Piloting attachment psychoeducation provided to parents of children with severe disabilities: Testing the feasibility of a digital micro-intervention

Abstract

Background

A digital micro-intervention offering attachment psychoeducational videos was explored regarding its feasibility in parents of children with severe disabilities. Method: A mixed-methods study (including daily diaries and one-time questionnaires) with 16 parents (75.0% female) of children with severe disabilities (up to 10 years of age) was done during a three-week intervention. Results: Parents were positive about the video series and almost no drop-out occurred. The videos stimulated their learning and thinking and offered parents some personal meaning. Preliminary efficacy tests showed no major changes in parents’ parenting self-efficacy (PSE) or perceptions of statements on parent–child attachment. Conclusions: The study showed promising results regarding the micro-interventions’ acceptability and implementation. The limited efficacy testing did not show major changes in parents’ PSE. Further research is needed to investigate the differential relevance of the micro-intervention, based on parents’ needs, as well as its optimal embeddedness in a broader intervention trajectory.

Keywords

attachment parenting self-efficacy psychoeducation severe or profound intellectual disability young children

Introduction

The belief in oneself as parents bolsters parental functioning and competence, which benefits not only the child but also the parent, and their mutual interactions (Benedetto and Ingrassia, 2017; Kendall and Bloomfield, 2005). Parenting self-efficacy (PSE) or ‘perceived parental efficacy’ (De Montigny and Lacharité, 2005) has been proposed to encapsulate ‘the collection of expectations that parents hold about the success of their parenting activities’ (Schuengel and Oosterman, 2019: page 642). The concept is thought to be dynamic and to be shaped by parents’ behaviours, knowledge and perceptions (Teti and Gelfand, 1991). The current pilot study examines the feasibility of a digital micro-intervention focussing on enhancing PSE among parents of children with severe disabilities by watching psycho-educational videos that act on their knowledge of parent–child attachment. Such a digital micro-intervention is a short, highly focused intervention that is delivered in the parents’ daily life, lowering the threshold for participation and engagement, and focuses on proximal behavioural, cognitive or emotional changes (Baumel et al., 2020).

Almost all parents feel the need to be a beloved attachment figure in the relationships with their children (Bowlby, 1969). An attachment relationship refers to a persistent, affectional bond between a person and a specific other person, most often between parents as primary caregivers and their children (Bowlby, 1969; Cassidy, 2016), and reflects a history of interactions of both showing and responding to attachment behaviours (Schuengel et al., 2013). In children who are limited in their expressive communication, such as children with severe disabilities, parents might notice less attachment behaviours (such as seeking proximity), which might, in turn, lower their beliefs in themselves as attachment figures (Schuengel and Janssen, 2006; Vandesande et al., 2019). Psycho-educating parents in the theme of attachment, including the ways in which (subtle) attachment behaviours are shown and can be reacted to sensitively, might be beneficial to strengthen these parents’ PSE.

PSE is operationalised in several ways in the literature and can, consequently, be measured on different levels: 1) general (overall belief of the parent in oneself), 2) domain-specific (beliefs regarding a specific domain, such as parent–child attachment), and 3) task-specific (beliefs regarding specific parental tasks, such as the ability to react sensitively to the child’s communicative signals) (Benedetto and Ingrassia, 2017; Schuengel and Oosterman, 2019). Furthermore, PSE may be related to the quality of parent–child attachment relationships, because higher levels of PSE lead to more competent parent behaviours in a bidirectional, transactional way (Jones and Prinz, 2005), and this, in turn, strengthens the children’s self-regulatory competences and the mutual interactions between the parents and their children. Teti and Gelfand (1991) have demonstrated that there is an association between PSE and maternal sensitivity, and others (e.g. Donovan and Leavitt, 1989; Mouton and Roskam, 2015) have demonstrated that PSE is an important determinant of maternal sensitivity, which is one of the most robust predictors of attachment security (Ainsworth et al., 1978).

However, achieving high levels of PSE is not always self-evident, especially when raising children with complex support needs (Benedetto and Ingrassia, 2017). As Jones and Prinz (2005) described, PSE not only leads to more competent parent behaviours, but success experiences resulting from those competent behaviours also in turn boost PSE. When children’s development is compromised due to, for instance, cognitive or behavioural problems, these positive reinforcements are often less clearly present in the children’s behaviour, compared to their typically developing peers (Schuengel and Janssen, 2006). The current study focuses on children with severe or profound intellectual (or multiple) disabilities. These children have a significant cognitive (or multiple) delay (corresponding with an estimated IQ < 40 at adult age) and have life-long extensive support needs (Maes et al., 2020). In addition, the prevalence of (neuro)motor impairments is higher in this group (Arvio & Sillanpää, 2003) and they often communicate at pre- or protosymbolic level (Dhondt et al., 2019). The severe and complex disability of these children can reduce the clarity of their behavioural responses to their parents (Schuengel and Janssen, 2006; Schuengel et al., 2013). For example, they show less clear attachment behaviours such as support seeking during distress, which is nevertheless an important signal for caregivers to nurture their self-confidence as a parent (Bosmans et al., 2020; Kobak and Bosmans, 2019).

