The purpose of this article is to introduce an intervention called Training to Enhance and Nurture Development (TEND), an adaptation of the Filming Interactions to Nurture Development (FIND) intervention developed in the US (Fisher, Frenkel, Noll, Berry & Yockelson, 2016). TEND is a video coaching programme delivered in a group context, and central to the model is the concept of Serve and Return, developed by the Harvard Center on the Developing Child. We aim to explain this concept through multiple perspectives, including the perspectives of some of the people involved in the delivery of the programme and participants in the groups.
We begin with outlining the methods of this article, followed by setting the context of the needs of infants in foster care, which is the original intended target population of TEND. There is then a brief description of Video Interaction Guidance ((VIG) Kennedy, Landor & Todd, 2011). This is in order to provide a better known theoretical framework in UK for TEND to be presented alongside. Next, we introduce TEND, including its history and description of its implementation across the UK to date. We will outline the key concepts within TEND, namely “Serve and Return”. This is followed by a discussion of the possible links with VIG. Finally, some of the people involved in TEND explain the impact of the programme on them.
This article is not a research paper; instead its purpose is to raise awareness of TEND, an intervention currently being delivered across the UK. A separate and full evaluation of the Road Test and Pilot trials of the programme is currently underway by the National Implementation Service.
Even though this is a discussion article about the main concept in TEND, it is still important to explain how the article came about and how it was put together. Various people involved with TEND agreed to contribute and collaborate together, including two previous participants of the group, two facilitators and two TEND video editors. Each were asked to answer a series of questions about Serve and Return. The questions were designed to explore how people explained the concepts and experience of watching and discussing video clips. The contributors’ answers were collated by the UK TEND lead, and snippets were selected in a way that might help to explain the model of video coaching. In the positive spirit of TEND and other video interaction methods, contributors were also asked about the benefits of TEND. The full transcripts are available upon request.
The majority of children are taken into the care of their Local Authorities as a consequence of exposure to trauma experiences, neglect, abuse, parental mental health issues, and chronic stress. All of these factors can have a negative impact on a child’s health and development and infants entering foster care typically have a high incidence of developmental delays, deficits in adaptive behaviour and a large number of behavioural problems (Hochstadt, Jaudes, Zimo & Schachter, 1987; Vig, Chinitz, & Shulman, 2005); for babies and infants this occurs Results indicated that these children have a much greater incidence of chronic medical conditions, are likely to weigh significantly less and be significantly shorter than the general population. require significant amounts of medical sub-specially care, have a high incidence of developmental delays, and major deficits in adaptive behavior and have a large number of behavioral problems often associated with psychiatric disordersResults indicated that these children have a much greater incidence of chronic medical conditions, are likely to weigh significantly less and be significantly shorter than the general population. require significant amounts of medical sub-specially care, have a high incidence of developmental delays, and major deficits in adaptive behavior and have a large number of behavioral problems often associated with psychiatric disordersResults indicated that these children have a much greater incidence of chronic medical conditions, are likely to weigh significantly less and be significantly shorter than the general population. require significant amounts of medical sub-specially care, have a high incidence of developmental delays, and major deficits in adaptive behavior and have a large number of behavioral problems often associated with psychiatric disorderswhen brain growth is most active. Meeting the complex needs of this vulnerable group of young children presents extensive challenges for targeted early intervention service systems which should aim to help foster care to be a positive healing process for the child. The conception of TEND in 2013 came from the understanding that infants awaiting adoption should be parented within environments that are supportive to their developmental needs. Development of TEND began on this premise and was funded by the DfE, who were interested in an intervention that could meet the needs of this population, but that was simple to learn and could be done to scale. TEND has been delivered across five Local Authorities in England. A total of 19 facilitators have been trained and 13 groups delivered, and nearly 70 foster carers have been through the programme.
A brief description of Video Interaction Guidance ((VIG) Kennedy, Landor & Todd, 2011)
VIG is a video interaction based intervention, which is now widely used across UK and over the world. VIG ‘guiders’ focus on positive interactions that occur between parents / caregivers or professionals with their children, by first videoing the dyad doing an activity together. This film is then edited, guided by the characteristics of attuned interactions, into a short film and stills that highlight a parent following a child’s initiative and responding in a way that led to successful communication. Through the use of the shared review session, parents are helped to recognise interactions that are better than usual and to reflect on what they did to contribute to this.
