Improving Attachment Security in Early Childhood Intervention: A Framework From Constructivist Grounded Theory

Aim

The current study aimed to investigate how attachment security could be improved within the context of ECI in Australia; however, the results have relevance for ECI practitioners, managers, researchers, and academic educators internationally. The research question was:

Method

CGT methods were utilized for this study as they are appropriate when little is known of the research area, the study is explorative; and the researcher does not assume one truth (Birks & Mills, 2015; Charmaz, 2014). As for other forms of grounded theory, the aim of CGT is to develop a theory that is “grounded in real world data” (Newby, 2014, p. 491). CGT stands out from classical grounded theory (Glaser & Strauss, 1967) in that the theory arising from the research process is viewed as a co-construction of the researcher and the participants (Charmaz, 2014).

The approach in the present research respected the existing knowledge, skills, and practices of ECI professionals and involved them in the process to achieve results that were meaningful and translatable to their practice because the data are grounded in their experience (Newby, 2014). CGT influenced decisions regarding how and from whom data were gathered and how data were analyzed, with these activities occurring concurrently (Charmaz, 2014) (see Figure 1). This ongoing analysis led to theoretical sampling; the emerging themes informed decision-making regarding ongoing participant recruitment (Birks & Mills, 2015; Charmaz, 2014). Focused-coding was undertaken to develop categories representing the major themes (Charmaz, 2014). Diagramming was then employed to facilitate the process of developing the proposed framework (Charmaz, 2014). Throughout every phase of this iterative process, memoing was employed, that is, written reflections regarding emerging ideas, insights, and feelings regarding the research and analysis, enhancing the ability of the researcher to identify theoretically relevant data, known as theoretical sensitivity (Birks & Mills, 2015). Memoing also facilitated theoretical analysis, informed theoretical sampling, and provided an audit trail of the process (Birks & Mills, 2015). Theoretical saturation was reached when no new codes emerged from the data (Birks & Mills, 2015).

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Figure 1.

CGT Methods Used in Study.

Initially, the founders of grounded theory, Glaser and Strauss (1967), urged undertaking a literature review be deferred until after a theory was developed to minimize the risk of the emerging theory not being grounded in the data. Other grounded theorists, and Strauss himself, later acknowledged that this delay could be impracticable and that there were benefits to conducting a purposive preliminary review, like ensuring the research was required and theoretically sensitizing the researcher (Birks & Mills, 2015; Charmaz, 2014). As advised by Birks and Mills (2015), the preliminary literature review for the present study was contained to the minimum necessary, and a formal review was conducted following the development of a theory or, in this case, a framework. In keeping with the chronology of the study, new literature is introduced after the findings with the proposed framework and in the discussion (Dunne & Üstűndağ, 2020).

Participant Recruitment

Ethics approval was obtained from La trobe University Human Research Ethics (HEC1805).

In line with a CGT approach, the types of participants recruited evolved through the process of ongoing analysis of the data (Charmaz, 2014). The initial purposive sample (Sample type A, Table 1) consisted of five ECI professionals recruited voluntarily from one ECI provider organization offering a Key Worker approach. The provider organization had previously trained ECI professionals to enhance their knowledge of attachment and was selected for participant recruitment to enhance the likelihood of capturing effective practices.

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Table 1.

Participant Details.

Sample type  A—ECI professionals—5  B—intervention experts—4  C—attachment-focused (non-ECI) professionals—4  D—parents—3  E—child development experts—5

Disciplines of professionals interviewed  Early childhood specialist education—3  Maternal and child health nursing—1  Mothercraft nursing—1  Occupational therapy—2  Psychology—4  Social work—5  Speech pathology—2

Other details  Organizations participating—9  Professionals with ECI experience—10

Total—21

Note. ECI = early childhood intervention.

