ReAttach Protocol for Adoption and Foster CareBuilding Family Cohesion

Samenvatting

Due to global wars, food shortages, and natural disasters, the number of orphans worldwide is growing (1). These orphans have survived terrible circumstances but have lost their parents. In addition to providing safe shelter and basic needs for survival, providing a safe home to grow up in is essential. Foster families and parents who adopt these children do incredible work. However, at the same time, these newly blended families are dealing with older, traumatized children who are much more vulnerable than babies who are given up for adoption before their first birthday (2, 3, 4). The older children have an increased risk of later emotional problems (5).
ReAttach is a transdiagnostic intervention for children and adults with mental health problems. As a brief, not-trauma-focused family-intervention (6), ReAttach aims to optimize learning conditions and development. This paper describes how ReAttach can promote the mental health of adopted and foster children and increase their resilience, well-being, and personal growth. When used strategically, the applicability of ReAttach and ReAttach Specializations (Wiring Affect with ReAttach (7) and New Mind Creation (8) becomes even more attractive. Combining ReAttach to optimize learning conditions with tailored connecting interventions is an excellent opportunity to promote mental health and personal growth.

Introduction

How we treat vulnerable individuals, such as foster children or orphans, says a lot about our ability to love people who are not directly related. It requires undeserved kindness to strangers without expecting anything in return. The extent to which we are willing to selflessly care for others and promote their interests reflects our empathy, honesty, and fairness.

In contrast, ignoring the needs and interests of strangers in need is a sign of personal or social decline and a failure of collective responsibility. This neglect indicates selfishness, lack of empathy, cruelty, and injustice on an individual level and as a symptom of decay in society. The youngest children can often still count on our compassion, although we have learned from war and conflict situations that even babies can be completely abandoned to their fate and left to die [9].

There might be several reasons why people turn away from the most vulnerable. When others look the other way, social pressure can create increased tension among individuals who want to help, causing them to refrain from doing so. Nimphy et al. [10] state that when parents portray strangers as a threat to their children, they pick up feelings of discomfort and fear. This promotes polarization since, due to this threat perception, children no longer identify themselves with these strangers. Of course, this is a two-way street. If a group is excluded based on specific characteristics, those considered "different" can no longer identify with the "normals." Threat perception and polarization are a dangerous development that could lead to dehumanization and violence. Dehumanization, perceiving other humans in ways that deny their full humanness, is a dangerous tendency that might lead to atrocities such as genocide, lynching, ethnic cleansing, and denial of human rights [11,9,12].

Helping others in need is a far more socially desirable behavior, especially when it involves undeserved kindness without expecting anything in return. Nevertheless, research warns that we should look more critically at the motivators of altruistic behavior to detect dependency-oriented helping in groups in which the helper feels threatened in his position [13]. Brady et al. [14] suggest that interventions, such as metacognitive training, can reduce disapproval and threat perception and promote tolerance for strangers [15]. ReAttach facilitates adoptive and foster families, using a tailored, transdiagnostic, multifamily approach promoting family cohesion, secure attachment, and autonomy.

Inclusion Criteria

The ReAttach protocol for A&F, as described here, focuses on children who are placed after their first birthday. According to Van den Dries et al. [2], children adopted before their first birthday were as securely attached as a sample of non-adopted children. This outcome shows how resilient young babies are in their development, which supports Bowlby's [16] hypothesis that corrective attachment experiences may enhance secure attachment patterns.

The A&F protocol focuses on three natural stages these families go through: 1) Expectations and Preparations, 2) Inclusion and Bonding, and 3) Secure Attachment and Resilience.

Expectations and Preparations

Research has shown that internationally adopted children are at increased risk of developmental problems. Logically, future caregivers are concerned about potential pre- and postnatal risk factors, maltreatment, or neglect that might negatively affect their development [17][18][19]. Orphans also run a greater risk of developmental problems due to the negative influence of stress, such as problems with physical growth, brain development, and social, emotional, and cognitive development [18]. A child's transition to an adoptive or foster family can significantly improve development [2][19].

Future parents are less optimistic about the future of the adopted or foster child compared to other children because they are, not entirely without reason, at the very least heightened alert to developmental problems. They have lost their optimism bias even before the start of the family process. To prepare parents well, we recommend discussing the benefits of the optimism bias as an important protective factor for individual and family health [20][21][22]. Parents' positive expectations about the child's future help to downregulate hypervigilance and focus on positive stimuli, positive affect, and resilience.