The relational focus of VIG occurs in the context of a parent’s own goals: what they want to be different in their relationship with their child. VIG encourages a process of change by engaging parents to reflect on and ultimately to believe and act in ways that help them realise their own hopes for a better future in their relationships with those who are important to them.
VIG explicitly trains guiders to themselves interact in ways that are attuned to a client’s initiatives, to be more in tune with their own and their client’s state of mind. There are differences and similarities with TEND, which will be discussed in this article.
What is TEND?
TEND is the result of collaboration between the Department for Education (DfE), the National Implementation Service (NIS) and Professor Philip Fisher, Melanie Berry, Kyndal Howell and colleagues at the Stress, Neurobiology and Prevention lab at University of Oregon, USA. It is underpinned by social learning theory, theories associated with parental sensitivity as well as recent neurological research on the impact of abuse and neglect. Central to the programme is the understanding that infants’ experiences in the early years set the foundations for their futures (e.g. Leadsom, Field, Burstow, & Lucas (2013); Schore (2003)).
TEND is a twelve week programme for foster carers and kinship carers with babies and small children (up to 4 years of age). TEND specifically targets the carer-infant relationship, and its overarching aim is to support carers to interact with their infants in ways that have been shown to positively influence developmental outcomes. TEND facilitators attend an initial four day training and then receive weekly consultation and coaching from NIS consultants for the duration of the programme. Consultants help to embed the training and keep fidelity to the model.
Foster carers are supported through a video coaching method, which was derived from an individually focused intervention called Filming Interactions to Nurture Development (FIND), developed by Phil Fisher and colleagues. FIND draws on the Marte Meo video coaching intervention as well as microsocial interaction research at the Oregon Social Learning Center.
The role of a video coach is similar to the role of a guider in VIG, and video coaching is the phase in the group where facilitators and participants talk together about the video clips, somewhat similar to a shared review in VIG. TEND is innovative in the way that it adopts video coaching methodology and applies it in a group format. This group based approach uses film to guide foster carers to further develop their own naturally occurring skills to promote a child’s development across multiple domains.
Foster carer and child are filmed by TEND facilitators, who then send the raw footage to be edited by NIS editors to be made into a short clip that demonstrates existing optimum interactions within one of five elements of Serve and Return, depending on the curriculum of the group at that time. The refined film is then sent back and shared with the carer and group where the micro interactions are discussed as a method to increase future sensitive care. The group-based nature of the programme activates both the benefits of group based learning and also gives an economy of scale, enabling delivery to a large foster care population.
In addition, each week foster carers have a new toolbox skill to discuss and learn. Toolbox skills are evidence informed strategies appropriate to common problems associated with infants and young children, with some topics specific to Looked After Children, such as contact and the impact of trauma and neglect. The toolbox skills include strategies to promote positive behaviour drawn from evidence-based parent management training programmes developed at the Oregon Social Learning Center.
What is Serve and Return?
Within the group video coaching method of TEND, the concept of Serve and Return is central. The concept of Serve and Return comes from the Harvard Centre for the Developing Child (National Scientific Council on the Developing Child, 2007), and is a term used to describe specific and important interactions between parents and children. In the words of a participant on the programme talking about Serve and Return: “A serve is always child led. This could be in the way of a look, a smile, a question, word, cry, or change in behaviour. The care giver returns this serve by showing they have noticed. They may answer the child, focus their gaze on the same thing, reassure or give a cuddle when child is upset. They are responding by showing they have noticed the serve.”
A facilitator adds, “Serve and Return is a simple concept that describes a child taking the lead in everyday activities. The strength of the model for me is that it underlines the importance of the adult waiting for the child to ‘serve’ and the importance to the child of the carer noticing, and valuing them, and taking the lead in some interactions on a regular basis.” Similarly, an editor adds, “I would describe Serve and Return as an interactive and dynamic process that emphasises the foster carer’s response to a child’s needs in a way that validates and confirms their actions.” Finally, another editor concludes: “The strengths of Serve and Return are that it allows the parents to step back and follow the child’s lead and rather than leading the activities, allowing play to progress at the child’s pace. This understanding also helps increase the bond between child and parent as they learn to play together in a mutually supportive way.”
