Design of a longitudinal study of the effectiveness of a haptic interaction-based rehabilitation intervention for a foster family

Dydenkova Eva ORCID: 0000-0002-8079-1660 Chief Expert, Moscow affective touch laboratory 117485, Russia, Moscow region, Moscow, Akademika Volgina str., 6 dydenkovaeva@gmail.com

Theoretical background of experimental workThe problem of adaptation of a child in a substitute family

The problems of foster children and adoption are significant for modern Russian society.

According to the latest estimates published on the platform “To be precise” of the charity foundation “Need Help”, 515,191 children under the age of 18 who were left without parental care (including adopted children) lived in Russia in 2020, and the amount of state funding aimed at solving the problem of orphanhood amounted to 720 billion rubles. The percentage of children returning is very high and continues to grow annually. According to open data (although there are no exact statistics), 5-6 thousand returns of children to orphanages are recorded annually in Russia, which is about 60%. On the one hand, this reflects the severity of the problems that arise when raising children with experience of institutionalization, first of all, problems related to their psycho-emotional disorders and behavioral disorders, the formation of attachment and trusting relationships ^[1], on the other hand, such an interruption of upbringing in a substitute family aggravates the psychological trauma of children and worsens the prospects for their further socialization, increases the risks of deviant behavior, adversely affects the quality of later life ^[2], increases the social and financial burden of the state. The family will also have to face the consequences of returning the child to the orphanage: along with relief will come disappointment, guilt and insolvency ^[2]. Thus, the task of increasing the effectiveness of measures aimed at the successful adaptation of a child in a foster family is important and relevant for all participants in the system of substitute parenting.

One of the main reasons that complicate the process of adaptation to the conditions of family life and reduce the psycho-emotional stability of children in substitute families is a high level of chronic stress and lack of adequate maternal care at an early age ^[3], which is often manifested in the inability of the child to control his own behavior and interact effectively with others, as well as in his rejection of family norms and values ^{[4, 5]}. The dependence of the child's age at the time of entering a substitute family and returning him back to the institution is shown: the older the child, the higher the risk of experiencing secondary orphanhood ^{[6, 2]}. In addition, the determining condition for the ability to establish attachment relationships with adults is the presence of close experience of interaction with the primary figure of attachment (usually the mother) in the first year and a half of life ^[7]. At the same time, such a gloomy forecast made for children left without parental care and a limited circle of caregivers at a very early age does not imply the cessation of attempts to contribute to the restoration of broken self-regulation mechanisms in children.

The problem of tactile stimulation deficiency in a child with institutionalization experienceThe aspiration or desire for something is often revealed only after it is taken away.

The COVID-19 pandemic became an example of this, forcing us to minimize social touches, which made their importance for the physical and mental well-being of a person noticeable ^[8]. However, the importance of touching is not so new and today the topic of tactile interaction in the parent-child dyad is one of the most relevant and promising in modern psychology. Touch is the first feeling that develops in a person's life and the first form of communication with the outside world ^[9]. This is a well-known primary human need ^[10], which plays a leading role in the relationship between parents and infants and the development of infants ^[11]. It has been empirically proven that the lack of physical contact with the parent leads to significant problems of the child's development ^{[12, 13]}.

Today, it is known that a person has a specialized tactile perception system that combines highly sensitive mechanoreceptors associated with unmyelinated type C fibers (CT system) ^[14]. CT afferents are slow, unmyelinated and mechanosensitive skin fibers that carry information about affective touch ^[15]. Affective touch is defined as tactile stimulation with a hedonistic or emotional component, transmitted by CT afferents that are localized in the skin hair and respond to stroking touches with a well-defined speed range of 3-10 cm/sec ^{[16, 17]}. In other words, tactile stimulation of the hair skin with moderate pressure and slow speed ensures the emergence of unconditional moderately pronounced positive affects, thereby reinforcing our subjective disposition to tactile social contacts.

