits
during which the parent and the child are being video- taped. Research has
shown that this intervention has positive effects on parenting and on reducing
child problem behaviors, in particular in families with marital problems and
high levels of daily friction.

A Canadian research group has recently tested the effectiveness of an
intervention based on and similar to VIPP-SD. They included families with
substantiated child maltreatment. These families, with 1-5-year-old children,
were randomly assigned to the intervention and a care-as-usual condition. They
found the intervention to be effective in improving parenting skills and the
quality of the parent-child relationship even in maltreating families.

VIPP-SD as a tool for assessing the parents* capacity to improve.
VIPP-SD would be a good candidate to also function as a diagnostic instrument
for assessing parental capacity to improve (see also Lindauer et al., 2010 ;
Van IJzendoorn & Bakermans-Kranenburg, 2010). It is currently the only
parenting intervention in the Netherlands that would be suitable for use as a
diagnostic tool. It offers the opportunity to assess current functioning and
parental behavior that needs to be targeted and to improve these targeted
behaviors in a relatively short period of time. With the addition of objective
measures of progress over time, it meets Harnett*s (2007) four steps in the
assessment of the parents* capacity to change (see above).

Indeed, the Canadian research group has explored ways to use the intervention
as a diagnostic instrument. At the Clinic for the assessment and intervention
of young children and their families at the Child Protection Services of
Montreal-University Institute (CPS-UI) they developed a protocol for assessing
the parenting capacity of parents of young children who have been reported for
child maltreatment. They integrated the short-term parenting intervention into
their protocol to assess parenting capacity and are currently investigating the
effectiveness of this protocol. They asked the evaluators from this and a
standard protocol about the improvements observed in the parent-child
relationship and the usefulness of the protocol for assessing parenting
capacity. The researchers found that evaluators of the intervention based
assessment protocol observed significantly more positive changes in the family
as compared to the evaluators of the standard assessment protocol. A logical
and necessary next step in this line of research would be to evaluate whether
decisions based on an intervention based protocol are more reliable and
actually lead to better outcomes for both the children and parents.

Stressregulation and parenting.
Parents in child protection cases can be challenged with different problems and
stressors, for instance financial problems, psychopathology of the parent, the
experience of stressful life events and/or problems in the parent- child
relationship. The way parents regulate their stress is an important factor in
insensitive parenting. It is argued that parents who use harsh discipline might
lack the skills that are necessary for sensitive parenting (Milner, 1993;
2003), which could be linked to physiological differences between sensitive and
insensitive parents (Joosen et al., 2012). Several studies have shown that
abusive parents have difficulties regulating the stress they experience in
reaction to child signals (McCanne & Hagstrom, 1996). For example, Out et al.
showed that stress hyperreactivity to infant cry sounds was associated with
intended harsh caregiving responses (Out, Bakermans-Kranenburg, Van Pelt, & Van
IJzendoorn, 2012). In addition, Joosen et al. reported that stress
hyperreactivity to infant cry sounds predicted harsh discipline during
mother-child interactions nine months later (Joosen, Mesman,
Bakermans-Kranenburg, & Van IJzendoorn, 2013).

The proposed study will test whether the intervention-based parenting
assessment of the parents* capacity to improve (VIPP-APP; Video-Feedback
intervention to promote Positive Parenting for the Assessment of Parenting
Potential) contributes to improved decision making in a child protection
context. The aims of the study are as follows:
1. To test whether children with an advice about out-of-home placement based
on VIPP-APP will show fewer emotional and behavioral problems in comparison to
children with an advice based on regular assessments.
2. To test whether the advice about the necessity of out-of-home placement
based on initial assessments are more often modified by professionals after
VIPP-APP.
3. To test whether professionals feel more certain about their advice
following VIPP-APP as compared to regular assessments.

