A good parent-child relationship is important for child development. Interventions can improve parental sensitivity and increase secure attachment, but the effects are modest. Offering interventions to improve parent-child relationships is only appropriate in specific target groups. The same holds true for interventions to prevent child maltreatment. It is important to select interventions that have been tested for effectiveness.
Children with traumatic experiences (adverse childhood experiences) display more health problems later in life. Adverse childhood experiences include emotional and physical maltreatment and neglect, sexual abuse, domestic violence in the home, (which are all defined as child maltreatment) divorce, parental psychological problems or parental imprisonment. In recent years, the youth care sector has paid a great deal of attention to the importance of attachment for child development. How important is secure attachment for the healthy development of children? And how effective are interventions aimed at improving attachment in order to prevent adverse childhood experiences (and their consequences)? That is the focus of this advisory report. It was drawn up at the request of the then State Secretary for Health, Welfare and Sport, by the Committee on Early Childhood Attachment and the Prevention of Childhood Traumas.
The Committee has surveyed the current state of science. First of all, the association between adverse childhood experiences and health problems was examined. The Committee then focused on the relationship between a good parent-child relationship (parental sensitivity and secure attachment) and the prevention of adverse childhood experiences and the consequences thereof. When it comes to preventing adverse childhood experiences, the Committee has focused on those experiences that can be influenced through the parent-child relationship meaning child maltreatment. A good parent-child relationship, after all, will not prevent divorce, parental psychological problems or parental imprisonment. However, improving the parent-child relationship could potentially protect against the adverse effects that children may experience as a result of these adverse childhood experiences, as it could increase the resilience of children.
Association between adverse childhood experiences and health
Scientific research has shown an association between adverse childhood experiences, specifically child maltreatment, and the development of health problems later in life. These are primarily psychological problems, but may also include physical conditions such as diabetes, cardiovascular diseases and pulmonary diseases. Children differ in their susceptibility to adversity due to both genetic predisposition and environmental factors. As a result, the long-term effects of adverse childhood experiences may differ between children.
The parent-child relationship and child development
A good parent-child relationship is based, among other things, on the sensitivity of the parent (caregiver) towards the child (recognising the child’s behavioural signals and responding adequately) and is evidenced by a secure attachment style. There is an association between secure attachment and positive socio-emotional development. An insecure attachment style, on the other hand, is associated with an increased risk of child behavioural problems. There are also indications that a good parent-child relationship could be a protective factor for children raised in unfavourable conditions (e.g. adverse childhood experiences), because it makes them more resilient. In addition, a good parent-child relationship is associated with a lower risk of child maltreatment.
Adverse childhood experiences can be passed on from generation to generation. For example, parents who have been maltreated as children have a higher risk of abusing their own children. However, this risk in itself is small. The Committee therefore does not believe that a focus on intergenerational transmission over other risk factors is desirable. Important risk factors for child maltreatment include parental psychological problems, parental criminality (these are both adverse childhood experiences in their own right), or parents who perceive their child as a problem.
Effectiveness of interventions
There are a large number of interventions aimed at improving parental sensitivity and attachment. The scientific literature shows that these interventions can be effective in a broad group of families, although on average the effects are not very large. The effectiveness of interventions is greater when a child is six months or older than during pregnancy and the first months of the child’s life. Research in the Netherlands, among other countries, has shown that interventions that make use of video feedback lead to a higher sensitivity and responsiveness on the part of the parent. There is insufficient data to assess whether interventions aimed only at improving sensitivity and attachment ultimately lead to the prevention of child maltreatment in some families. There is also insufficient data to assess whether these interventions can protect against the consequences of adverse childhood experiences by making children more resilient.
In addition, there are also interventions that (among other things) aim to prevent or halt child maltreatment. These interventions generally consist of several components aimed at improving families’ situation, including the parent-child relationship. The effectiveness of these interventions increases with the severity of a family’s problems. In families where child maltreatment is already an issue, they can contribute to halting maltreatment. In families where there are only risk factors for child maltreatment, the effect is less clear-cut. On average, interventions to prevent child maltreatment have little or no effect on these families. However, some interventions have been shown to be effective in preventing maltreatment, but only in families with a specific combination of risk factors. For instance, Dutch research into the VoorZorg intervention method has shown such an effect. Some interventions can also reduce risk factors for child maltreatment. Dutch research into the intervention methods PCIT (Parent Child Interaction Therapy) and Stevig Ouderschap has shown such effects. There is insufficient data to assess the long-term (health) impact of interventions that prevent child maltreatment or reduce risk factors.
Bottlenecks in the area of evidence-based practice and identification of groups at risk
The effectiveness of most of the interventions to improve parental sensitivity and attachment or to prevent child maltreatment that are available in the Netherlands is not known. The effectiveness of interventions is important, because of limited time and resources and because interventions can have undesirable side effects and can even be counterproductive when used in the wrong population.
The first step of targeted prevention is that the eligible population for interventions is identified by the various professionals who work with parents and children. The Committee finds that the identification of families with (a combination of) risk factors and families experiencing problems concerning parent-child relationships is currently inadequate. Instruments are currently being developed to identify to what extent parents are sensitive and whether there is insecure attachment. Instruments to identify risk factors for child maltreatment already exist, but these are only moderately predictive of the actual occurrence of maltreatment. Instruments to identify child maltreatment itself also have reliability issues; in addition they are still underused and have only rarely been tested.
The Committee does not recommend offering interventions to improve parental sensitivity and attachment to all parents in the Netherlands. At this time, there is too little evidence that this is sufficiently effective in a general population and that the advantages outweigh the possible disadvantages.
According to the Committee, interventions for which there is proof of effectiveness should be differentially available. Families where child maltreatment is already an issue should be offered effective interventions to halt maltreatment, which can include improving parental sensitivity and attachment. Families with risk factors for child maltreatment should be offered effective interventions to prevent child maltreatment and/or to improve parental sensitivity and attachment. Parents experiencing problems in the relationship with their child should be offered effective interventions to improve parental sensitivity and attachment.
It is important that the needs of families are properly assessed, ensuring that appropriate interventions are offered (no interventions for minor problems in the event of serious problems, and no over-treatment in the event of minor problems).
The Committee recommends promoting the use of interventions that have been shown to be effective in practice. This can be done, among other ways, by using the Databank Effectieve Jeugdinterventies (Effective Youth Interventions, Database) when choosing interventions, based on proof of effectiveness. Attention should also be paid to the implementation of interventions as incorrect implementation can limit the effectiveness. This requires training professionals who provide care to children and families. The Committee recommends researching gaps in available knowledge, particularly in the areas of effectiveness of interventions and identifying groups at risk.
Finally, the Committee recommends ensuring that the knowledge gathered in this advisory report is disseminated among professionals involved in youth care, maternity care, and among other (healthcare) professionals who deal with families.