Parents’ levels of PSE are, however, not invariable (Benedetto and Ingrassia, 2017). PSE has been a strategic target in interventions, especially to attain short-term changes (Hohlfeld et al., 2018; Kendall and Bloomfield, 2005; Schuengel and Oosterman, 2019). One particular strategy to target PSE in interventions is by using psychoeducation, possibly because knowledge contributes to shaping PSE (Teti and Gelfand, 1991). For example, Shorey et al. (2015) reported a positive effect on PSE in first-time mothers receiving postnatal psychoeducation. Similarly, Chau and Giallo (2015) advised to provide (postnatal) psychoeducation on fatigue to prevent the negative effects thereof on first-time parents’ PSE. In a study on parents of children with a mild intellectual disability in Sweden, Huus et al. (2017) concluded that being well-informed leads parents to develop higher levels of PSE.

The current pilot study examined the feasibility of a psychoeducational digital micro-intervention for parents of children with severe or profound intellectual disabilities, which entailed watching four psycho-educational videos on parent–child attachment (both in general and applied to children with disabilities). The current study piloted the video series in a small sample of parents and explored three particular domains of its feasibility (following the typology of Bowen et al., 2009):

1) Acceptability of the micro-intervention by parents: How did parents of children with severe or profound intellectual disabilities perceive the video series in terms of the personal meaning it had for them? How did they react to the intervention?

2) Implementation of the micro-intervention: To what extent was the intervention successfully delivered to the parents in their home environment? How many videos did they actually watch (fully, repeatedly, in pieces…)?

3) Limited efficacy of the micro-intervention: How did parents’ PSE levels change from before to after watching the video series? How did parents’ knowledge on parent–child attachment change from before to after watching the video series?

A mixed-method approach (with a predominant focus on the quantitative data) was adopted, using both online daily sampling tools and questionnaires.

Method

Participants

Using purposeful sampling, a total of 23 families were invited by e-mail and an invitational video to participate in the current study. These families were known to the authors from a previous study, in which they were interviewed about their parent–child relationship. Three families (13.0%) did not respond to the invitation after several reminders, and two families (8.7%) indicated that they refrained from participation. The reasons for non-participation were the difficult family circumstances and not being able to incite themselves to watch online (psychoeducational) videos, respectively. The other 17 families (73.9%) agreed to participate in the study, of which one dropped out before the start of data collection (without a specified reason). The relevant parent and child characteristics of the current sample are presented in Table 1. All parents had at least one child with a severe or profound intellectual (or multiple) disability or whose child functioned at that level according to the care professionals in case an official diagnosis was (yet) lacking. These children officially lived at home with their biological parent(s), which implied that they spent most evenings/nights, weekends and holidays with the participating parent(s), although the children’s participation in (specialised) day care or school was not excluded. Only a minority of children (temporarily) spent only three days a week with their parents (n = 2) or alternated weekly between their divorced parents (n = 2).

Table 1.

Sample characteristics (n = 16).

Parent characteristics		M	SD	n (%)
Gender
	Female (participating mothers)			12 (75.0)
	Male (participating fathers)			4 (25.0)
Age (years)
	Mothers	40.78	5.26
	Fathers	43.30	5.52
Work situation of the participating parent
	Full-time (external employer)			9 (56.3)
	Part-time (external employer)			5 (31.3)
	Full-time personal assistant			2 (12.5)
Cohabitation of (biological) parents
	Yes			14 (87.5)
	No			2 (12.5)
Child characteristics (of child with severe or profound intellectual disabilities)
Gender
	Girl			6 (37.5)
	Boy			10 (62.5)
Age (years)		7.95	2.00
Cause of severe or profound intellectual disabilities ^a
	Known			2 (12.5)
	Unknown			14 (87.5)
Parity
	Firstborn			10 (62.5)
	Second born			5 (31.3)
	Third born			1 (6.3)
One or more sibling(s)				12 (75.0)
	One			4 (25.0)
	Two			6 (37.5)
	Three			2 (12.5)
Attend special education or day care full-time				12 (75.0)
Sleep at home (every night) ^b				13 (81.3)

^aIn case an official diagnosis was given to the children (besides the broader diagnosis of severe or profound intellectual disabilities), these were versatile including a range of genetic, neurological and medical syndromes. For some children a combination of multiple diagnoses was reported.

^bFor two children, this implied alternating between both parents’ houses due to co-parenting after marital separation.

Procedure

After parents’ initial consent via e-mail or telephone, they signed written informed consents. The entire data collection was done online in a period of three consecutive weeks (see Table 2). The researchers consulted with each family to plan these weeks according to the families’ agenda. This flexibility was important to families because the data collection occurred during the Covid-19 pandemic and this entailed some additional challenges (e.g. children who could not go to day care). In families where the child was not at home for three consecutive weeks (e.g. due to hospitalisation, respite care or co-parenting), the research was planned as much as possible so that the child was at home with the participating parent in Week 1 (pre-measures) and Week 3 (post-measures). In case the participating parent did not spend time with their child on a specific day during the latter weeks, they responded ‘not applicable’ on the daily diary questions and their diary answers of that day were not included.

