In March 2009, the Centre jeunesse de Montréal-Institut universitaire (CJM-IU), launched a kit entitled Les défis du lien. The kit provides an initiation, in French, to two assessment tools related to parent-child attachment: the Q-sort by Pederson (Pederson, Moran, & Bento, 1999) for maternal behaviour and that by Waters and Deane (1985) for attachment behaviour.
Better understanding for better intervention
The CJM-IU is one of Canada’s largest public child-protection agency. Its mandate is to provide services aimed at supporting parents in meeting their parental responsibilities and developing their parental capacities. Moreover, as a university institute, it also pursues a teaching and research mandate. The CJM-IU strives to acquire a better understanding of the causes underlying the problems afflicting maltreated children, to remedy these problems and, insofar as possible, to prevent them (Young, 2008).
Over the past decades, attachment theory (Bowlby , 1988, 1980, 1973-1969, 1982-1969 ) has allowed gaining a firmer grasp of the very disorganized reactions of children that had seemed inexplicable until then (Bakermans-Kraneburg, Van Ijzendoorn, & Juffer, 2005). It has also allowed comprehending just how much time matters in the life of a child (Coster, Wolfs & Courtois, 2007; Paquette, 2004) and just how important it is to act rapidly (Gouvernement du Quebec, 2009). Today, we know to what extent instability in the life of very young children can affect their development (Chamberlain, Price, Reid, Landsverk, Fisher, & Stoolmiller 2006; Allen, & Vostanis, 2005; Cicchetti & Toth, 1995). We have understood also that various factors can affect parenting capacities (Cicchetti & Valentino, 2006).
Notwithstanding these advances, there are still numerous challenges associated with child victimization to be met. The stability of life projects continues to be cause for concern (Paquette, Labrecque, & Gaudet, 2005), mobilizing families and assisting change in a context of authority is not easy, decision-making in a socio-judicial context is a complex affair, and the issues surrounding placement remain unresolved. This is why it is important to bring to bear all means capable of enhancing the impact of interventions by making the most of existing knowledge.
However, experience has shown that, despite the progress achieved in terms of knowledge development and despite the fact that best practices are sometimes known and recognized, the capacity of practice settings to integrate innovations in their day-to-day activities remains limited. According to recent studies, only a slim proportion of practitioners, all disciplines considered, including medicine–which is quite troubling—apply best practices with their clientele (US Department of Health and Human Services, 1999).
According to McGlynn, Asch, Adams, Keesey, Hicks, DeCristofaro, & Kerr (2003) :
« […] Americans receive about half of recommended medical care processes. Although, this point estimate of the size of the quality problem may continue to be debated, the gap between what we know works and what is actually done is substantial enough to warrant attention. » p. 2643
Chaffin & Friedrich (2004) make a similar observation :
« […] most field services provided to abused children and their families are not based on any clear evidence that the services actually work. It is common for models to be widespread despite fairly strong evidence that they do not work well, at least as currently implemented […] » p. 1098
How can we explain this state of affairs? Multiple factors are no doubt at play. Part of the answer rests on the fact that good practices must first get to those likely to apply them. As it happens, the circulation of information remains a considerable challenge despite the advance of information technologies. Although information is certainly more accessible, sorting through the phenomenal amount disseminated requires time, keenness and know-how—three elements not always in abundant supply.
Furthermore, even when good practices catch the attention of potential users, they are not always exportable or applicable as is. They often need to be reworked and adapted to the specificities of the practice context before being implemented. They must be examined, experimented, tested, and remodelled. In addition, any such adaptation must preserve the integrity of the good practices. This transformation effort, too, requires time, keenness and know-how. It necessitates an even greater investment than the previous challenge in that it often calls for the setting whence the knowledge derives—often but not exclusively universities—to join forces with the practice setting in order for the endeavour to bear fruit. In sum, gaining access to knowledge regarding best practices is not easy for interveners operating on the front lines on a daily basis. According to Torrey, Finnerty, Evans, & Wyzik:
« Implementing a new practice in a routine mental health care setting entails promoting change in the behaviour of groups of mental health providers. Theorists suggest that behaviour changes when intention to change is combined with the necessary skill and the absence of environmental constraint » p. 884
The idea of producing this kit to render information on these two card-sort measures accessible initially arose in response to a need on the part of CJM-IU personnel for greater knowledge access. The transfer of knowledge concerning these instruments constitutes a constant challenge on account of personnel mobility and retirements.