Next, four professionals with expertise in interventions or tools which target parent–child relationships (Sample type B, Table 1) were approached directly to participate in interviews with the consent of their organizations. The interventions or tools participants utilized included Parenting Interactions with Children—Checklist of Observations (PICCOLO) (Innocenti et al., 2013), Make the Connection (O’Neill et al., 2018), Parent–Child Mother–Goose (Scharfe, 2011), and Tuning in to Kids (Havighurst et al., 2009). PICCOLO is a tool designed to measure parent–child interactions in the domains of affection, responsiveness, encouragement, and teaching (Innocenti et al., 2013). Make the Connection is an attachment-focused parenting program that can be used in group or individual work with children and parents (O’Neill et al., 2018). Parent–Child Mother–Goose is a group program for parents and children using songs, rhymes, and stories to enhance child language and social skills and the parent–child bond (Scharfe, 2011). Tuning in to Kids is a group parenting program focusing on the emotional connection between children and their parents (Havighurst et al., 2009). The first three of these interventions or tools, while not designed especially for children with DD, nor all purported to address attachment, were selected as they were known by the authors to be used to varying degrees in ECI in Australia to positively influence the parent–child relationship and, fortuitously, experts in these tools and methods were in Victoria, enabling face-to-face interviews. The Tuning in to Kids interview was pursued as self-regulation was raised by five of the first eight interviewees, and another raised the Tuning in to Kids intervention.

Four organizations providing a range of community-based child and family services with an attachment focus were approached to participate in the study. Four staff with various roles, disciplines, and experience volunteered from one of the organizations (Sample type C, Table 1). Two experts (Sample type E, Table 1) came from another two of these organizations, while the fourth organization did not participate.

It became evident to the researchers from the ongoing data analysis that a parent perspective may bring greater depth to the data. Following an amendment to the ethics approval, parent participants (Sample type D, Table 1) were recruited via two organizations that had contact with over 7,000 families. Advertisements seeking parent volunteers were placed on the organization’s website, providing the initial sample of ECI professionals, and in the newsletter of a sixth organization.

Finally, five professionals were approached directly to explore emerging themes as they were known to have expertise in various areas of child development (Sample type E, Table 1), including infants’ experience of family violence, Australian First Nation’s People’s view of parenting, autism spectrum disorder (ASD) and attachment, child welfare and attachment, and ECI and child development. All agreed to participate.

Participants

Participants from Sample A had more than 20 years of experience working with children and families, primarily in ECI. Some also had experience in other related roles—early childhood education and family work with older children with disabilities. Participants from Sample B had experience training others in the program or tool about which they were interviewed. All professionals interviewed were qualified allied health or early childhood education professionals.

Three parents (Sample C) of children with DD volunteered and were interviewed—two biological mothers and an adoptive father. The disabilities or delays of their children included cerebral palsy, Down syndrome, global developmental delay, and intellectual disability. Two of the four children had some ASD symptomology but not a diagnosis of ASD.

The 18 professionals interviewed came from various disciplines (see Table 1 for details). The five expert informants (Sample E) and one of the intervention/tool experts had PhDs related to the topic for which they were interviewed. The parents (Sample C) also came from professional backgrounds. Participants were Caucasian (19), Australian First Nation (1), South Asian (1), female (19), and male (2). For anonymity, the quotes from interviews will be cited as “parent” or “professional.”

Data Collection

Interviews were conducted with parents and professionals to explore how ECI professionals could improve the attachment security of children with DD. Charmaz (2014) asserted that in-depth, semi-structured interviews are highly suitable in CGT methods as they enable expansive exploration of a topic and permit the interviewer and the interviewee to contribute more freely than a structured interview would allow. The interviews for the present study were all conducted by the first author, a PhD candidate who is a registered psychologist, between July 2017 and June 2020. The interviewer was an employee at the organization from which the first purposive sample was drawn and knew nine of the interviewees professionally. The other 12 interviewees were unknown to the interviewer prior to the interview. Interviews were audio-recorded, ranging from 28 to 96 min, with an average of 61 min. Interview schedules were developed by the first author as a guide for the interviews of each sample type of participant and individually for each expert. The second and third authors reviewed the schedules to promote content validity. Questions varied according to how each conversation evolved (Charmaz, 2014) but, in general, covered professionals’ experiences of working with families on attachment, families’ experiences of building a bond with their child and of ECI services, and strategies to improve attachment security experienced by parents or professionals. The interviews with the purposive sample all began with an invitation to talk about a time when they had worked with a family having had concerns about attachment. The intervention experts were asked to explain the intervention in detail, exploring the elements within the intervention and discussing how the interviewee perceived the effectiveness of the intervention with program participants. Interviews with parents began by asking them to talk about their child and family, what it was like developing a relationship with their child with a disability or developmental delay, and what professionals may have done, which was helpful or unhelpful to the parent–child relationship. The interviews with attachment-focused (non-ECI) professionals were similar to the purposive sample exploring the strategies they used to support the development of secure attachment. Finally, interviews with experts involved more detailed discussion on aspects of attachment that arose from the first 16 interviews and required more in-depth investigation of theoretical and empirical underpinnings. The first 13 interviews were conducted face-to-face, but then, due to the COVID-19 pandemic, the final eight interviews were conducted via Zoom (6) and via telephone (2). Despite designing the study to enable face-to-face interviewing, the researchers found, as did Sturges and Hanrahan (2004), that the modality of the interview did not negatively impact the quality of the data collected.

