The effects of the Attachment and Biobehavioral Catchup parenting intervention for children with intellectual disabilities in South Africa

This thesis comprises four studies. The first study—a systematic review—distilled the practice elements common across 45 effective attachment-based interventions, and examined how profiles of practice elements were associated with key child variables (child age, ethnicity, location and risk status). Findings indicate that there is notable similarity across practice element profiles in terms of the use of relationship-building, video-feedback, psychoeducation and home-based approaches. However, some distinctions were observed. Interventions for younger infants frequently involved direct demonstration and modelling, while those for older infants and young children consisted of feedback-based approaches. Interventions for vulnerable/at-risk parents consisted of intensive guidance, while those for groups indigenous to North America benefitted from a comprehensive and multifaceted package of practice elements. Finally, interventions for adolescents were frequently implemented in parent-group format, involving role-plays and discussions between parents, with limited direct involvement of the child. These distinctions may inform clinical applications of attachment-based interventions targeted at the needs of specific populations. The second study sought to: i) explore the parenting-related challenges, perceptions of current care and needs of caregivers of children with ID in South Africa; and ii) obtain expert/professional perspectives on the challenges and needs/wishes of caregivers of children with ID. Primary caregivers of children with ID and health professionals participated in this mixed-methods study. Findings suggest that parenting-related stress and self-efficacy may be at risk for caregivers of children with ID in South Africa. Explanations for this focused on experiences of criticism from significant others, lack of assistance from individuals and institutions, difficulties with understanding their child’s needs, and difficulties in coming to terms with their child’s diagnosis. Caregivers expressed satisfaction with healthcare services for their child with ID. However, they also highlighted gaps relating to caregiver-focused support for building their relationships with their children. This underscores the need for relationally-oriented interventions for parents and their children with ID in South Africa. The third study sought to evaluate the effects of the Attachment and Biobehavioral Catch-up (ABC) intervention on maternal sensitivity, attachment security, and child affect/cortisol regulation in dyads in which the child had significant developmental delays/ID. A single-case, multiple-baseline study was conducted across three parent-child dyads. Visual analysis showed improvements in maternal sensitivity and attachment security over time and across dyads, but cortisol results were inconclusive. Statistical analyses also did not converge with the visual analysis. The intervention was also positively received, was found to be relevant and helpful, and both the parents and intervenors observed positive changes in the nature of parent-child interactions over time, highlighting the social validity of the ABC. The findings on the effects of the ABC for this cohort of children are tentative but promising. The final study aimed to obtain expert/professional opinion, and caregiver impressions, on the ABC intervention to inform potential adaptations for the population of children with ID and the local South African context. To do this, an exploratory qualitative and Delphi study was conducted with parents and intervenors involved with the ABC, parents of children with ID not involved with the ABC, and a panel of experts. Results show that the ABC’s strengths-based and supportive coaching approach combined with reinforcing feedback fostered a safe environment for caregivers. This facilitated significant learnings for those who received the ABC. Coaches were similarly supported through quality supervision and encouraged by caregiver commitment to the process. Some key recommendations included: training coaches in identifying the anomalous communication styles of children with ID and in activating referral networks, identifying and training local and community-based coaches and partnering with NGOs to address logistical as well as context- and culture-related factors involved in implementing the ABC in a novel setting.