Table 2.

Overview of the intervention protocol.

Week 1: Pre-measures	Week 2: Intervention	Week 3: Post-measures
- One-time questionnaire (background, knowledge, parenting efficacy) – Day 1	- Watching 4 videos on parent–child attachment – Day 8–14	- Daily diary questions – Day 15–21
- Daily diary questions – Day 1–7	- One-time questionnaire on the viewing experience – Day 14	- One-time questionnaire (knowledge, parenting efficacy) – Day 22

Before the start of data collection, all parents received a personalised and detailed time table with estimations of their time investment (based on several trials during a pilot phase). In the first week, a one-time questionnaire was sent to parents using Qualtrics (https://www.qualtrics.com) to collect background information and the pre-measures on attachment knowledge and PSE. In addition, parents received daily diary questions for seven consecutive days via m-path (https://m-path.io/landing/). M-path is a free tool, designed at KU Leuven (Belgium), to provide blended care for clients by connecting the therapist and the client through a user-friendly app. Besides for its clinical purpose, the app is as well appropriate for use in research. The diary questions (see ‘Instruments’) were sent to parents daily using m-path on a pre-agreed time point (in the evening). In the second week, all measurements were interrupted so that parents could participate in the intervention at their own pace, which consisted of watching four psychoeducational videos (using the private weblinks in e-mail and/or the home button in m-path). On the last day of the second week, parents received one-time questions via Qualtrics on their viewing experience. In the third week, parents received the exact same daily diary questions via m-path and finally, they filled out the post-measures on attachment knowledge and PSE via Qualtrics (after completing the daily measures on seven consecutive days). Parents were asked to complete all questionnaires alone, so that it only represented the experience of the participating parent. However, in the questionnaire on parents’ viewing experience, parents were allowed to pool their opinions when they watched the videos together with their partner. The Social and Societal Ethics Committee (KU Leuven, Belgium) ethically approved the research design and protocol (G-2020-2343).

The digital micro-intervention

The micro-intervention consisted of watching psychoeducational videos on parent–child attachment and sensitivity at home. Psychoeducation refers to a series of educational interventions in which parents receive information on a specific theme, in this case the theme of attachment and sensitivity for children with disabilities. In this way, psychoeducation is aimed at increasing parents’ knowledge, skills and increasing their parenting efficacy (Bonsack et al., 2015). In this study, the (Dutch) psychoeducational video series consisted of four parts in a specific order with a duration between approximately 11 and 19 minutes for each part (the total duration was a little below one hour). The videos were developed in close collaboration with two parents of children with disabilities who gave feedback on the script as experts-by-experience and after several feedback rounds between the authors and the surrounding research team. The videos were assembled using fragments of interviews with researchers (on the domain of intellectual disability, and/or attachment), footage of interactions between children of the target group and their caregivers, spoken citations from parents and animated visuals (with voice-over). In the first video (tinyurl.com/y27y9ykw), called ‘Safe haven, secure base: A short introduction in parent-child attachment’, parents got a broad overview of the most important concepts of attachment theory. In the second video (tinyurl.com/y6c8dpau), called ‘Parents talking: My child with a disability and me, a glimpse into our relationship’, the perception of parents on their attachment relationship was explored. Quotes from other parents (peers) had a central place in the video, but to ensure privacy these were anonymised and recorded by actors. In the third video (tinyurl.com/y523p8l8), called ‘Researchers talking: The unique relationship between parents and their child with a disability’ an overview was given of the attachment research that was recently conducted by the authors in the specific target group of children with severe or profound intellectual disabilities. In the fourth and final video (tinyurl.com/y433cl3q), called ‘I see, I see… what you can see as well: About reading the signals of a child with a disability’, the importance of sensitivity was talked through with parents, complemented with hands-on illustrations and tips from a special education teacher.

Each of the four videos ended with an invitation to reflect upon some questions, related to the content of the video. The invitation also included an encouragement to talk these topics through with their partner, family members and/or professional caregivers, if desired. These assignments were non-binding; which implies that parents were not asked to hand in their answers on these reflection questions. Examples of the reflection questions were: ‘How does your child show that (s)he needs proximity?’ (Video 1); ‘Which quotes of parents reflect your own experience the best?’ (Video 2); ‘With which behaviours does your child differentiate between known and unknown persons?’ (Video 3); ‘How does your child express his/her emotions?’ (Video 4). Finally, in the fourth video, a (non-binding) appeal was made to parents to record and talk through their child’s interactions or behaviours using short videoclips (as was demonstrated in the video).

