It is well-established that the quality of the early caregiving environment, and specifically the quality of the interaction and the relationship between young children and their primary caregiver(s) are positively associated with a wide array of children’s social, emotional and cognitive outcomes (e.g. [1,2,3].). Caregivers thus play a pivotal role in determining quality of care for children’s development. In Denmark, where the current study is conducted, the majority of children younger than three years are enrolled in professional childcare more than 30 h per week [4]. Therefore, the childcare setting constitutes an important part of children’s early caregiving environment, and following, childcare quality becomes important in terms of promoting healthy child development.
When defining ‘quality of care’ in childcare, a distinction between structural and process quality is typically made [5]. Structural quality refers to characteristics such as caregiver-child ratio, group size, caregiver educational level, and caregiver stability. Process quality refers to the quality of experiences and interactions (with caregivers, other children, materials, and parents) children have within the childcare settings [5]. Whereas structural quality is considered a prerequisite of process quality and as such of indirect effect on children’s developmental outcomes, process quality is thought to directly affect young children’s well-being and learning as well as long-term healthy social, emotional, and cognitive development [6,7,8,9,10]. The importance of process quality for children’s development is stressed by the results from a recent meta-analysis of 17 longitudinal studies including 16,461 children from nine European countries. This review showed that high-level process quality in early childcare has a significant positive and lasting association on children’s language and cognitive development irrespectively of family background and SES [11].
In early childcare (i.e. children younger than 3 years old) the relationship and the daily interactions between children and their caregivers are considered the most important aspect of process quality [12, 13]. In both high and low SES populations studies have found that young children’s development and well-being is directly linked with caregiver-child interaction quality [14,15,16,17]. While all children benefit from high quality caregiver-child interactions [5,6,7,8], (positive and negative) effects of the caregiver-child relationship are strongest for children at higher risk for adversity [9, 18,19,20].
In Denmark, a number of interventions have been implemented in center-based childcare to promote healthy development in children coming from at-risk backgrounds [21]. However, the majority of the interventions focus on improving specific child skills such as language acquisition or motor development [22, 23]. As studies show that the quality of the caregiver-child relationship can act as a protecting factor in vulnerable children’s lives [9, 18,19,20] this is an important target of intervention in terms of preventing adverse child outcomes.
A recent meta-analysis examining the effects of interventions focusing on professional caregivers’ relational capacity and interactive skills on the caregiver-child interaction quality found a moderate positive effect on overall caregiver-child interactions (k = 19, Hedges’ g = 0.35) [24]. While the authors conclude that intervention programs in early childcare may lead to higher childcare quality, they also stress that there is a need for more well-designed randomized controlled trials of various interventions to shed light on which intervention programs are most effective in terms of promoting interaction quality and supporting healthy development in children.
Therefore, the overall objectives of this study are to examine the effect, acceptability, and feasibility of a professional development intervention based on the Circle of Security approach [25] offered to Danish caregivers working in childcare centers with children aged 0–3 years old.
Caregiver interactive skills and sensitivity
Caregiver sensitivity refers to the extent to which a caregiver recognizes children’s individual emotional and physical needs and responds appropriately and promptly to their cues and signals [26] and is the key aspect of caregiving in attachment theory [27, 28]. Parental sensitivity is known to be predictive of a range of positive child outcomes, such as attachment security, language, cognitive, and socio-emotional functioning [29]. Accordingly, sensitivity is considered a key element of professional childcare quality [30]. Indeed, professional caregivers who are responsive to the children’s need for comfort, closeness, and regulation during distress and at the same time stimulate the children’s exploration and provide opportunities to learn, are generally considered as providing high-process-quality childcare [13, 31, 32]. Therefore, caregiver sensitivity is an important target for interventions in childcare and it is the primary outcome in the current study.