Data Analysis

Following CGT methods, theoretical analysis was conducted concurrently with data collection via coding and memoing (Charmaz, 2014). Transcripts were created following each interview, then coded, memoing undertaken and adjustments made to questions asked in subsequent interviews, together with decisions regarding further types of participants to recruit. The first five interviews were transcribed by a professional transcriber and checked by the first author. The first author transcribed the following 16 interviews with the assistance of Trint, a software program that transcribes audio into text. Transcriptions of the interviews were uploaded as they became available into NVivo 12, a software system used to assist with the management of qualitative data. The first author undertook initial coding with peer validation from the second and third authors.

The first author was the primary analyst for this study, with peer review conducted by the second and third authors at each stage of the process to enhance reliability. Reflexivity, facilitated by memoing and peer debriefing, were used to manage the influence of bias (Charmaz, 2014).

The first author leaned more toward coding as a “lumper,” coding larger tracts of data together rather than a “splitter” breaking down data into much smaller pieces (Saldana, 2016, p. 24). CGT maintains a focus on “actions and processes rather than themes and structures” (Charmaz, 2014, p. 15). Thus, initial coding was inductive and carried out using mainly Process Coding, otherwise known as action coding, which employs gerunds (“ing words”) because they focused on what people were doing (Saldana, 2016).

Once a transcript was coded, the first author hand-wrote memos detailing each code used in a transcript. As memoing is intended to be an “uninhibited activity” (Birks & Mills, 2015, p. 40) with “an emphasis on spontaneity and natural flow” (Birks & Mills, 2015, p. 43), handwriting was used. Memos facilitated constant comparative analysis (Birks & Mills, 2015), including discussion of the relationship between excerpts included under one code, example excerpts, relationships with other codes, and thoughts the author had regarding the data, the codes, and the process. The data coming from all 21 interviews were initially coded with 287 codes. The first author then reviewed every code, rereading all the excerpts in each code and ensuring appropriate placement. A codebook was then created by the first author listing every code with a definition, how many interviews it came from and how many excerpts were coded this way, example citations, and links to other codes. These further stages of analysis brought about some amalgamations of similar codes, reducing them to 249; for example, “Struggling to accept diagnosis” merged with “Not wanting child to have disability” as there was no clear distinction between excerpts under these codes. The second and third authors reviewed the codebook to enhance consistency.

Most codes were generated in the analysis of the first five interviews. Only two new codes were created by the 12th interview, and none from the 13th interview. The interviewer had anticipated a series of new codes to emerge from the parent interviews, but no new codes were developed. Rather, parents provided a first-person perspective of the issues raised by the professionals indicating data saturation. In CGT, theoretical saturation is sought, meaning that data gathering has reached a point where no new theoretical understandings are emerging to contribute to the developing theory or framework (Charmaz & Thornberg, 2021). The emerging themes were explored through individualized interviews with a range of experts. The interviewer again anticipated new codes would arise from the expert interviews, but instead, these interviews generated low numbers of existing codes as the discussion was more focused on themes raised in earlier interviews. The concepts in the proposed framework have been well explored in the interviews and can be supported by the data gathered.

The first author conducted focused coding. The process of constant comparison between the incident-by-incident codes from the initial coding phase facilitated the identification of ten conceptual categories. For example, a category named “The System” was generated from the grouping of conceptually linked codes, including “Helping parents understand what ECI is,” ‘Increasing skilled workforce,’ and “Waiting for help.” Further analysis of these 10 categories resulted in the selection of 7 primary categories, which have been used to structure the findings. The first author then undertook diagramming and memoing to analyze the relationships between the categories, identify the primary themes, select the core category, and create the proposed framework, which follows the “Findings” section. The proposed framework brings together the seven key conceptual categories and the two primary themes, which are further explored in the discussion.