Assessment of the parents' co-regulation dynamics with the M.I.S.T. [23][24] provides insight into the family system's strengths and challenges. The W.A.R.A. (Wiring Affect with ReAttach) can help parents cope with uncertainty and negative affect and teaches them to downregulate acute stress [25][7].

Inclusion and Bonding

Family cohesion is an essential protective factor for the mental health of all family members [26][27]. In families with higher cohesion and better attunement, children thrive more in terms of emotional health, less negativity, lower anxiety, and better coping skills [27][28][29]. Differences in perception within families are inevitable; in newly formed families, perspectives can vary even more. When the tolerance for differences is low, differences in perception lead to more conflicts, disturbing family cohesion. High family conflict is associated with poor mental health symptoms. Therefore,understanding and tolerating each other is protective and more adaptive [28,29].

ReAttach is a salutogenic intervention focusing on health restoration and optimal development conditions [31][32][33]. It assumes developmental plasticity, which includes adaptability and neuroplasticity. Due to developmental plasticity, individuals with the same genes develop differently, allowing them to adapt to different environments during development [34][35]. These differences in outcome do not make the individuals different in disposition or potential. They mainly took another route. Without trivializing individual differences, ReAttach focuses on health and development rather than on disorders or trauma. In the context of adoption and foster care, ReAttach can build adaptive schemas in the family system, promoting resilience and positive mental health outcomes.

Mirror Neurons and Attunement

In the development of secure attachment between babies and caregivers, the activation of the mirror neurons is an essential component. Good working mirror neurons synchronize brain activity which is crucial in bonding and attunement. ReAttach Affect Coaches always check in both children and adults the presence of activated mirror neurons, before the start of ReAttach’s social cognitive training.

In absence of good working mirror neurons they provide exercises parents and children can do in the presence of the ReAttach Affect Coach.For the youngest children rhythmic tactile playful exercises with parents and siblings help to stimulate the mirror neuron system in all family members.

Older children might benefit from grooming activities, in which touch is both functional, safe and a way to take care of each other.

Joint attention in group activities (without the distraction of devices) help the brain to synchronize and foster attunement.

Social Cognitive Training

The ReAttach intervention includes social cognitive training that focuses on developing empathy through identifying with others. Identification reduces feelings of exclusion or difference while increasing understanding and compassion. When the relationships within a group change because someone new joins, ReAttach can play a preventive role and actively promote family cohesion. In addition to tailored ReAttach sessions, techniques such as the W.A.R.A. [6,7] and the Forgive and Forget Hood [FFH, 36] can be used to reduce overstimulation and negative affect. A ReAttach Affect Coach can offer these techniques face-to-face or teach them as a self-regulation tool.

Wiring Affect with ReAttach (W.A.R.A).

The W.A.R.A. is a fun exercise for all ages when experiencing unpleasant feelings. The family can use the W.A.R.A. as first aid in case of acute stress, pain, anxiety, or depression [25]. W.A.R.A. can help to tolerate complicated feelings such as guilt, shame, or insecurity without focusing on trauma, ensuring that safety within the family climate is guaranteed.

Tolerance for Differences - Forgive and Forget Hood (FFH)

The Forgive and Forget Hood (FFH) is a self-regulation technique suitable for adults and children over eight who want to clear their minds. We conducted a one-family study to assess the hypotheses that a) FFH reduces individual burden and b) FFH reduces intolerance towards another person or a partner.

Participants were divorced parents, two sons (9 and 13 years old), and father's new partner. All participants provided informed consent to use their anonymized data for the study and publication. The FFH was provided by individual remote training as a self-regulation tool. We assessed each participant’s total burden and partner/person intolerance using a single question on a 0 - 100% scale. We measured the burden and intolerance load at different time points: T0 (before FFH), T1 (immediately after FFH), T2 (five minutes later), T3 (the same day before going to sleep), and T4 (the next morning). We used SPSS [37] for descriptive statistics of the data.

Table 1.Mean repeated measures of the total burden of five family members

Descriptive Statistics Total Burden
Dependent Variables	Mean	Std. Deviation	N	Min	Max
T0 - before the FFH	78.40	27.844	5	30	97
T1 - immediately after FFH	38.00	40.094	5	0	95
T2 - five minutes later	36.60	34.753	5	0	90
T3 - before bedtime	33.60	46.096	5	0	88
T4 - the next morning	22.00	25.884	5	0	50

Table 1. presents the mean total burden of the family members involved in percentages. As you can see, this mean burden dropped from 78.40 to 38.00% immediately after the intervention. The other measurements show that the mean burden decreased even further over time: the average burden had fallen to 22.00 % the morning after the FFH. This result indicates that this family system experiences less burden after FFH.