Other bodies, too, have expressed a marked interest in these card-sort measures. Our establishment is solicited on a regular basis by interveners operating in the areas of prevention and protection, as well as by students in Quebec or abroad engaged in study or research projects who are seeking out information on these tools. As it turns out, while information is relatively easily accessible in English , the same is not true in French. Furthermore, the literature contains accounts of their application for research purposes above all (Tarabulsy, Provost, Moss, Bernier, Maranda, Larose, Larose & Tessier, 2005; van Ijzendoorn, Vereijken, Bakermans-Kranenburg, & Risksen-Walraven , 2004; Pederson, Gleason, Moran, & Bento, 1998; Pederson, Moran, 1996; Posada, Waters, Crowel, & Lay, K.-L., 1995), whereas our experience has taught us that these instruments are of great clinical value and utility. The idea of creating a kit sprang out of this need.
Importance of contextualizing tools: attachment theory
However, the desire to transmit scientific knowledge to users operating in practice settings raises a major challenge, namely, that of preserving its essence while rendering it user friendly. Indeed, it is hard to simplify something complex without losing something in the process.
As it happens, the two card-sort instruments are founded on attachment theory. This is why different experts–professors, clinicians, child psychiatrists, psychologists, and managers—bear witness in the kit regarding the clinical challenges associated with childhood attachment and the contribution of the card-sort measures to intervention. The aim of these testimonials is to promote the proper use of these instruments, bearing in mind both their potential and their limitations.
Potential, limitations and risks
According to Larin (2007) , the biggest advantage afforded by these card-sort measures is to provide, on the basis of the reflection carried out and the consensus reached by experts, a synthesis of what needs to be observed in the parent-child attachment tie. The scientific rigour exercised by the research teams that developed these assessment instruments allows clinicians and researchers to benefit from knowledge without the pain of conducting a literature review or of actually carrying out research.
The use of these card-sort instruments affords many benefits, including the possibility of validating clinical intuition, as all observers use the same 90 items to reach decisions regarding the quality of what transpires in course of their observations. This provides observers with common reference points for analyzing what goes on in a dyad. These are concrete instruments that incite the observer to focus on the observation and that offer a solid analytical framework. As a result, observation is elevated to a higher degree of refinement that translates into a more acute clinical judgement. The use of these instruments sharpens the ability of observers to discern the behaviours that favour or undermine the establishment of secure attachment.
The card-sort method has the advantage of preventing the halo effect thanks to the constraint it imposes on the observer to describe what he finds most significant in the parental behaviour. It is also of particular interest due to its focus on the attachment behaviours of children and on parental sensitivity to them. This method provides precise anchors that allow drawing a picture of the tie at a given point in time. Moreover, from a longitudinal perspective, it affords the opportunity to verify potential changes over time.
The two card-sort instruments are useful also in establishing a common language regarding the concepts of parental sensitivity and attachment. This fosters complementarity and coherence across the various services offered as part of an intervention. Finally, these instruments allow generating precise objectives with a child’s parents or other attachment figures by focusing on certain specific behaviours that, as we know, are amenable to change through therapeutic work.
Though use of the card-sort instrument presents numerous advantages, a caveat is in order regarding their limitations. First, it is important to keep in mind that the information obtained by way of these tools remains incomplete. The issues surrounding the parent-child relationship are of such complexity that they necessarily go beyond what can possibly be determined via a mere card-sort instrument. As underscored by St-André (2007) , while the use of these instruments fosters better communication among professionals and allows sketching a profile, it does not allow formulating a diagnosis.
To make proper use of these instruments, observers must be trained. Moreover, this must occur together with others for the sake of good inter-rater reliability. Using a card-sort instrument also requires a minimum amount of rigour when observing. Observers must take the time not only to watch properly but also to reflect upon the behaviours noted when sorting the cards. Furthermore, the results obtained through a card-sort instrument carry, like all standardized measures, a margin of error. In addition, according to Parent (2007) , the present state of the research on these tools does not allow defining cut-off points between normal and clinical populations. Further studies are required in order to establish these thresholds. Finally, according to Moss (2007), the Q-sort for attachment behaviour does not allow classification by style (A, B, C, D). If it becomes necessary to identify the attachment type of high-risk children, such as those with disorganized attachment, observers will need to be trained in decoding these styles.
Developing a kit to make the most of existing knowledge
Developing a kit such as Les défis du lien is both stimulating and demanding. It constitutes a rigorous and structured process that requires the collaboration of multiple experts, administrators and frontline clinicians. It is an experience that calls upon clinicians to become familiar with an assessment approach that places technology at the service of content. It is also a process that requires a certain technological know-how. Finally, a commitment from the organisation is required so that a sense of ownership develops within the practice milieu. As so accurately remarked the group of Torrey in 2003 : « To improve the availability of services that have been shown to work, leaders must lead ».
References
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Les défis du lien: an attachment assessment kit
Authors
Paquette, Francine, Coordinator,
Centre d’expertise sur la maltraitance,
Centre jeunesse de Montréal-Institut universitaire
Canada