Importance

Evidence emerged from the interviews emphasizing the importance for children with DD to receive the kind of sensitive and responsive parenting that supports the development of secure attachment. Data indicated that (a) children with DD required considerable assistance, encouragement, and repetition to learn; (b) substantial assistance to build skills in self-regulation; and (c) had a sizable likelihood of experiencing abuse and neglect:

Challenges

The data indicated that attachment security might be harder for children with DD to attain due to the emotional impact of parents realizing their child is developing atypically. This was evidenced through interviews with professionals and parents, referring to strong emotions such as guilt, grief, and devastation. The search for a diagnosis, the pressure felt by some parents to “fix” the child, and the stress inherent in gaining access to a multitude of services in pursuit of this aim was again evidenced by both professionals and parents. The child’s limitations in communication also arose from both parent and professional interviews as a clear factor in increasing frustration and impeding synchrony between the parent and the child:

. . .if you think about how language works or about how conversations work, they always work within certain parameters, within certain timings. If somebody speaks too fast or too slow, then that makes the connection break down. . . (Professional)

So, I don’t have any other children, so I don’t know what it should be like, but I guess with his speech delay, I have felt like there is a limit to how we connect. There’s just not really much back and forth, so there is only so deep you can go. (Parent)

Other interviewees indicated that difficulty in coming to terms with a diagnosis might impact a parent’s ability to emotionally connect and be attuned to the child’s needs and abilities, for example:

. . .she was not being able to, or struggling to accept this diagnosis and that he did have an intellectual disability. She wasn’t really in tune with his skills or his abilities, and so she would often engage with him way above his ability. (Professional)

Having made a clear and free choice to adopt severely disabled children, the absence of emotional turmoil regarding the disability stood out with the adoptive parent. A mission to bond had been their clear and successful priority when each child came into their care. All three parents spoke of the emotional impact of professional insensitivity, for example:

The pediatrician sent us to a physiotherapist who, at the end of the first session, when I was walking into the waiting room, said, “You should probably get him on NDIS [National Disability Insurance Scheme].” I left there crying. I mean, you want your child to be normal. I felt bad enough that I had to take him to a physiotherapist, and now she is telling me he has a disability as just an offhand remark while I am leaving. After the end of the second session, she said, “I think he has autism.” Once again, I left crying. I had to get my husband to come to the physio sessions with me because they upset me so much. (Parent)

The parent compared this negative experience to her experience with the next physiotherapist, who “is very positive,” making her feel better about herself as a parent and “feel better about my child. As a parent, you notice all the things your child can’t do, and having her notice what he can do makes me feel better about him.”

ASD was the most commonly discussed diagnosis, and interviewees suggested ASD may pose additional challenges to the attainment of attachment. Reasons provided by interviewees included that it can be harder for parents to synchronize with their child and tune into their interests. Also, it may be harder for parents to detect the more subtle or idiosyncratic signs that their child is attached to them, which can impact the parent’s feelings toward the child. In addition, sensory overload may distress the child and thus over-activate the child’s attachment system.

The System

Data emerged from the interviews about how aspects of the overarching system providing ECI funding and policy could be most conducive to improving attachment security for children with DD. First, interviewees indicated that the ECI system should enable early, easy access to high-quality services. The effectiveness of the intervention would thus be enhanced due to greater neural plasticity during early infancy. In addition, for families to access high-quality attachment-focused services, the overarching system providing ECI would need to foster the ongoing professional development of ECI professionals, as many of the professionals interviewed indicated that they did not learn about attachment in their undergraduate training. Some interviewees indicated that they had learned about attachment in subsequent professional development training, while others learned from their colleagues through transdisciplinary teaming and supervision, which also supported them emotionally to persevere in what was sometimes emotionally challenging work with families:

Also, just being able to draw on the resources within the team, with my Team Leader and also with other team members. I did a lot of coming back and debriefing about what I was seeing and am I on the right track kind of thing. (Professional)

Finally, but importantly, data indicated that the system providing ECI should either only fund high-quality holistic ECI services or provide adequate support to families to understand best practices in ECI. The data indicated that parents were not being adequately supported to make informed choices about ECI approaches:

I have heard about the Key Worker model, but I don’t really know much about it. The pediatrician told us we need physio, so we did that and then she sent us to the speechie, and she sent us to the OT, so we have gone full medical model without even necessarily choosing that. It seems like an important decision to make but I just don’t know. (Parent)

The Key Worker

The data analysis strongly indicated that the relationship between the parent and the ECI professional is critically important in effecting change. The importance of the professional-family relationship was discussed as not just a matter of role modeling positive interactions but, rather, as a deep, non-judgemental engagement with a professional who genuinely cared for the family and was sensitive to their individual and cultural needs because, for example:

. . .it’s hard for someone to open up and talk about how they’re feeling as a parent and how they feel about their child if it’s not all glowing and how it should sound. So, to sit with that and be okay with that, I think is important (Professional)

A coaching approach, defined by Rush and Sheldon (2005) as a strategy to facilitate adult learning by supporting the ability of the learner to reflect, plan and develop the effectiveness of their actions, was supported by the data. In addition, examples provided by interviewees of interventions that did not have positive outcomes were contrary to a coaching approach. Effective coaching elements discussed by multiple interviewees included following the parent’s lead, partnering with parents so that they are co-designing strategies, modeling strategies, and asking parents questions to learn more about what they already know, do, and prefer. One professional described the effect of applying a coaching approach with a mother, saying:

. . . I think if I hadn’t helped her develop that ability to reflect, she may never have gotten to that point of even looking inward and talking about how her relationship had changed with him in those early times, and then what she wanted to have happen.

Working with an attachment focus altered many aspects of what an ECI professional might do, say, think or even how they physically position themselves when working with a family. One interviewee described her attachment-focused approach in ECI as follows:

. . .we’re entering the space of a family and so, our focus needs to be on them and their relationship and growing the skills between them. It’s not just building capacity of the parent. It’s actually that you can’t build capacity of the parent without the parent actually having a good relationship with their child. It has to start with a good relationship before we build the capacity for it to be effective. (Professional)

Assessment

Participants identified various ways of formally or informally assessing parent–child interactions. First, there was a range of risk factors for insecure and disorganized attachment, which, if present, could prompt ECI professionals to prioritize attending to the parent–child relationship. These risk factors, similarly identified by Rees (2005), included family violence, drug or alcohol abuse, mental illness, young families, poverty, social isolation, parents who have been in care themselves, parental disability, rural/remote, and families who have experienced intergenerational trauma such as First Nations or refugee families. One of the interviewees summed up the impact of these risk factors for insecure or disorganized attachment in addition to the risk arising from a child having DD as follows:

In a sib[ling] group of three or four, this is just one child and then the parent might have the financial stress, the family violence, the partner distress, whatever’s going on, their own unresolved trauma from childhood, you know, their own limited capacity through their own disability like you know, you just get it stacked up against you in terms of setting the right conditions for a secure attachment to be formed. (Professional)

Participants discussed a range of tools that assisted professionals in understanding more about the parent–child relationship whether these risk factors were present or not. One interviewee described how the PICCOLO (Innocenti et al., 2013) assisted parents and professionals to reflect on parent–child interactions when used formally and how familiarity with the tool shaped the observations subsequently made by an ECI professional ensuring a focus on, and support of, the parent–child relationship. Interviewees discussed how tools that are commonly used in ECI, such as routines-based interviews and ecomaps (McWilliam, 2010) or, alternatively relational maps for First Nations children (Stewart & Allan, 2013), could provide information about how the child relates to others as follows:

So, you know how we might sit with people and do like an ecomap or genogram to look at the humans in their world. You know, who’s their doctor? Or who’s their support people? . . . Who are their primary attachments? If this type of assessment included a relational understanding and professionals actually ask, “Hey, you know, is there any landscape that is really important to you? Are there any animals who are part of who you are? Are there particular ancestors that you think about?” Then that just allows the professionals to know some of the support network around the child a lot more but also, it makes the child feel a lot more seen. (Professional)

Participants from Sample group C (see Table 1) talked about what they looked for in more natural observations of parent–child interactions to guide their intervention, such as (a) ease with one another; (b) parental responsiveness to child cues; (c) reactions to tantrums or ruptures in the relationship; (d) following the child’s lead in play; (e) child response to separation from the parent; (f) alignment of parents; or (g) child’s comfort seeking. One expert recommended that when observing what happens when a parent and their autistic child separate, the focus should be more on proximity than on social behaviors such as eye contact. An Australian First Nations parenting expert stressed that care must be taken when observing First Nations’ children to ensure Western assumptions do not lead to misunderstandings, saying, “. . .it’s also dangerous because it’s so opposite to First Nations’ understanding of attachment. It can create the most terrible misunderstandings. Misunderstandings that have terrible outcomes.” For example, a First Nations child may not display distress when left alone because they may feel an ancestor is with them, or they may not be upset at being taken from their parent and placed with another relative as that relative may hold a parent status for them.