Instruments

Background questionnaire

Parents completed a general questionnaire on a few selected background variables (constructed by the researchers), gathering information on the parents’ characteristics (e.g. the current employment of the parent, birth date), the family’s characteristics (e.g. received family support) and the child’s current daytime activities and the amount of nights that they sleep at home. For the other relevant background variables (such as the child’s birth date and diagnoses), parents were explicitly asked for permission to use these data from the previously collected data-set of (Vandesande et al. 2021), to which all consented.

The viewing experience questionnaire

At the end of the intervention week (Week 2), parents received questions on their viewing experience to explore the acceptability and implementation of the micro-intervention. The questionnaire comprised open questions, multiple choice questions (with single or multiple answers), rank order and scale questions. First, parents were asked to give information on the timing and context of watching the videos (e.g. the number of videos that were fully watched, the amount of viewing sessions, whether videos were watched several times, the company with whom and the setting in which the videos were viewed). Second, a few questions asked about using videos as a medium to provide psychoeducation, whether they had experienced this as pleasant or not and whether certain topics were missing. Third, several questions probed towards the personal meaning that the videos had for the parents (e.g. order of relevance, whether they completed the non-binding reflection tasks, what had struck them the most). For this purpose, parents also rated nine statements on a 10-point (star) scale. An overview of these statements is given in Table 3.

Table 3.

Descriptive statistics of the statements on parents’ viewing experience (rated on a ten-point scale).

To what extent…	M	SD	Min	Max
…have you learned something through the videos?	7.25	2.14	2.00	10.00
…did watching the videos make you more confident about yourself as a parent?	6.88	2.13	2.00	10.00
…would you recommend the videos to other parents of children with disabilities?	8.38	1.71	6.00	10.00
… did watching the videos have an impact on how you perceive your relationship with your child?	6.56	2.50	1.00	10.00
… did watching the videos make you doubt on yourself as a parent?	3.38	2.28	0.00	7.00
… have you thought about the content of the videos afterwards?	7.94	1.34	6.00	10.00
… have you talked to others about the videos afterwards?	4.63	2.80	1.00	10.00
… did watching the videos make you think about things you normally don’t (really) think about?	7.38	2.19	3.00	10.00
… did watching the videos mean anything to you personally?	8.25	1.57	6.00	10.00

The Perceived Maternal Parenting Self-Efficacy Scale (PMP-SE; Barnes and Adamson-Macedo, 2007)

To take inventory of PSE during the pre- and post-measures, parents completed the PMP-SE, which was originally developed to operationalise domain-specific PSE in the target group of preterm infants (Barnes and Adamson-Macedo, 2007). Due to the overlap in some of the specificities of care for young babies and care for children with severe disabilities (such as the accents on reading cues, soothing, medical care…), the items of the PMP-SE were appropriate to study parenting efficacy in parents of children with severe or profound intellectual disabilities. In order to make the items applicable for the current study, the term ‘baby’ was, however, changed to ‘child’. Other authors, such as Shorey et al. (2015) have used the PMP-SE as well in target groups other than preterm infants. These authors evaluated a postnatal psychoeducation intervention for first-time parents and reported positive effects on the parenting efficacy measured by the PMP-SE. Together with other studies (e.g. De Cock et al., 2015), the PMP-SE seemed sensitive to change due to the effects of interventions (Schuengel and Oosterman, 2019).

The PMP-SE consists of 20 items, each to be rated on a four-point scale, ranging from strongly disagree to strongly agree. Exemplary items are: ‘I believe I can tell when my child is tired and needs to sleep’, ‘I can read my child’s cues’ and ‘I believe that my child and I have a good interaction with each other’. The PMP-SE has four a priori defined subscales to measure parenting self-efficacy on the domains of a) caregiving procedures, b) evoking behaviours in the child (e.g. soothing), c) reading the child’s behaviours and communicative signals and d) situational beliefs (ability to evaluate the overall interaction).

Daily diary questionnaire

For seven consecutive days during pre- and post-measures, parents answered daily diary questions (once a day) during the evening. First, parents indicated the total number of hours that the child spent with them that day (with exception from the hours during the night). Second, parents answered (using a slider) on a scale from 1 (not at all) to 100 (very much) to which extent they felt like a good parent for their child on that particular day.

Attachment knowledge questionnaire

During pre- and post-measures, parents evaluated ten statements on parent–child attachment in general and in children with disabilities (see Figure 1 for an overview). Examples of the statements, to be rated on a four-point scale (ranging from strongly disagree to strongly agree), are: ‘As a parent, you are in complete control of your child's attachment development’ or ‘Children with severe disabilities do not develop preferences for certain persons’.

Data analysis

Missing data

Data was missing for one parent on the daily diary questions on the second day of post-measures (Week 3). For all other parents, the daily diary questions were registered each day (total amount of registrations was 223 across 16 parents). However, due to the child’s stay in residential care, respite care or rehabilitation for certain days on which the parents did not see their child, data was excluded for eight days across four parents in the pre-measures (Week 1) and for seven days across three parents in the post-measures (Week 3). In total, 208 registrations of the daily diary questions were eventually included in the analyses.