In a recent study, different groups of rats were stroked daily at a rate optimal for the activation of CT afferents (5 cm/sec), at a rate beyond the optimal range (30 cm/sec) and not stroked at all. All three groups of rats were subjected to chronic stress for 2 weeks (intensive forced swimming). The researchers studied the effect of touching on the physiological state of the body in a stressful situation: serum corticosterone levels, anxiety and depressive behavior in these three groups. It turned out that slow stroking significantly reduced the stress-induced increase in corticosterone levels and reduced anxiety. As for depressive-like behavior, rats who received touches at any speed showed less closed behavior, spending significantly less time in a corner than rats from the control group who were not subjected to forced stress at all ^[18].

It has been shown that when the c-tactile system is activated by gentle touches, the production of the hormone oxytocin increases significantly ^{[19, 14]}, which is responsible for reinforcing a positive attitude towards other people, for altruism, for stimulating prosocial behavior, which significantly facilitates interpersonal contact ^[20]. Such a neurobiological connection explains the value of social contact and affective touch. Moreover, CT afferents are evolutionarily the oldest sensory afferents ^[14], and parents intuitively stroke their babies at the optimal rate for activating CT afferents ^[21]. The reader of this article may remember himself stroking a cat and will understand that his hands also know how to make effective (from a social point of view) touches.

Tactile defensiveness in children in substitute familiesRecent studies demonstrate that the ability to perceive gentle touches is plastic.

The long-term effect of early tactile deprivation on the ability to feel gentle touches as pleasant in adulthood has been noted. For example, adults with an early unfavorable childhood ^[22] or unreliable attachment ^[23] showed reduced sensitivity to gentle touches compared to those who were brought up in a family. Such reduced sensitivity to slow strokes and gentle touches is called tactile defensiveness or rejection of social tactile contacts ^[24]. Thus, it was found that people with a history of traumatic ties with parents and broken attachment perceive gentle touches (slow strokes of moderate strength) as unpleasant, while participants with organized attachment rate the same tactile sensations as pleasant ^[23]. In addition, subjects from the experimental group (with impaired attachment), upon presentation of tactile stimuli (slow gentle stroking), activation of limbic and paralimbic structures of the brain was observed according to the "hit or run" principle. It is likely that tactile defensiveness (subjective interpretation of gentle touches as unpleasant) originates in unfavorable developmental conditions characterized by the absence of parental touches.

It was found that the known therapeutic effect of touching is possible only in a situation of receiving pleasure from tactile contact. Thus, the production of the hormone oxytocin during the activation of ct afferents by slow stroking occurs only when these touches are subjectively assessed as pleasant ^[25]. When checking the therapeutic effects of gentle touches on rats, it is enough to catch the latter and present the optimal tactile stimulus with a wet brush ^[20]. But the situation becomes more complicated when it comes to grown-up human cubs who have their own experience and subjective attitude to touches from other people, which cannot but have a certain effect on the perception of tactile contacts, and therefore on their effectiveness. It has already been shown that children who find themselves in a difficult life situation often have increased tactile defensiveness, and sometimes complete intolerance to other people's touches. This can lead to the formation of a vicious circle: tactile defensiveness forces us to abandon tactile interaction with other people, which does not allow us to use the positive effect of stimulating the CT system, contributes to a decrease in oxytocin production and, ultimately, aggravates social disorders and internal mechanisms of self-regulation. Thus, a decrease in the level of the hormone cortisol in saliva after the presentation of slow tactile stimulation occurred only in those children in the orphanage who sought contact with other people and demonstrated pleasure from massage ^[26].

 Connection of tactile stimulation and self-regulationThe experience of early distress has a negative impact not only on psychological development, but also on cognitive development.