Table 2.Mean repeated measures of the P-intolerance of the five family members

Descriptive Statistics P-intolerance
N=5	PIT 0	PIT1	PIT 2	PIT 3	PIT 4
Mean	84.00	35.00	30.00	18.60	17.80
Std. Deviation	20.43	38.40	36.91	31.62	29.90

Table 2. presents this family's mean scores on partner/person intolerance. Before FFH, the mean score was 84 %, and slowly but steadily decreased to 17.80 % the next morning. The involved children and adults felt more tolerant, which is better for family cohesion and secure attachment.

Comparison of the mean PIT0 and PIT4 scores with the Wilcoxon Signed Ranks Test revealed a significant difference between the two related samples, with a Z-score of -2.032 and a p-value of 0.042, suggesting that the second measurement is significantly lower (or different) than the first. This result indicates that this family system experiences significantly less P-intolerance after FFH.

This family was part of a larger sample of 16 participants, comprising five males (31.3%) and 11 females (68.8%). Participants' ages ranged from 6 to 85 years, with a mean age of 43.25 years (SD = 18.67), indicating a diverse age distribution within the sample. All participants provided informed consent to use their anonymized data for the study and publication.

Table 3. describes the repeated measures of the mean total burden scores before (T0) and after remote Forgive and Forget Hood. Before FFH, the mean total burden score was 82.19 (SD = 16.62), while at T4, it decreased to 29.38 (SD = 25.94).

Table 3.Mean repeated measures of the total burden (N=16)

Descriptive Statistics
Total burden	N	Minimum	Maximum	Mean	Std. Deviation
T0	16	30	100	82.19	16.626
T1	16	0	95	50.25	31.261
T2	16	0	90	39.56	28.793
T3	16	0	88	36.88	32.993
T4	16	0	80	29.38	25.941
Valid N (listwise)	16

Table 4. describes the repeated measures of the mean Person/Partner intolerance scores before (PIT0) and after remote Forgive and Forget Hood. Before FFH, the mean total Pi-score was 80.19 (SD = 16.88), while at PIT4, it decreased to 25.69 (SD = 31.78).

Table 4.Mean repeated measures of the P-intolerance (N=16)

Descriptive Statistics
	N	Minimum	Maximum	Mean	Std. Deviation
PIT 0	16	50	100	80.19	16.889
PIT 1	16	0	95	42.69	37.357
PIT 2	16	0	90	34.88	34.932
PIT 3	16	0	80	27.25	32.755
PIT 4	16	0	80	25.69	31.788
Valid N (listwise)	16

A comparison of the mean scores at Time 0 (T0) and Time 4 (T4) using the Wilcoxon Signed Ranks Test revealed a significant difference between the two related samples, with a Z-score of -3.520 and a p-value of less than 0.001. This pilot indicates that the mean score at T4 was significantly lower than at T0, suggesting that the FFH-remote intervention enabled participants to reduce their total burden. A summary of the test statistics can be found in table 5.

Table 5.also describes the repeated measures of the mean Person/Partner intolerance scores before (PIT0) and after remote Forgive and Forget Hood. Before FFH, the mean total Pi-score was 80.19 (SD = 16.88), while at PIT4, it decreased to 25.69 (SD = 31.78).

Test Statisticsa
N = 16	T0 - T1	T0 - T2	T0 - T3	T0 - T4	PIT0 - PIT1	PIT0 - PIT 2	PIT0 - PIT3	PIT0 - PIT4
Z	-3.517b	-3.339b	-3.518b	-3.520b	-3.519b	-3.624b	-3.519b	-3.519b
Asymp. Sig. (2-tailed)	<.001	<.001	<.001	<.001	<.001	<.001	<.001	<.001

Results

These first explorative pilot studies indicate that remote FFH significantly reduces total negative affect, such as individual emotional burden, and decreases partner intolerance as well. The results are promising. FFH might be an accessible tool to promote more adaptive parenting styles and family cohesion. After all, when families can forgive and forget each other's mistakes and tolerate irritating traits, they can provide a safer place to grow.