Analyses

With regard to the acceptability of the micro-intervention by parents, descriptive statistics (e.g. M, SD, Min, Max, frequencies) were reported for the nine rated statements, which questioned parents about the personal meaning the videos had for them and the yes/no questions. These results were illustrated and/or nuanced with quotes from parents’ answers on the few complementary open questions, filled out in the viewing experience questionnaire (immediately after the intervention week): ‘What do you remember most about watching the videos? What has struck you the most? Was it pleasant/unpleasant for you to watch these videos?’.

With regard to the implementation of the micro-intervention, frequencies and/or percentages were calculated for the different answer categories (e.g. the number of videos they had fully watched, the number of viewing sessions…).

Finally, to test the limited efficacy of the micro-intervention, descriptive statistics (M, SD, range) were calculated for the sum score and the subscale scores of the PMP-SE during the pre- and post-measures. A paired sample t-test checked for a statistical significant difference between the means of the pre- and post-measures of the PMP-SE (with significance level .05). The Shapiro–Wilk normality test indicated a normal distribution in the population for the pre-measures, W(16) = 0.96, p = .65 and the post-measures, W(16) = 0.91, p = .11. For the daily diary measure of parenting self-efficacy (‘To what extent do you feel a good parent for X today?’), descriptive statistics were calculated (M, Median, SD, range) for the pre- and post-condition separately. A paired sample-test was conducted to check for statistical significance. The assumption of normality was met for the pre-measures, W(16) = 0.96, p = 0.67 and the post-measures, W(16) = 0.93, p = 0.21. In addition, Non-overlap of All Pairs (NAP) values were calculated to contrast the pre- and post-ratings of parents on the daily diary question. NAP is a nonparametric method to judge the improvement between two phases (typically used in single-case research), by looking at the extent to which data in the baseline (pre-condition) do not overlap with data in the intervention (post-condition). The advantage of using NAP over mean or median differences across phases, is that they are less susceptible to extreme outliers since each pair of data-points across phases are compared (Parker and Vannest, 2009). NAP values range between 0 and 1, with values above 0.50 indicating an improvement (Parker and Vannest, 2009). In the current study, NAP values were firstly calculated for each parent and afterwards combined in a weighted average NAP value across parents (the combined NAP effect size) using a web-based NAP calculator (Vannest et al., 2016). With regard to parents’ opinions concerning the general statements on parent–child attachment, figures were constructed to display the distribution across answer categories (in percentages). There was opted to only discuss shifts in these distributions in the pre- versus post-condition, not to calculate a score to indicate the amount of ‘correctly’ answered statements (since answers can often be nuanced).

Results

Acceptability of the micro-intervention

All parents indicated that videos were a good medium to provide psychoeducation on the theme of attachment. In the open questions, they explained that the videos were overall clear, well assembled, enjoyable to watch, accessible and motivating (though some minor suggestions for improvement were given related to the structure, the backgrounds, the music and the pace). Several parents indicated that online videos in itself were a good medium, because they offered the possibility to pause in order to reflect, to watch certain parts several times and to fit them in their personal schedule. For most parents, the videos were enjoyable because they gave more insights and because it offered them some kind of confirmation (e.g. that they matter, that they are going on the right track). A large number of parents explicitly mentioned that the relativising message of the videos, namely, that it is normal for parents to struggle sometimes with noticing, reading and interpreting signals of their child and the concept of good-enough-parenting, was the most important message of the videos for them. However, one parent nuanced this by indicating that the video series left her with mixed feelings, as she explained:

‘It was pleasant to see the video series but sometimes also difficult, confronting. It raised many questions: Do I hug my son enough? The other parents don’t seem to mention the pressure and the restriction in freedom that we experience in caring for our son, why is that? He is now temporarily living [partially] in residential care. How does that impact our attachment relationship? What is it like for him not to see us every day now?'

‘The video-recorded interaction with the teacher was nice to watch, but also raised concerns about my own parenting. Am I doing well enough? There may not be enough quality moments because life is already so busy. I certainly thought it was a good thing that the emphasis was placed in the videos on good-enough-parenting. That message made me feel good’.

To the question which video they considered most relevant, half of the parents (n = 8) placed the fourth video on sensitivity at the top of their hierarchy (75% of the parents placed this video on the first or second place). Several parents explained that this video contained the most hands-on practical advices, which they very much appreciated. Over 60% of the parents indicated that the first video, which comprised a general introduction on attachment, was very relevant (i.e. first or second place in the hierarchy; n = 10; 62.6%). For half of the parents, the third video, in which researchers talked about parent–child attachment research in the target group of children with disabilities, was the least relevant (almost 70% of the parents placed this video on the third or fourth place; n = 11, 68.8%). Ten parents reported that they didn’t miss anything in the video series (62.5%); the others (n = 6, 37.5%) suggested, for example, to add video fragments of other parents (not anonymised), more hands-on tips and information on grandparents.

