Phase 1 of the study aimed to refine the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) programme (which has previously been adapted for foster care in the Netherlands) for the context of children in foster care in the UK. This intervention is named the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline, Foster Care [VIPP-FC (UK)]. In this chapter, we provide a succinct description of VIPP-SD and summarise the adaption process.
The VIPP-SD is a brief home-based attachment and parenting intervention. It is highly acceptable to families, has a clear and empirically supported model of change and has good evidence of efficacy with families of young children in many settings.21 Practitioners who are trained and accredited to deliver the intervention visit families at home for six 90-minute sessions. Sessions 1–5 take place biweekly and focus on improving the carer’s sensitivity to the child. Session 6 is a booster session; it can take place approximately 1 month after session 5 and focuses on consolidating the information provided in sessions 1–5 and teaching carers sensitive discipline skills. In the original intervention programme, there is usually an additional booster session.
Sessions involve both the carer and the child, and start by video-recording carer–child interactions, following specific intructions that are given to the parent/carer (e.g. to play with a certain toy, to read a book together, to share a meal). The intervener films clips that provide the basis for themed discussions in the next session, when the intervener plays the clips back to the carer and discusses what they are observing. Themes include recognising the child’s attachment signals and expressions, providing prompt and adequate responses to them, promoting empathy for the child, praising positive behaviour and appropriate ignoring of negative behaviour. Carers are also given exercises and tips. Session content is consistent across families, although its presentation and the video feedback are tailored to the specific needs of each family. This description of the VIPP-SD also applies to the modified VIPP-FC. A summary of the VIPP-FC adaptation process follows.
Methods
Prior to this study, the intervention manual for the VIPP-SD had been modified for a foster care population, resulting from pilot clinical work conducted in the Netherlands.28 We proposed to further modify this revised intervention (VIPP-FC) to specifically account for the clinical features of RAD, as well as to incorporate local (UK) health and social care policies and practices. In addition, given the differences between foster care in the Netherlands and foster care in the UK, other potential differences between the two groups of children and carers had to be considered.
An expert advisory group of the programme developers, UK clinicians (including colleagues in CAMHS, social care and the third sector) and foster carers was set up to review the existing VIPP-FC manual and advise the Manual Development Working Group (composed of members of the study team), which implemented the recommended changes. The consultation and revision processes were iterative, consisting of three advisory meetings and three rounds of manual revision. The Manual Development Working Group made an initial adaptation of the existing VIPP-FC manual for the context of children in foster and kinship care in the UK; this draft version of the manual was used in a small case series (phase 2a). After the completion of the intervention programme with participants in the case series, the Manual Development Working Group met again and further modified the manual. This modified manual was then used in the feasibility RCT (phase 3) of the research project and was reviewed once the RCT was completed.
Results
Although the adaptation process was planned to primarily focus on adapting the VIPP-SD/Dutch VIPP-FC for use in a population of children with high levels of difficulty in the domain of RAD symptoms, the Manual Development Working Group decided early on that the existing (Dutch) VIPP-FC manual was already constructed to handle clinical issues linked to RAD presentations. Therefore, the modifications that resulted from the work of the Manual Development Working Group dealt primarily with either contextual characteristics of the UK foster care population or more general needs that many children in this setting may present with, rather than RAD symptoms per se. These are described in more detail in the next two sections.
Initial adaptation of the VIPP-SD programme for the foster care population
Although the Leiden group’s original version of VIPP-SD for foster care was tailored to be appropriate for children in foster care,28 the adaptation undertaken in the Dutch context did not reflect the UK setting; as previously noted, the majority of changes recommended by the Manual Development Working Group reflect these differences in context and practice between the UK and the Netherlands. Before outlining the second phase of adaptation for the UK context, we summarise the main differences between the original VIPP-SD manual and the adapted VIPP-FC manual, as adapted by the Leiden group for the Dutch foster care context.
On the whole, the original VIPP-SD manual and the VIPP-FC manual were very similar, with similar tasks, visits and messages. However, the VIPP-FC manual included some extra key themes introduced in the manual specifically for foster children:
- Additional content highlighting that foster children do not always show what they are feeling, as they may not be used to having their needs met, hence the need to address the more subtle signals of the child.
- Additional content about not asking for help – children in foster care do not always behave in the ways that carers would expect them to, hence the need to react to the absence of attachment behaviour as well (e.g. if they do not cry when they hurt themselves, the carer should show them attention anyway to demonstrate that they can be trusted when something is wrong). These were added by the Leiden developers to encourage children to learn that they can rely on their carers. These modifications, in particular, relate to difficulties in the domain of RAD symptoms.
- Additional content regarding the importance of physical contact – how it can cause anxiety for children who have experienced maltreatment and how gently encouraging it can help them overcome these anxieties, particularly if it is done in a structured and sensitive way (such as a song involving touch).
- Additional content encouraging carers to compliment/praise small steps in the right direction – this is even more important for allowing foster children to know that they are doing something right.
- Additional content about strategies to manage indiscriminate friendliness.
- Alternative tasks to those in the original manual; for example, some short extra tasks were added that involve physical touch in a game/song to introduce physical touch in a safe way for the child.
- ‘Don’t touch’ task puts more emphasis on maintaining eye contact with the child than in the original VIPP-SD version, and also a suggestion of naming a book or toy to play with after they have calmed down so that they can more easily imagine the reward they will receive if they are able to wait.