Secure Attachment and Resilience

New Mind Creation

In contrast to Van den Dries et al. [2], who argue that early intervention is needed to restore secure attachment, we find that secure attachment can be trained later in life by interventions such as ReAttach New Mind Creation [8].

The New Mind Creation is a wonderful tool for older children, teenagers, adolescents and adults with chronic or complex psychological or psychosomatic problems. ReAttach Affect Coaches can use the New Mind Creation to train secure attachment patterns and to activate a Growth Mindset as well.

The advice for the young children is to focus on building optimal learning conditions and positive parenting with adaptive parenting schemas : fostering tolerance, empathy, compassion, optimism bias and investing in family cohesion by being present during joint activities. Parental training is advised since secure attachment in parents increases stress tolerance and parental resilience.

Discussion

The ReAttach Protocol promotes family cohesion and enhances mental health in adoptive and foster families. It provides a diverse and comprehensive array of tools tailored to address the intricate needs of these families. These tools focus on the emotional, cognitive, and social aspects that can be impacted in children placed after their first year and in families facing the difficulties of bonding later in life.

To begin with, the stimulation of the mirror neuron system through ReAttach exercises is crucial for improving the emotional connection between caregivers and children. This neurobiological aspect underpins the basis of empathy and imitation, enabling children to absorb emotional responses and social behaviors demonstrated by their caregivers. In newly established families, this type of non-verbal, embodied interaction assists in minimizing social distance and enhances emotional bonding.

Moreover, attachment-enhancing activities included in the ReAttach protocol advocate for the development of secure relationships. Through secure, predictable, and emotionally responsive exchanges, children start to alter their internal working models of relationships, shifting from distrust or self-dependence to trust and co-regulation. These activities are especially beneficial for children with attachment insecurity or disorganized attachment styles as they offer corrective emotional experiences.

Additionally, social cognitive training, focusing on identification, addresses the necessity for inclusion and mutual understanding in blended family environments. By improving the ability to recognize oneself in others, ReAttach alleviates the sense of difference or threat among family members. This process is essential in overcoming early maladaptive schemas and encourages group unity, tolerance, and emotional security.

Furthermore, Wiring Affect with ReAttach (W.A.R.A.) offers a straightforward intervention that acts as emotional first aid. It enables children and caregivers to quickly alleviate acute stress, anxiety, or discomfort without needing to revisit past traumatic experiences. As a collective family activity, W.A.R.A. strengthens emotional resilience and aids in developing co-regulation patterns in everyday life.

Additionally, the Forgive and Forget Hood (FFH) plays a significant role in alleviating the overall emotional burden and personal intolerance within family dynamics, as indicated by the pilot studies conducted. When families learn to accept each other’s flaws and forgive previous errors, it creates a home atmosphere characterized by psychological safety, adaptability, and personal growth. The considerable reductions in both emotional burden and person intolerance scores reveal the potential of FFH to serve as a catalyst for harmony and emotional healing.

Finally, New Mind Creation is a distinct module for fostering a secure attachment style through psychoeducation and mindset development. It promotes a growth mindset and collaborative problem-solving, preparing families to confront challenges together as a cohesive unit. By encouraging mutual support, New Mind Creation enhances interpersonal connections and nurtures a forward-looking, solution-oriented approach to family life.

Collectively, these elements of the ReAttach Protocol align with a salutogenic perspective—emphasizing factors that bolster health and well-being rather than focusing solely on pathology. They acknowledge the adaptability of human development and the transformative power of positive relational experiences. Particularly in the realm of adoption and foster care, where past hardships frequently coexist with new possibilities for healing, ReAttach presents a promising, structured, and evidence-backed pathway to resilience and family unity.

Conclusion

The ReAttach Protocol for Adoption and Foster Care aims at improving the mental health and family cohesion of adopted and foster children and their families. The protocol is primarily written for children placed after age one and focuses on three phases: expectations and preparations, inclusion and bonding, and secure attachment and resilience. This paper also discusses interventions such as ReAttach, W.A.R.A. (Wiring Affect with ReAttach), and the Forgive and Forget Hood (FFH) to reduce stress and increase tolerance. It also includes pilot studies showing that FFH can reduce negative emotions and intolerance.

Declaration of interest

Paula Zeestraten-Bartholomeus is developer of ReAttach, W.A.R.A. the New Mind Creation and the Forgive and Forget Hood,

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