This study is based on a RCT with an experimental and control group. Families
who are referred to one of the four family psychiatric facilities in the
Netherlands for an evaluation of their parenting capacities in the context of
an out-of-home placement decision with a child between the age of 0-6 years old
will be recruited. If the parents give informed consent to participate in the
study, they will be included and randomly placed in one of the two treatment
groups. In week 1 mother and child will be asked to participate in a pre-test,
to assess different parent and child factors. The family therapist will be
asked to formulate a preliminary advice about the placement decision for the
child. The treatment, either the treatment with VIPP-APP or the care as usual,
will start after the pre-test and will take place from week 2-7. In week 8 a
post-test will take place to measure the same aspects of the mother and child
as in the pre-test. The family worker who works with the family will be asked
to formulate a final advice about the placement of the child. After six and
twelve months, two follow-up assessments will take place, either through home
visits or phone calls, depending on the parents' preference. During these
assessments an interview is conducted and questionnaires are filled out by the
parents, and, in case the child is living in a foster family, by the foster
parents.

A flow chart of the study design is provided on page 16 of the research
protocol.

The intervention method used in this study is called the Video- feedback
Intervention to promote Positive Parenting for the Assessment of Parenting
Potential (VIPP-APP). The VIPP-APP is based on the VIPP-SD (Video- feedback
Intervention to promote Positive Parenting and Sensitive Discipline), a
preventive intervention aimed at parental sensitivity and sensitive discipline,
which in turn will improve the parent- child relationship and interaction and
will prevent or decrease behavioural problems in young children. The VIPP-APP
is an adapted version of the VIPP-SD for families in a child protection context.

The themes of the VIPP-SD are:

Themes based on parental sensitivity:
1. Exploration versus attachment behavior: teaching parents the difference
between the exploratory play of the child and contact seeking of the child,
with an explanation of the different reactions the parents can provide.
2. *Speaking for the child*: to make the parent aware of the subtle signals of
their young child.
3. Sensitivity chain: showing the importance of prompt and adequate responses
of the parent to the signals of the child in a chain of sensitivity: the
child*s signal, the parents sensitive response and the child*s positive
reaction to the sensitive response of the parent.
4. Sharing emotions: stressing the importance of sharing positive and negative
emotions between parent and child.

Themes based on sensitive discipline:
1. Inductive discipline and distraction: showing that induction (explaining why
something is not allowed) and distraction can be used as noncoercive responses
to difficult behavior of the child.
2. Positive reinforcement by rewarding positive behavior of the child and
ignoring the negative attention seeking of the child.
3. The use of a sensitive time- out to deescalate the child*s temper tantrums.
4. Focusing on empathy for the child from the parent and clear limit setting
for the child.

The last two sessions (session 5 and 6) will be used to integrate all the
previous themes and advice.

A more detailed overview of the VIPP- APP is provided in the research protocol
on page 20-22.

The families will be asked to fill out questionnaires, participate in
observational tasks and physiological measures that are not intrusive or
dangerous. The researchers and family workers in the facility will make sure
participants can ask questions and everything will be explained carefully. The
pre- and post-test will take 1 hr for the child and 1.5 hr for the mother and
will take place in the facility were the families are staying. The two
follow-ups will take half an hour each. The 6 VIPP- APP sessions will take 1.5
hr each in a time span of 6 weeks. If the mothers encounter difficult themes or
feelings, they will be supported by the family workers and psychiatrist if
needed. The video-taping might be confronting for some mothers, but this method
is also used in the therapy settings for the control group. Family workers that
encounter difficulties are able to share these issues in meetings that will be
held frequently with the researchers and other family workers.
Other studies that investigated the VIPP, or similar interventions, in samples
of abusive mothers show no negative consequences of the intervention (Moss et
al., 2011; Bernard et al., 2012). Furthermore, Cyr and colleagues (2012)
investigated the VIPP as a diagnostic instrument to assess parenting capacities
in child protection cases and report no negative consequences. This is also the
case for a former study in one of the family psychiatric facilities (Yulius),
that also used possibly confronting questionnaires, an attachment measure and
saliva collection (e.g., Reijman et al., 2014).
The goal of the study is to test whether the intervention based parenting
assessment of the parents* capacity to improve (VIPP-APP; Video-Feedback
intervention to promote Positive Parenting for the Assessment of Parenting
Potential) contributes to improved decision making in a child protection
context. If the VIPP-APP appears to be effective in assessing parenting
potential, this instrument could improve the way decisions about out-of-home
placement are made which may lead to better outcomes for children. This would
be a very valuable finding.