Table 3 reports parents’ evaluations of the videos with regard to the personal meaning it had offered, rated on a ten-point scale. In general, parents reported that the videos stimulated their learning and thinking, had personal meaning for them and they would recommend these videos to their peers. One parent reflected: ‘He sends out signals, but I have never really thought about what it is like for him when there is no response to those signals. Also, I was not aware that those signals affect his attachment to us’. These reflections made some parents more aware of the subtle signals and stimulated close observation: ‘I now find myself observing much more in detail how he deals with strangers in order to see if I can deduce anything from his gaze/posture...’, ‘It made me realise that attachment is a broader concept than I sometimes think, that small things are also related to attachment, (…) that patience is something that we must cherish and build on in order to get even more reaction, that every sound can mean something and that reflection is needed in order to be able to interpret this’. For several parents, recognising themselves in the stories of other parents or in the examples that were given, was very powerful: ‘It really struck me that I recognised myself so much in what people I didn't know personally said about the relationship with their child with a disability. It is rare that I have the opportunity to speak to another parent in a similar situation or at least in such a way that has depth’. Furthermore, as Table 3 shows, the videos did not make them doubt themselves as parents. On the other hand, the videos also did not stimulate talking on the subjects and did not impact their perception of the relationship with their child. One parent explained that it was difficult to apply the theory of attachment to their specific situation.

Implementation of the micro-intervention

In this study, all parents had fully watched the four videos, either in one (n = 1, 6.3%), two (n = 6, 37.5%), three (n = 6, 37.5%), four (n = 2, 12.5%) or more than five (n = 1, 6.3%) different viewing sessions. Two parents watched one or more videos several times (12.5%). Most parents watched the videos alone (n = 14; 87,6%), except for two parents who watched them with their partner (12.5%). The majority of parents watched the videos at home, when it was calm (e.g. when the children were sleeping; n = 13; 81.3%). With regard to the reflection questions, two parents reported that they completed them all (12.5%), seven parents completed a few of them (43.8%), five parents did not yet complete them but planned to (31.3%) and two parents were not planning to complete the questions anymore (12.6%).

Limited efficacy testing of the micro-intervention

Table 4 reports the descriptive statistics of the sum and subscale scores of PSE, measured by the PMP-SE (Barnes and Adamson-Macedo, 2007). The mean for PSE in the pre-condition is slightly above the mean in the post-condition (a difference between the means of 1.44 in a theoretical range of 20 to 80 points). This trend is also notable on the subscale scores, except for the first subscale (i.e. care taking procedures). However, a paired samples t-test conducted to preliminary compare PSE in the pre- and post-condition, showed no significant difference in the scores for the pre- (M = 65.19, SD = 7.15) and the post-measures (M = 63.75, SD= 7.50), t(15) = 1.09, p = .29.

Table 4.

Descriptive statistics of the PMP-SE (n = 16) pre versus post.

	M		SD		Range		Potential range
	Pre	Post	Pre	Post	Pre	Post	Potential range
Factor 1: Care taking procedures	13.00	13.19	1.79	2.01	11–16	11–16	4–16
Factor 2: Evoking behaviour(s)	22.19	21.56	3.53	3.56	16–27	14–28	7–28
Factor 3: Reading behaviour(s) or signalling	19.19	18.56	2.43	2.66	15–23	14–23	6–24
Factor 4: Situational beliefs	10.81	10.44	0.98	1.09	9–12	8–12	3–12
Total sum score	65.19	63.76	7.15	7.50	51–78	52–79	20–80

On average, parents rated themselves as a good parent during the daily diary questions in the pre-condition (M = 75.12, SD = 13.38, Med = 75.36, Min = 49.71, Max = 96.14), and even higher during the post-condition (M = 78.00, SD = 9.87, Med = 78.71, Min = 58.00, Max = 90.71). A paired samples t-test conducted to compare these ratings in the pre- and post-condition, showed no significant difference at the .05 level, t(15) = -1.77, p = .10. The NAP effect sizes showed individual variability, ranging between 0.24 and 0.97 (and p-values between .85 and .03). The combined NAP effect size was 0.58, indicating small improvement on the group-level according to the criteria of Parker and Vannest (2009).

Figure 1 compares the percentages of parents’ answers on the parent–child attachment statements in the pre- versus post-condition. On both time points, there were statements on which there was more discord across parents (e.g. ‘When a child is born, he/she is immediately attached to his/her parents’), and statements on which there was more unanimity (e.g. ‘A child builds an attachment relationship with his/her parents through many repetitive care experiences’). Comparing the pre- and post-condition, the distribution of parents’ answer categories showed a similar pattern for most statements. There were, however, some small shifts in the gradation of their answer over time (e.g. shifts from agree to strongly agree on the statement ‘As an attachment figure, it is important that you support your child in difficult moments, but also that you encourage exploration’). In general, the category ‘I don’t know’ was less used by parents during the post-condition. However, in the post-condition, some statements seemed to raise additional doubts that were not reported in the pre-condition (e.g. ‘Children with (severe) disabilities have as many opportunities as typically developing children to express their preference for certain persons’). Furthermore, in the post-condition, there were shifts that expressed parents’ positive appraisals, for example to the ‘agree’-side for some statements (e.g. ‘If you don’t react sensitively and warmly to your child once, this will not have an immediate effect on the relationship’), and to the ‘disagree’-side for other statements (e.g. ‘Children with (severe) disabilities are more often insecurely attached compared to typically developing children’). In case parents’ answers were (close to) unanimous, their answers were in line with what the researchers would have expected. This was with the exception that over 70% of the parents disagreed with the statement that children with severe disabilities were more often insecurely attached compared to typically developing children, whereas literature suggests the contrary.