Tactile experiences are the foundation for the early development of autonomic self-regulation, which then becomes part of more complex models of executive functions. A recent study ^[27] shows the influence of affective tactile stimulation on the development of early self-regulation skills related to the child's future cognitive abilities. Another research group ^[28] compared executive functions in children in substitute families (with experience of institutionalization) with children from biological families. Children with adoption experience had lower rates of attention, planning and working memory. At the same time, earlier admission to the institution correlated with better results in terms of attention and inhibition in comparison with the group having family experience before institutionalization, which contradicts the results of another study ^[4], which showed a greater violation of inhibitory processes in children who found themselves in a child's home up to 1.5 years old. At the same time, the results of the studies discussed unanimously confirm the low level of development of executive processes in children in substitute families in comparison with children from biological families.

It was found that such aspects of parental education as sensitivity, attentiveness and support for autonomy make a significant additional contribution to the development of the child's performing functions.  Support for autonomy turned out to be the strongest predictor of a child's executive functions, regardless of the child's general cognitive abilities and the mother's education ^[29]. These data enrich the previous results of the study of stress response systems in children and confirm the significant role of interpersonal parent-child relations in the development of children's ability to self-regulation. At the same time, the problem of cognitive development has a long-term character: despite the fact that a substitute family implies a protective function that promotes self-regulation, parents should be prepared for the fact that difficulties in executive processes can be observed even after seven years of stay in a substitute family ^[28].

Practical grounds and description of rehabilitation intervention based on tactile influencePractical reasons

Caring touch is the most important component of natural education and is a protective factor that has a significant impact on the development of the nervous system of infants ^[21].

Children with experience of institutionalization or abuse at an early age have a predictable deficit of high-quality tactile contact with a caring adult ^[22]. The absence of implicit memory of parental care, due to neglect of primary needs in infancy, leaves its mark on a person about the pattern of relationships that is reproduced and fixed literally from the cradle to the grave from generation to generation ^[30]. At the same time, it has been shown that more intense and prolonged tactile contact between mother and child at an early age can reverse the negative effects that have developed due to the lack of gentle tactile stimulation in previous experience ^[31].  This gives reason to hope that a rehabilitation intervention based on a tactile approach can in some way reproduce the sensory experience of already grown-up children living with the consequences of attachment trauma and tactile contact deficiency ^[32], increasing their resistance to stress ^[21] and preventing cognitive development difficulties ^[28].

A significant obstacle to the use of rehabilitation techniques based on tactile influence is the high prevalence of negative attitudes towards touching from other people in children who find themselves in substitute families. In this regard, the effectiveness of rehabilitation intervention depends on whether it is possible to overcome the tactile defensiveness of the subject in order to learn to enjoy massage and gentle touches of other people. The other extreme of tactile interaction with others will be indiscriminate friendliness: willingness and desire to engage in tactile contact without taking into account the context (too often, too long, without mutual desire, with a stranger). This is probably due to the formation of the body image in children with experience of institutionalization significantly different from children from biological families, which is expressed by a negative disparaging attitude towards their own body, mismatch of the spheres of the “head” and “body”, weak differentiation of body parts, violation of the integrity of bodily boundaries ^[33]. That is why it is extremely important to take into account the individual characteristics of children, the psychophysiological mechanisms of tactile defensiveness ^[24], the characteristic features of indiscriminate friendliness and to use reasonable approaches aimed at creating conditions for effective child-parent tactile contact.

Description of the rehabilitation support systemThe planned rehabilitation intervention is a system of training and support of substitute parents in the process of mastering tactile interaction with children for 6 months.

In a recent study analyzing the quality of play interaction between substitute parents and children based on a 5-minute video recording, the importance of supporting parents in developing contact and interaction skills with children was noted ^[34]. The planned support program within the framework of the intervention is aimed at improving the playing competencies of substitute parents, potentially implemented in a natural, direct way during a normal day.