It may be challenging for a professional caregiver to stay sensitive to children who have been exposed to low-quality parental care [33]. Children from families at higher risk of adversity are more likely to enter childcare with so-called insecure attachment strategies developed in the interactions with their primary caregiver(s). Child-caregiver attachment quality reflects the emotional bond between a child and a specific caregiver, and is defined by the child’s tendency to seek comfort, help and protection in situations perceived by the child as uncertain, threatening, or in other ways distressing [28]. A child’s attachment relationship to its primary caregiver forms this child’s expectations and behavioral strategies when interacting with new caregivers [28], and a child who has developed insecure attachment strategies to the primary caregiver may show externalizing behavior or social withdrawal when in need of comfort and support [34]. For the caregiver, this may in turn may make it more difficult to interpret and meet the child’s needs as compared with (secure) children who seek comfort and help when needed [28, 35]. Accordingly, it has been documented that the quality of the relationship between children and their professional caregivers often corresponds to the quality of the parent–child attachment relationship [33], thereby putting children who are insecurely attached to its primary caregivers at ‘double risk’. Indeed, children exposed to low quality parental and low quality childcare are consistently found to have the worst developmental outcomes [36,37,38].
While research thus suggests that a child’s interactive strategies may be reproduced in interactions with new caregivers, meta-analytic evidence also shows that the interactive behavior, and specifically the caregiver’s ability to stay sensitive to childrens emotional needs, predicts the quality of the relationship between children and their professional caregivers independently of the children’s relationhip quality to their primary caregivers [33]. In other words, if the professional caregiver is able to stay sensitive to a child who is insecurely attached to its primary caregiver, it is possible for the child to develop a secure relationship to the professional caregiver regardless of the quality of the child’s attachment to the primary caregiver. An important focus of the intervention tested in the current study is to support caregivers in staing sensitive and responsive to children who may not display their emotional needs clearly, i.e. to understand “the need behind the behavior”.
Caregiver mindmindedness
A caregiver’s capacity to treat the child as a psychological individual, i.e. the capacity for mentalizing [39], is thought to be a prerequsite for a caregiver’s ability to be sensitive to children’s needs [40]. It is generally accepted that the ability to mentalize may be linked with both the current state (e.g., stress) and/or more stable factors, such as the caregiver’s own attachment experiences [40]. Particularly in situations where the child and/or the caregiver is distressed, the ability to mentalize is considered essential for continuously providing sensitive caregiving [39, 41]. Keeping a mentalizing stance towards the child enables the caregiver to interpret the child’s behavior in terms of emotional needs. This ability is particularly important when interacting with children who are distressed, socially withdrawn, or in the early phases of language development and interpretation of behavior is the means to understanding the child’s needs [39, 41].
The concept “Mind-Mindedness” (MM) is one way that mentalizing has been operationalized [42]. MM is defined as the caregiver’s tendency to treat the child as a psychological individual with a mind of its own and to “tune-in” to the child’s perspective, while being aware that internal states motivate the child’s actions [43]. While research shows that MM is associated with observed (sensitive) interactive behavior in parents [44], the quality of the parent–child attachment relationship, as well as child developmental outcomes [45, 46], studies on the links between MM and interactive skills in professional caregivers are scarce. However, the existing studies indicate a positive association between MM and sensitive behavior [47,48,49] and between MM and caregiver emotional involvement [50].
In sum, this research suggests that together with sensitivity, MM/the ability to mentalize is an important focus of intervention in the childcare setting.
The Circle of Security classroom approach
In the current project, we test the effect of the COS-Classroom model (COS-C). COS-C is adapted from the parenting program, the Circle of Security-Parenting (COSP) [25] and modified to fit the professional childcare context [51]. COS-C is an attachment theory informed professional-development program. It is a manualized eight-session group intervention for caregivers of children aged 0–5 years that combines psycho-education with a mentalization-based approach [51]. The COS framework aims to facilitate caregiver sensitive responsiveness, emotional availability and caregiver emotion regulation, and a core assumption of the model is that enhanced reflective capacity (mentalizing) is the mechanism through which caregiver sensitivity improves which, ultimately, is the key to support secure attachment relationships between caregivers and children [25]. Increased reflection is assumed to be closely related to caregivers’ understanding of how their own relational history and emotion regulation strategies may affect their relationship with the children in their care.
An important intervention tool in the program is a graphic illustration, the “Circle of Security” (Fig. 1) capturing core asumptions of attachment theory [28]: that children develop a secure attachment relationship if the caregiver provides “a safe haven” (i.e. is available when the child is distressed and needs comfort) and “a secure base” (i.e. is available when the child is exploring and supports the development of new competencies). Througout the intervention, the Circle of Security graphic is used as an observational and analytical framework for the caregivers to explore and reflect on how to support positive development in the children in their care.
Figure 2 provides an example of how the material of the intervention has been adapted to capture the reality in group-based childcare, i.e., that the caregiver most of the time must provide a secure base and safe haven for several children who often have differing needs “on the circle”.