Discussion

The current feasibility study piloted a psychoeducational video series on attachment targeted at parents of children with severe or profound intellectual disabilities. The digital micro-interventions’ acceptability, implementation and preliminary effects on parenting self-efficacy (PSE) and parents’ perceptions of attachment were explored. The three-week intervention study included 16 parents of children between four and ten years old with severe or profound intellectual disabilities, which is a group of almost 75% of the invited parents. Overall, the study showed promising results concerning the micro-intervention’s acceptability by parents and implementation. In our sample, the preliminary efficacy tests did not show major changes on PSE and only little changes on parents’ perceptions of attachment comparing pre- and post-measures.

With regard to the video series’ acceptability (Research Question 1), parents were positive on using these videos as a medium for psychoeducation. They indicated that the videos had offered them some kind of personal meaning (e.g. some parents reported feeling acknowledged in their role as attachment figure) and had stimulated their learning and reflection. They would consequently recommend the videos to peers. Especially the fourth video, on parental sensitivity, was best welcomed by parents because of its hands-on tips, modelled by a teacher with years of experience within the target group. This seems to suggest that parents’ questions were mainly situated at the domain of reading and being responsive to the (subtle) communicative cues of their children, as was corroborated by previous research (Vandesande et al., 2019, 2021). Indeed, this requires a complex interpretation process given the children’s limited communicative abilities (Singh et al., 2015). Drawing on the one parent’s testimony of being left with mixed feelings after watching the video series, it should be acknowledged that careful consideration is needed regarding the ways psychoeducation is offered to particular (vulnerable) parents. For instance, for some parents a follow-up discussion with a clinician or combination with other micro-interventions (such as video-feedback) can help to better understand and apply certain aspects of the videos.

In the current study, the digital micro-intervention was implemented successfully in the parents’ daily life (Research Question 2), as was reflected by the low numbers of drop-out (both in the reactions to participate and during the intervention). All parents fully watched the videos at least once, as was intended, and the majority completed and/or plan to complete the (permissive) reflection tasks.

With regard to the preliminary effects on PSE and parents’ knowledge/perceptions of attachment (Research Question 3), both the one-time questionnaire of PSE and the daily diary question, showed no significant pre-post changes on a group level. This was with the exception of the combined NAP value of the daily diary questions, which was less subjected to outliers, indicating small improvement after watching the videos regarding the question of feeling like a ‘good parent on that particular day’. On an individual level, variation in parents’ answers was, moreover, registered. Parents’ answers regarding the statements on attachment showed similar patterns over time, except for some small shifts (for example, in the strength of their chosen answer category). Interestingly, the answer category indicating ‘I don’t know’ was less selected during post-measures, but at the same time some new uncertainties popped up. This suggests that, whereas parents were stimulated by the videos to reflect on certain issues, for some parents, the videos did not completely answer their questions on the topic (e.g. the issue of whether sensitivity is changeable). In addition, it was remarkable that 70% of the parents reported, after watching the videos, that they agreed with the statement that children with severe disabilities were not more at risk for developing insecure attachment. Although children with severe or profound intellectual disabilities do not necessarily develop insecure attachment, literature suggests that they are more likely to be classified as insecurely attached (Howe, 2006; Schuengel et al., 2013; Schuengel and Janssen, 2006). The fact that parents perceive this otherwise illustrates their positive mindset and resilience (Blacher et al., 2007; Luijkx et al., 2019; Van keer et al., 2019; Vandesande et al., 2019), and the positive message of the video series. Thompson et al. (2013) described that positively reframing could be a possible coping style to handle the negative aspects of raising a child with developmental disabilities. Another explanation can be that ‘security of attachment’ is a highly value-laden term for parents, carrying the implication of them being ‘bad parents’. In future research, the use of these technical terms should be investigated, especially with regard to the extent to which this elicits a social desirability bias.