Revisions to the VIPP-FC manual: the work of the manual development group
The modifications made to the VIPP-FC manual for this study were based on discussions within and feedback from the Manual Development Working Group, as well as on learning acquired during the case series, feedback from which was also reviewed by the Manual Development Working Group (see Chapter 3). Some modifications reflect changes to the manual itself, such as the wording of certain messages or tasks, whereas others have to do with the broader context for delivery of the intervention, such as introduction of forms and letters to aid in the delivery of the VIPP-FC in UK mental health services. There follows a summary of all of these modifications:
- An additional guidance document was written to be used alongside the manual for interveners working with specific types of carers/children. This document aimed to guide interveners on where they should adapt their wording to ensure that the language they use is sensitive and tailored to the circumstances of a child and their foster carer; for example, the VIPP-FC manual regularly asks the intervener to refer to the child having had ‘previous adverse experiences’, but this was considered not always appropriate for some carers, such as when the carer is a relative of the birth parent or when the carer has had the child since birth. The four main groups that required the modified wording were (1) a child in a SGO, (2) a child in kinship care, (3) a child who has been with the family since birth and (4) a child who is likely to stay with the family on a long-term basis. As an example, for the fourth group of children, we removed a paragraph that referred to the importance of the carer’s relationship with the child even if they were not going to remain with them long term.
- Following feedback from the Manual Development Working Group, we changed the word ‘obey’ to ‘do what you ask them to do’ throughout the manual as it was felt to be a little outdated and because it has negative connotations that contrast with the sensitive parenting that the VIPP-SD is trying to encourage.
- We shortened the manual to from seven to six visits as it was deemed more suitable for the sometimes short-term nature of placements within the population of foster children and to minimise the chances that the intervention work would be disrupted by a change in placement. The timing of the last two visits was also changed so that there was only a 2-week gap instead of a gap of 3 or 4 weeks, again to ensure that the programme could be finished relatively swiftly.
- A games booklet was introduced to the manual (adapted from a version created by the Tavistock and Portman NHS Foundation Trust for use with adopted families) to give to the carer in visit 4, which includes numerous songs involving actions and touch for the carer to use as a resource with the child (and with other children they may care for currently or in the future).
- The Goal-Based Outcome form was incorporated into the manual. This change reflects a standard requirement in CAMHS in the UK, where this form is used as a routine outcome measure and has also been incorporated more generally into clinical practice. The Goal-Based Outcome form is completed during a discussion with the carer in visit 1, to gauge and manage their expectations and goals for the programme, and to reframe or find common ground from which to work if their aims are out of the scope of the programme. The intervener also completes a final Goal-Based Outcome form with the carer at the end of the programme in visit 6 to assess if and how the goals were met, and if not, why not.
- Some extra guidance was added for the intervener supporting them in explaining or framing the importance of the work, even if the placement is expected to be short. The guidance helps the practitioner to explain that research supports the view that responsive and sensitive care is important for children even when relationships do not last, and that the relationship they build with them in this early stage of life can act as a foundation for the child’s future relationships and well-being. This was to counter beliefs that foster carers might have that it is best not to ‘bond’ with the child if they are not likely to be with them long term, and to help them understand how important it is for the child to experience warm and supportive care, regardless of the length of the placement.
- In keeping with the need for close communication between members of a child’s professional team, a closing letter was introduced in which interveners are instructed to write a letter about how the programme went, what improved and what issues may still require support at the end of the programme, which is sent to the social worker, copying in the foster/kinship carer.
- All names of Dutch games/songs were changed to English ones and additional instructions were added to explain how they worked, in case carers were not familiar with them.
- Photograph booklets were provided for the carer and child at the end of the programme with stills from their VIPP-FC/research videos depicting memorable moments of shared sensitive interaction. It was decided that this booklet with stills was a more acceptable option than providing the video clips themselves, owing to the complexities of consent and data protection of video material in this population.
As previously mentioned, the majority of these modifications were introduced during the initial phase of the work of the Manual Development Working Group, and some were added after the Manual Development Working Group considered feedback from practitioners and supervisors after the case series cases were completed. Although the manual was open to further modifications on review of the RCT cases, no additional changes were deemed necessary to the manual and programme themselves. Nevertheless, challenges with interveners’ capacity and availability, as well as interveners having dual roles in some cases (e.g. interveners who also worked in other roles in the local authority or mental health service provider), throughout the RCT led to discussion of the best model for the delivery of the VIPP-FC, which we return to in Chapter 8.
Discussion
The VIPP-SD is a well-evidenced parenting intervention informed by both attachment and social learning models. It uses video feedback as the primary means of introducing change by focusing the caregiver’s attention on moments of connection and examples of sensitive care highlighted by a trained intervener, who uses their knowledge and skills to frame their feedback into a coherent, attachment-informed message, drawing attention to the child’s cues and communications, the carer’s sensitive response and the positive effect that this has on the child. Despite its extensive track record for promoting sensitivity in parenting in a range of populations, VIPP-SD has not been used before in the context of UK foster care and has only recently been adapted for the foster care context in its country of origin, the Netherlands. Transporting the VIPP-FC to the context of UK foster care requires careful attention to the particular needs and ways of communicating and interacting that children in foster care may present with, as well as the professional context and systems around the child, so that it can be used efficiently by practitioners in CAMHS and other related sectors. Our initial appraisal and adaptation of the VIPP-FC treatment manual suggests that it is well suited to the needs of children in foster care and the Manual Development Working Group’s suggested modifications should make it suitable and appropriate for the UK CAMHS context. The acceptability of the intervention from the point of view of foster carers is considered in greater depth in Chapter 7.