The “Circle of Security” also reflects another core assumption from attachment theory: that a child’s exploration, play and learning depends on the the child’s experience of the caregiver as available and responsive to the child’s need for emotional support [28] (“filling up the emotional cup”, see Fig. 1). Therefore, the model assumes that supporting caregivers’ ability to be a secure haven and a secure base is simultaniously supporting child learning and autonomy.
Another core theme of the program is how to be “Secure hands” for the child, i.e. being able to be a caregiver who is “bigger, stronger and wiser” while still being “kind”, referring to the ability to take charge and set limits for children in a sensitive manner, a theme which is of particular importance in the childcare setting where structure and limit setting is a key aspect of process-quality [30, 52].
To support caregivers’ ability to interpret children’s behavior in terms of emotional needs (mentalizing), and in particular the needs behind the behavioural strategies of insecurely attached children, the notion of ‘cues’ and ‘miscues’ is introduced. Secure children generally communicate their needs clearly (via ‘cues’), for example by seeking closeness or by crying when needing emotion regulation and comfort, or by asking for help when in need of exploration support [26]. Applying the language introduced in the COS approach, insecurely attached children may “hide their needs” and “miscue” caregivers, for example by avoiding the caregiver when they in fact need closeness and comfort (avoidant strategy), or by seeking closeness and being “clingy” when in fact in need of exploration support (resistant/ambivalent strategy)[26]. Figure 3 provides an example of how an avoidant strategy is illustrated in the COS-C program. This theme is of particular importance in terms of facilitating the caregivers’ ability to remain sensitive sensitive towards children who have developed insecure interactive strategies.
An essential part of the program is the use of pre-produced video vignettes of both problematic caregiver-child interactions and interactions where the caregiver is responsive and sensitive. These are used to illustrate how caregivers’ may or may not struggle in meeting childrens’ emotional needs and to faciliate group reflection and learning.
In addition to the adapted visualization of the Circle of Security (Fig. 2), the COS-C program includes material and exercises on “indentifying the invisible children” (e.g., socially withdrawn children), how to support children and parents during check-in and pick-up situations, how to meet the needs of children who are “hard to connect with”, and naming the children’s feelings [51]. Another important adaption focuses on how to facilitate interactive repair between children which is pivotal for fostering positive peer-interactions.
During the sessions, the COS-C facilitator supports the caregivers in using the Circle of Security graphic to reflect on the video material and on examples from their daily interactions with the children in their care. Moreover, the caregivers are invited to reflect on what may prevent them from meeting a child’s needs in specific situations. This joint reflection is hypothesized to be the mechanism of change for the intervention.
While an important goal of the intervention is to facilitate the caregivers’ reflections on children’s mental states, another is to support the caregivers in reflecting on their own mental states and how these might impact their ability to support the child’s changing needs “on the circle”. In doing so, the COS model fits in the category of mentalization-based interventions, wherein understanding of the child’s behavior and the caregiver’s response is organized through recognizing, appreciating and hypothesizing about mental states of the child, but also those of the caregivers themselves [40].
While evidence from parent–child studies suggests that the COS approach can positivly improve caregiver sensitivity, caregiver-child attachment security, and caregiver self-efficacy, [25, 53] research on the COS approach in in the childcare setting is still very limited, though promising. Gray [54] conducted a quasi-experimental pilot study investigating the impact of the COSP intervention with licenced childcare providers (N = 34). Findings indicated an increase in the childcare providers’ self-efficicacy corncerning the management of challenging child behaviors compared to a control group not receiving the intervention (N = 17). In another study [55], attending a COS training workshop resulted in increased empathy as well as greater understanding of attachment theory-principles among 202 practitioners working with families of young children. However, differences among sample characteristics and intervention format does not allow for comparison of study results and also limits generalizability to other childcare practitioners and work environments. No previous study has investigated effects on observed interaction quality and caregiver mentalization in the professional childcare setting.
The moderating role of personal and structural factors
Previous intervention studies of COS-based programs with parents have found that intervention effects may vary for different subgroups [56,57,58,59] albeit comparisons and firm conclusons across studies are limited due to the use of dissimilar intervention formats and measures. Yet, to gain insight into the issue of “what works for whom?” in this study, we explore two potential moderators, i.e.professional caregiver attachment and staff stability, of the effect of COS-C—to examine if the intervention affects different subgroups of caregivers differently.