The system has three key aspects related to the direct implementation of the program: (1) training and support of parents, (2) a set of forms of tactile interaction of the parent-child dyad, (3) assessment of the quality of tactile interaction and providing feedback. These aspects of the intervention are designed taking into account the duration of the intervention and the tasks of retaining participants in the project with a sufficient level of involvement.

(1) Parent education and support.Work with parents takes place in small groups (no more than 5 families) in an online format using the selected messenger. The group is led by a specially trained instructor who has mastered the developed rehabilitation program to transfer it to parents and children.  The tasks of the group leader include creating conditions for the exchange of experience in the parent community, maintaining and developing motivation to participate in the project, weekly training of participants in forms of tactile child-parent interaction. An important principle of the program, which is broadcast to parents, is the fact that interaction with the child begins only with a mutual desire and immediately stops if one of the participants has such a desire disappears.

(2) The totality of forms of tactile interaction is several dozen selected tactile activities suitable for child-parent interaction and corresponding to the goals of intervention. For example, preference is given to dynamic tactile stimuli rather than static touches ^[35]. In addition, ultralight touches that resemble crawling on the skin of an insect and provoke hypersensitivity of tactile perception are strongly avoided. Such an ultralight touch - knismesis - is presumably associated with tactile defensiveness ^[36]. The task of this aspect of the intervention system is to ensure that it is possible to choose from a given variety of tactile forms of interaction that are most suitable for a specific parent-child dyad. The result will be a formed stock of accessible and natural forms of activities that help the parent to provide 15-20 minutes of tactile contact with the child on a daily basis. A recent study has shown that even 10-minute tactile stimulation protects adult rats from many anxiogenic and anhedonic effects of stress ^[18].

Forms of tactile interaction are classified according to the daily rhythm of life, have different formats of teaching parents and differentiated by forms of activity.  Thus, there are morning, afternoon, evening and bedtime activities ^[37], which have intuitive functions according to the time of day. Weekly training of parents and children takes place remotely with the help of online training with an instructor, as well as in a contactless format with the help of specially created visual teaching aids for parents (sending material twice a week). Differentiation of forms of tactile contact into such categories of joint child-parent activity as finger games, tactile play on the back, games with a blanket, game massage, tickling games, mom's acrobatics, dad's games and trust games. The forms of tactile contact are taught in such a way that, first of all, families learn the safest (from an emotional point of view) forms of interaction (for example, finger and palm games). The “complexity” of activities is gradually increasing: for example, tickling games ^[36] involving an imaginary threat require a certain level of trust from partners.

(3) Assessing the quality of tactile interaction and providing feedback is an important aspect, as it contributes to a sufficient level of involvement of participants in the project process (the effect of “positive control”) and provides material for a procedural analysis of the effectiveness of the rehabilitation approach. A tool for quality control of the implementation of the methodology is regular feedback from parents throughout the experiment. Feedback is collected on the basis of weekly reporting, which consists in filling out an online diary by a parent to assess the subjective experience of parental and child well-being, the quality of interaction and aspects related to the effectiveness of rehabilitation techniques using points on a 10-point Likert scale.

Longitudinal study designThe study consists of three stages.

At the first stage, primary diagnostics is carried out with the subjects (mother-child dyad). The second stage includes long-term work with the experimental group within the framework of the planned rehabilitation intervention for 6 months. At the third stage, a secondary diagnosis is carried out using the same diagnostic battery as at the first stage.

A sample of the study. The study will involve 90 replacement mother-child dyads and 45 blood mother-child dyads. The age of children is from 4.5 to 6.11 years inclusive. The study is planned on the territory of Moscow, St. Petersburg and Nizhny Novgorod. The distribution of replacement families in the experimental (45 dyads) and control (45 dyads) groups is provided by randomization, while the condition for participation in the experimental group is confirmation of the intentions and willingness of participants to implement the methodology in family life for several months. Confirmation of participation in the experimental group is carried out during an informal conversation with the substitute mother in order to clarify subjective expectations from the project. Blood pairs (45 dyads) act as a double control group. Access to the samples is provided by the support of the heads of the SPR (schools of foster parents), as well as the leaders of the local communities of foster parents, based on the interest of the families themselves in the tactile game theme and their desire to develop it in their families.