Strategies

The strategies emerging from the data were grouped into cognitive—those related to ways of helping parents shift their thoughts and/or feelings toward the child; and behavioral—those strategies focused on getting the parent to do something differently. Examples of cognitive strategies and illustrative quotes included:

. . . that’s very much about trying to become synchronous with your child and building on key behaviours like joint attention and communication bids that the child emits and then responding in a contingent way to those bids. . . try and build up that synchrony so that the child can communicate effectively. . . (Professional)

. . .we know that children are so good at picking up on physiological responses of their parents and caregiver as well and rely on that as their way of assessing safety. So, if a parent is presenting as highly anxious, they’re going to have an increased heart rate, be feeling quite tense and having all of those things going on internally which a child can subsequently pick up on and lead to them being unsettled. So, we do a breathing exercise of mindfulness of the breath. (Professional)

Other strategies emerged from the data that worked on more of a behavioral level. These focused on getting the parents to initially do something different, but ultimately might shift thoughts and feelings over time. Examples of behavioral strategies and illustrative quotes included:

And so, the conversation was about, you know, “Okay, these are all the bad things that your daughter is doing, when do you have fun together? What are the good things?.” . . And so, I said, “It could even be that she sat down, you know, really simple. That she walked to the kitchen—if it needs to be that basic, rather than yelling and screaming and running all the time.” . . so they ended up being really, I think, the start of a shift in the mindset, to say that “Actually, my daughter is not all that bad. There are good things that she has, and we’ve just got to find them.” (Professional)

So, we really want to foster that relationship and, yes, so the way to start that for me, was really “How can we have fun together?” And it was when we started talking about that, that I think Mum was then reflecting on “Actually yeah, I don’t have fun with her at all.” (Professional)

Finally, there were strategies discussed that may involve external supports or referrals:

. . .if you’re an OT or a speechie or a psychologist, it may not be your role to actually provide that mental health support to a parent or caregiver, [but] you are an important link in the chain and some of these families feel really isolated and they also may not realise that they need it. (Parent)

Formal programs—looking at the evidence and adopting or referring out to formal programs with a focus on parent–child interactions were discussed as being helpful. However, as stressed by one professional, only in addition to the individualized family work of an ECI professional, “We infuse our family services with these other programs that really do target the relationship base, but you can’t just do that.”

Some programs discussed required facilitators to run them to fidelity while others provided principles or a framework to guide practice. Formal programs discussed in the interviews included some with a clear focus on improving attachment security—Circle of Security (Powell et al., 2014), Make the Connection (O’Neill et al., 2018)—and those with a focus on improving parent–child interactions or communication: Cradle to Kinder (Fewster, 2016), Denver Model (Rogers, 2010), Hanen, Parent–Child Mother–Goose (Terrett et al., 2013), Peek-a-Boo (Bunston, 2006), PICCOLO (Innocenti et al., 2013), and Tuning in to Kids (Havighurst et al., 2009).

Outcomes

Finally, data arose from the interviews, which may help inform ECI professionals as to when their attempts to improve the attachment security of the children with whom they work are succeeding. Changes were observed in child development, such as improvements in communication, self-regulation, social skills, and behavior. Some children became more discriminating about who they approached for help. Changes were also observed in parental responsivity, affection, and encouragement, together with an enhanced understanding of their child’s perspective. Parents could see the positives and enjoy their child, their confidence increased, and they expressed more hope for the future. Parents gained skills in regulating their own and their child’s emotions. They reported less stress and were more visibly relaxed. Some parents followed the child’s lead more, were less emotionally dismissive, and more in tune with their child’s overall needs. The parent and child appeared more connected, enjoying each other’s company, and families were enjoying activities together:

And she was saying, “We’re now playing Snakes and Ladders, the three of us. We can sit there, and we can play a whole game of Snakes and Ladders and it ends okay, you know? It doesn’t end badly.” And just those moments like that, that you’re just going, “Yeah, it’s been worth it.” (Professional)

The bi-directional nature of these changes was illustrated by some interviewees such as:

And yeah, there was a noticeable change. She was conscious of not being too involved. She was able to step back, actually followed his lead, and allowed him to direct the play. So, when he changed play ideas, she went along with him and he opened up, like he responded to that. He actually got excited about what he was trying to show her or to play with and so immediately from the first visit video to the next you could see that he opened up. She naturally then became more positive because he was opening up to her and so, there was just a more of a team and more of a united relationship between the two of them. (Professional)