Two previous COS studies with mothers and infants have suggested that caregiver attachment style may moderate effects of COS-based interventions on caregiver sensitivity. One study [58] found that maternal unresolved trauma history moderated the effect of a 20-week COS intervention; mothers with unresolved attachment showed an increase in caregiver sensitivity compared to mothers without unresovled attachment, whereas the opposite was true in the control group. Another study [57] found that maternal attachment avoidance moderated the effect of COSP; after the intervention, mothers with high levels of attachment avoidance in the intervention group had more secure and less insecure-disorganzied children compared to the control group. We will add to this line of research by exploring professional caregiver attachment style as a moderator of the effect of COS-C on caregiver interactive skills.
In a childcare context, it is improtant to not only consider personal but also structural factors, such as staff stability. It is possible that structural factors affect the caregivers’ ability to implement learnings from the COS-C in their daily interactions with the children. While there is mixed evidence that structural factors are related to the quality of caregiver-child interaction [31], based on experiences from piloting of the COS-C, (see below), we consider it relevant to explore whether staff stability (sick leave and staff turnover) moderates the effect of COS-C. The results may inform future childcare centers’ decisions in terms of when to implement interventions targeting caregiver-child interactions.
Piloting of the COS-C
We piloted the COS-C with a group of seven professional caregivers and their manager from the same municipality from which participants for the current study are recruited. Information on acceptability and feasibility of the intervention was collected to inform the final protocol. One important learning from the pilot was that the intervention contributed to an increased sense of collegial support and perceived resources to cope with stress [60] and the participants reported that they felt less overwhelmed by managing challenging children and less inclined to call in sick. This is in line with experiences reported by the developers of the model [51] as well as results from a study where caregivers in center-based childcare reported increased resources to cope with work-related stress after participating in an intervention that aimed to improve their interactive skills [61]. By the use of both questionnaires and interviews, we therefore investigate the potential of the COS-C to positively influence caregiver’ perceived job resources and explore their experiences of completing the program with their colleagues.
Current study
Study aims
First, the main aim is to investigate the efficacy of COS-C in enhancing caregivers’ interactive skills when interacting with a group of children in a natural busy real-life setting and their mind-mindedness (MM). That is, we aim to evaluate if the COS-C can positively impact the core aspects of process quality in childcare. Moreover, we investigate the potential of COS-C to positively influence caregivers’ work-specific resources to cope with stress.
Second, building on literature suggesting that the ability to mentalize (here operationalized as MM) is important for caregivers’ sensitive responsiveness; we aim to investigate if changes in the caregivers’ mind-mindedness relates to changes in their interactive skills.
Third, we aim to explore if effects of the COS-C are moderated by personal and structural factors, here operationalized as the caregivers’ own attachment style and staff stability.
Fourth, we evaluate the implementation of the COS-C by examining childcare providers’ experience of the intervention’s acceptability and feasibility, and we will examine the degree to which acceptability and feasibility relates to the intervention’s effectiveness. Investigating feasibility and acceptability of the COS-C intervention is essential in terms of evaluating the potential for up-scaling and further implementation of the intervention in Denmark [62].
Fifth, we employ a qualitative approach to investigate a) how the caregivers and their managers make sense of changes caused by the intervention and b) how the caregivers experience the intervention in terms of its feasibility and acceptability when implemented in their daily practice.
Primary hypothesis
Secondary hypotheses
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The childcare providers in the intervention condition
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(a)
show higher levels of mind-mindedness,
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(b)
display higher levels of interactive skills (i.e., respect for child’s autonomy, structuring and limit setting, verbal communication, developmental stimulation, and fostering positive peer interactions), and
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(c)
report more work-specific resources to cope with stress.
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Intervention effects on interactive skills are mediated by changes in the caregivers’ mind-mindedness.
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Intervention effects are moderated by staff stability and the caregiver’s own attachment style:
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(a)
COS-C effects caregivers working in childcare centers characterized by higher levels of staff stability differently than childcare providers working in childcare centers characterized by lower levels of staff stability.
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(b)
COS-C effects caregivers with a secure attachment style differently than caregivers with an insecure attachment style.
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Intervention effects on interactive skills and mind-mindedness are predicted by childcare provider’s experience of the intervention’s acceptability and feasibility.