The object of experimental research is a developed rehabilitation intervention based on tactile parent-child interaction.

The subject of the study is the correctional and preventive potential of tactile contact (planned rehabilitation intervention) in child-parent relations in a substitute family.

The main hypothesis of the study is that a given rehabilitation program conducted for 6 months can significantly improve the ability of cognitive self-regulation in preschool children in substitute families.

Diagnostic tools. As an indicator of the effectiveness of rehabilitation intervention in general, we take positive dynamics in assessing cognitive development and self-regulation in children. Below are the parameters by which cognitive abilities are evaluated, and diagnostic techniques for measuring these parameters.

1. The ability to navigate in the flow of sensory signals and the quality of the available braking processes - a computer test to determine a simple and complex sensorimotor reaction ReBos ^[38].

2. The volume of working memory and the nature of interference in it – a software package for determining the characteristics of visual-spatial memory systems ^[39].

3. Cognitive flexibility and visual-imaginative thinking - color progressive matrices of J. Ravena for children under 8 years old ^[40].

4. Lateral preferences in sensory and motor spheres - a set of samples for children aged 4.5 - 6 years ^[41].

5. The formation of the mental model - the Sally-Ann test ^[42].

Touching between a mother and an infant is one of the types of intuitive behavior that forms the consistency between them necessary for the development of a child ^[12]. However, we assume that maternal sensitivity may depend on the characteristics of her sensory sensitivity, attitude to touch and general emotionality. In this regard, simultaneously with the diagnosis of the executive functions of children, it is proposed to assess the temperament of the mother using a test to determine the type of temperament of Jan Strelau ^[43], the type of attachment of the mother to the child using an adapted questionnaire by E. I. Nikolaeva (adaptation agreed with the author) ^[44]. In addition, the parent is also invited to undergo diagnostics to determine the quality of braking processes and the amount of working memory using the same techniques as with the child.

Diagnostic procedure. Diagnostics takes place during the home visit of an experimental researcher to each family for all tests. The duration of the diagnostic examination is about 80 minutes. The testing procedure is organized in such a way that the child gets a successful experience from participation. So, the whole diagnostic process is presented to the child in the form of a series of tests marked on the map. Each small “victory" within the framework of one or another test, the child marks on the map by sticking a sticker chosen according to his own taste, thereby approaching receiving a reward upon completion of the survey.

Statistical data processing. When statistically processing the results of primary (April) and secondary (November) diagnostics, it is assumed to take into account the invariable factors on which the results may depend: the age of entering an orphanage, the age of moving to a substitute family, the experience of interrupting parenting, family composition (full/incomplete), the presence of blood/replacement siblings, the current age of children.

ConclusionThe importance of a caring touch in the parent-child relationship can hardly be overestimated.

In blood families, the presence of tactile social contacts (playful, caring, routine) is more or less provided by simple instincts and the heritage of human culture. However, often children with experience of institutionalization have exactly the opposite experience: a lack of gentle touches at best, and at worst - physical interaction with a parent that brings pain.

Substitute parents need support in the process of developing tactile contact skills with the child. Probably the effectiveness of this interaction, measured only by the subjective feeling of lightness, pleasantness and naturalness of both participants, largely contributes to the successful adaptation of the child in a substitute family.

A feature of the planned research is an integrated approach that unites a team of specialists with different capabilities. In addition, the mandatory co-authors of the rehabilitation intervention program will be the final beneficiaries - substitute mothers, whose feedback will be qualitatively analyzed throughout the entire period.

FinancingThe study was supported by the grant of the Russian Academy of Sciences No. 22-15-00324 "Social tactile contacts and their role in psychoemotional rehabilitation".