There are five elements of Serve and Return, each of which is discussed for 2 weeks within the programme before moving on to the next in a step by step process:
- Sharing the child’s focus
- Supporting and Encouraging
- Back and forth
- Endings and Beginnings
How does TEND use Serve and Return?
TEND facilitators, during the video coaching section of each group, facilitate discussion with the aim of pointing out certain features of Serve and Return interactions that are occurring on screen. Video editors undergo their own training to be able to produce suitable clips for the groups to watch, as an Editor explains, “Serve and Return as a concept enables a careful deconstruction of an interaction in a clear and distinctive way.”
Facilitators use the short interactive sequences that demonstrate one of the five elements, and help deconstruct the interactions through specific editing techniques such as freeze frames (pauses that are inserted into a copy of the clip that cue the facilitator to point out salient aspects of the interaction) and descriptive text (written descriptions that precede each clip and primes the caregivers for what they are about to see). The films are used to teach and guide participants to observe these interactions on screen.
TEND is group based, which is in itself important to the model of change. As one facilitator states, “the use of video in TEND, especially in a group setting, has been a powerful teaching tool.” A participant agreed that this was a helpful part of TEND as it was “..encouraging all (of the) group to contribute, [and it] allowed members to share with, and encourage, each other.”
However, video coaching is a new skill that facilitators learn and video coaching within this method is also new. How to do this effectively has been an iterative process, where by watching all of the skilled TEND coaches running their groups the NIS have gleaned information about a number ways to improve the coaching. For example, one facilitator comments “We have found that eliciting from participants and encouraging them to identify the subtleties of the interactions has led to a warmer and stronger session. We have had to work on keeping focus on the structure of the edited videos as conversation can easily stray.”
How is TEND similar and different from VIG?
The video coaching is similar because:
Of the centrality of video
TEND uses edited video footage as a microscope, to look in detail at attuned interactions between carer and child. The footage shares the importance of such interactions in impacting on the development of a child, and as such provides the central focus of intervention. TEND therefore, as in other video interaction methods, looks to increase the frequency of a caregiver receiving a child’s initiative. Similar to Video Interaction Guidance, a coach uses the film to help carers identify what signals a child gives out and how a caregiver then responds. A facilitator comments that the “videos brought the concept to life and helped carers see what a valuable job they were doing both in their interactions but also in the child’s response.”
It is a strength based collaborative intervention
As with VIG, TEND focuses on the naturally occuring supportive behaviours that assist with the development of a child and the communication between carer and child. This positive nature of TEND seems to have positive effects on self-efficacy, as explained by a facilitator. “Carers were able to explain their feelings, such as of being ‘proud’ when a child led an interaction that resulted in success such as counting colours. Serve and Return, when followed more consciously, or seen through video coaching, is seen as a joint achievement. The child feels validated and the carer feels that they have helped in that achievement.”
Another facilitator comments on the deliberate strategy of only focusing on positive interactions: “The carers and parents see their and others’ micro interaction and receive only positive feedback. This has created a sense of achievement and optimism for parents and carers in often challenging situations. The carers have been very supportive of each other and seeing the videos can be a highly affirming experience. This seems to reinforce learning”.
It focuses on attuned interactions and their link to child development
Video coaching methods generally focus on helping caregivers become more aware of positive qualities of interaction, and how to use these qualities to support the child’s learning and developmental capabilities. Perhaps where TEND is somewhat different is the emphasis made about this link, as it explicitly teaches and reinforces the link that Serve and Return interactions have with brain development. Through psychoeducation carers learn the importance of sensitive caring for children whose development may have suffered from previous caregiving. For example, within the first group, the participants are shown three videos from the Centre from the Developing Child that help reinforce the meaning behind such interactions.
The importance of Serve and Return interactions are underlined by another facilitator: “Serve and Return interactions are important because they “build brain architecture. When a caregiver responds sensitively to a child’s signals neural connections are strengthened in the child’s brain and form the basis for the child’s emotional and social development. Serve and return always starts with the child’s cue.”
A facilitator adds, “The strength is that this builds connection between them and the child feels noticed and is more likely to serve again. It is very easy to learn as it is something that happens all the time.”
Also, a participant adds, “A serve can be shown in many ways and is a powerful way to encourage attachment and so important with children who may have missed out on this in their early years”.