Several limitations of the current study should be acknowledged. First, the pilot study stretched over a period of only three weeks (with one week of intervention). This may have been a too limited time span to have (significant) effects on PSE. In addition, during this three-week period a limited number of children in our sample did not spend time with the participating parent on a few of the days, due to foreseen circumstances (e.g. co-parenting after marital separation) or unforeseen circumstances (e.g. parent having to work late). In combination with the short time span of the intervention, these circumstances limit the chances of the intervention to have a profound effect on parents’ views of their parent–child relationship or sense of parenting self-efficacy. For future development of the intervention, it should be recommended to stretch the intervention period or to adapt it flexibly, depending on the particular family circumstances and parents’ needs. In that way, the chances are maximised for pieces of information of the psychoeducational videos to get through to the parents and that these bring about changes in parents’ perceptions or parenting self-efficacy, especially given the fact that these changes are assumed to occur in the presence of their children. It can also be hypothesised that small improvements in PSE might be overlooked because the intervention did not simultaneously target parenting competences, which might still be a source of negative feedback for PSE (Schuengel and Oosterman, 2019). For example, whereas parents are more aware of the importance of reading and reacting to their child’s signals, they might be even more frustrated when there are little successes in this area. Another explanation could be that the parenting practices addressed in the videos may not have mapped well upon the PMP-SE (Barnes and Adamson-Macedo, 2007). More particularly, the items of the PMP-SE are not all directly related to parental sensitivity and attachment, but also relate broader caregiving experiences that were not addressed in the psychoeducation (e.g. ‘I am good at bathing my child’). Second, as mentioned before, the sample was fairly limited, which resulted in low statistical power (Wilson Van Voorhis and Morgan, 2007), as is often the case in feasibility studies (Bowen et al., 2009). To account for the first and second limitation, future micro-trial intervention research is recommended, in which 1) the sample is enlarged to find more robust statistical effects and to create opportunities to make differentiated subgroups of parents, based on their strengths and needs (What works for whom?) and in which 2) the current micro-intervention is not only separately tested, but also embedded in a broader intervention trajectory, tuned to the profiles of these families. In the vignettes from the study of (Vandesande et al. 2021) it became clear, for example, that a large number of parents struggled with care-work-life balance or the lack of social (informal) support (in line with Van keer et al., 2019). However, these struggles might have an impact on the parent–child attachment relationship, these are not targeted by (mere) psychoeducation. Thus, including other intervention components is warranted to target these influencing struggles and allows us to look for possible synergetic effects, for example using the methodology of a micro-trial intervention study (as described in Leijten et al., 2015). A third limitation is that recruitment for the pilot study was done from a limited pool of parents, previously known to the authors from a different (non-interventional) study. A fourth and final nuance that should be acknowledged is the (time) context of this online study. The data collection occurred during the (second wave of the) Covid-19 pandemic. More stringent measures (including a strict reduction of social contacts) were taken during the three-week intervention period (for most parents at the start of the post-measures). This might have influenced parents’ perceptions, because we learned from the pre-measures that the earlier Covid-19 lockdown had a serious (negative) impact on most of these families (e.g. stress regarding health, care options that were suddenly restricted…).

In the latter time period, in which clinicians are forced to flexibly provide more remote/online interventions, the need to test the feasibility of new, digital interventions is urgent. The current feasibility study reported on a short psycho-educational video series on attachment for parents of children with severe or profound intellectual disabilities and showed promise regarding its acceptability by parents and its successful implementation. Most importantly, parents retrieved personal meaning from watching the video series, as it made them reflect more upon the theme of parent–child attachment and become more aware of the subtle communicative signals of their children. The preliminary efficacy tests showed, however, only small (no significant) changes in parents’ PSE or their perceptions on attachment comparing pre- versus post-measures. These preliminary results stress that the subjective impression of effect is something different than the observable effects on parents’ behaviours (as was also found in Damen et al., 2021). Clinicians should be aware of these results as to calibrate their expectations of the effects of a singular intervention component, such as psychoeducation or of the effects of interventions in this target group with a very short intervention period. Thought must, for instance, be given to how psycho-education can be embedded in an intervention trajectory (possibly consisting of multiple micro-interventions) and can be tailored to parents’ individual needs to have robust, beneficial effects on parents’ belief in themselves as attachment figures.

Footnotes

Acknowledgements

We thank all the parents for their generous participation in this online research, for their enthusiastic reactions to the videos and their constructive feedback. We also thank dr. Ines Van keer, who was – besides the authors – one of the researchers who psycho-educated the parents in the videos in Layman’s terms. We explicitly thank Evi Timmermans for inspiring parents with regard to being sensitive (in the fourth video) and Katja Jansen who did a great job editing the videos.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the FWO Flanders (Fonds Wetenschappelijk Onderzoek) under Grant 1174917N.

Author’s note

Please find attached our manuscript entitled “Piloting attachment psychoeducation provided to parents of children with severe disabilities: Testing the feasibility of a digital micro-intervention”, to be considered for publication in Journal of Intellectual Disabilities. Our manuscript has not been published or currently submitted elsewhere and is significantly different from other manuscripts we have submitted elsewhere.

Author contributions

All authors have contributed to, seen, and approved of the manuscript and agree to the order of authors as listed on the title page.

Ethical approval

This study met the ethical procedures and standards of the KU Leuven, Belgium.

ORCID iDs

Sien Vandesande

Carlo Schuengel

Guy Bosmans

Paula Sterkenburg

Bea Maes

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