The video coaching method is different from Video Interaction Guidance, in that:
It has a set curriculum
TEND uses the same curriculum as FIND, but each of the five elements of Serve and Return are discussed over 10 weeks, with an introductory and concluding session. Each element is discussed for two weeks, before moving on to the next. This has benefits: for example it lends itself very well to training and implementation, as it is a teachable and deliverable model and easily replicable. A facilitator states “The concept was easy to teach and the course built incrementally on each element in a simple way.” Similarly, another facilitator comments, “I found the concept of Serve and Return easy to learn. It is a basic notion that occurs in all interactions. Putting a name to it and understanding its importance means I am now able to notice these simple interactions and their benefits more often.”
The elements build on each other, starting with Sharing the Child’s Focus and ending with Endings and Beginnings. Although each element is briefly reviewed each week, there is a momentum moving forwards to the more complex elements of Back and Forth and Endings and Beginnings.
Set video editing and coaching method
Video clips are edited and coached in a particular way, which again aids learning the model. A short clip is copied to occur three times, where the second time the clip plays it has been edited to have pauses that highlight a particular facet of the interaction (e.g. a Serve, a carer waiting and pausing, a Return of the child’s serve or the positive impact on the child). A participant comments, “It was special to see the interaction between you and the child, and helped break it into stages to watch every moment. “
Unlike VIG, where a guider is helped through training and supervision to be very aware of the therapeutic relationship they are building with a parent, in TEND the emphasis is on helping coaches learn a basic framework and structure to coaching, with some examples of a script to adhere to. Again, this helps implementation (e.g. it is a skill that is quite easy to learn over time), but an important function of the weekly consultation calls with NIS consultants is helping TEND facilitators to reflect on their coaching, their relationships to group members and the group as a whole. Within these calls, coaches are supported to think about how to activate and engage the group in collaborative discussions and to be present in discussions, and be curious and accepting of individuals’ ideas.
No individual goals
The TEND process is not driven by individual goals, but rather it follows a curriculum. Carers are taken through one of the five elements of serve and return every two weeks of the programme.
Video coaches do not edit their own videos
Within TEND, editing is currently undertaken by staff within the National Implementation Service, where the role was enjoyed: “I’ve really enjoyed editing the videos. I find it so interesting to see the interactions between foster carers and their children because everyone has different styles of parenting. As I watch the videos, I’m always in awe just how powerful it can be for a foster carer to respond to a child’s sound or actions, because they continue to engage in their activity and sometimes there is a clear positive Return from the child.”
Another editor adds,”I have thoroughly enjoyed editing the TEND videos. It has encouraged me to focus on the small, and sometimes subtle interactions between parent and child that can easily be missed, but are crucial when looking at the child’s social development… There were always examples of Serve and Return in the raw footage we received, it is just about framing each interaction in a way to show the child’s lead.”
Editing film is a skill and editors undergo a four day training and ongoing fidelity adherence coaching. This implementation strategy has some benefits, in that it frees time for TEND facilitators to carry out their other roles in their local authorities. However, for coaches, “not being involved in the editing process can have its drawbacks”, so that “It has been important to take time to study the videos beforehand and practice coaching as there can be a variety of subtle behaviours and interactions”. For editors getting appropriate raw footage back was also a challenge: “The videos that I found helpful solely focused on the foster carer and the child who were completely in the frame of the camera, and were doing various activities. However, what I found challenging was when there were more people in the video which meant the foster carer would share his/her attention to the other person in the room or when the child interacts with the person filming, although I appreciate how hard this might be to not respond!”
It is group based
The value of a group based process is well summarised by a TEND facilitator: “The group experience was positive and by its nature is not challenging as it highlights the positives. There is value in teaching as a group and the group process worked to reinforce this. An example of this has been made in two groups where carers who have just taken on the care of child have formed a very quick attachment. This has been clear to other participants from the video clips and they have commented and said things like ‘it is like you have been together forever’. The impact of this would be missed or lessened if just one professional had commented but a peer or group validating this felt much more of a special moment.”
What are the perceived benefits?
Although this article was not designed to present evidence of the effectiveness of TEND, it has been interesting hearing from those involved about not just the benefits to the child, but also to the carers, facilitators and editors. Comments are grouped into three categories.
Interacting in intentional ways
Firstly a participant comments: “The concept was a new one for me but it is a positive natural occurrence. It made me more intentional to pick up on the serve from the young baby I was fostering. Since having two toddler brothers to foster I have benefitted by using it constantly. “
Two facilitators make the following observations: “The concept of waiting for the child’s signals has been powerful. Carers have said they are less focused on stimulating and structuring children and more interested in allowing them to develop their ideas, self confidence and sense of validation.”
“In my view underlying the importance of waiting has been most beneficial as carers are busy and aware that children who have been neglected need to catch up and taught lots of things that they have missed out on. Underlying the concept of waiting may have slowed these interactions down and it has been beneficial to some to have been taught this and also celebrating with them when a child begins to serve much more as an achievement.”
Another editor adds, “Serve and Return has made me realise that the parent does not have to lead the activities in order to stimulate the child. There is a lot for a child to learn by exploring their environment in a supported way, just knowing their parent is there to assist them if necessary can be all the child needs.”
An editor comments next: “I find myself describing Serve and Return to my family and friends because it’s relatable in their lives. It’s also made me more mindful of the interactions that I have with the children I come into contact with, such as at work or in my family. It has increased my knowledge of ways to Return a Serve from a practical point of view, and I also know now why it’s helpful to Return a Serve, drawing on from social learning theory, attachments and brain development. I am definitely looking forward to using what I’ve learnt in the future!”
A participant adds: “Now I notice that many carers are not as attuned to their child in the same way. I used what I had learned on the course to introduce the adoptees to the concept of serve and return.”
Impact on own practice
Finally, both facilitators highlight benefits to their own practice: “I study members of the public’s interactions with children all the time now, especially on public transport, noting serve and return interactions and elements! I am aware of my own interactions with my children and have found myself waiting and allowing my children more time to process and develop their ideas and actions.
In all my work with adopters I am advocating the importance of serve and return micro interactions as the basis for all healthy emotional development, and the importance of taking time to wait and be sensitive to their child’s serves. I’m interested in the idea of encouraging serves in the ‘mid- range’ of the spectrum, as opposed to either escalated or very subtle/withdrawn – which can be the case for children who have experienced early trauma. Facilitating TEND has made me a more optimistic, solutions focused and empathic worker”
“My practice has changed in terms of using new language to describe the interaction between a child and a carer rather than talking in terms of the huge topic of Attachment. I have been aware of the importance of slowing interactions down with children and can now use this concept to underline this to carers that I work with but also to validate the very skilled and hugely important role that foster carers do in supporting the development of Looked After children. “
What does the future hold?
Presently, as we write this article, data is being collated, which will help NIS evaluate more formally the impact of TEND and whether the simple explainable concept of Serve and Return, and the craft of the video coaching of FIND that has been adapted by the different skilled facilitators of TEND, have brought about positive outcomes in the UK. We are aiming to disseminate results by the end of 2016. The NIS is examining measures of child development, child behaviour, parenting behaviour and parenting stress, and preliminary results are promising. Certainly, anecdotally, many people who have been involved with TEND hold in mind the concepts and have been affected by them in some way. It will also be interesting to think about how facilitators’ relationships with group members have developed over time and how this important variable may have impacted on video coaching and outcomes for the programme.
We are also looking at finding ways to reduce some of the implementation challenges of running TEND, such as developing I.T. solutions for transferring videos, and building editing capacity within Local Authorities. We are also looking at how TEND might be adapted and applied to different groups of children and parents and carers. It is hoped that TEND will facilitate infant-led environments that are so beneficial to the long term developmental outcomes for maltreated children and can become an accepted cousin of the other excellent video interaction programmes.
Alistair Cooper*, Clinical Psychologist, Sally Atkinson, Senior Social Worker, Jo Hamilton, Foster Carer, Caren Jones, Foster Carer, Kylie Leones, Assistant Psychologist, Anna Lucock, Assistant Psychologist & Wendy Queralt, Fostering Team Manager
*Any correspondence please to Alistair Cooper, Clinical Psychologist, Maudsley Hospital, DeCrespigny Park, Denmark Hill, London, SE5 8AZ
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The medical and psychosocial needs of children entering foster care
Author links open the overlay panel. Numbers correspond to the affiliation list which can be exposed by using the show more link.
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