Susan SpiekerCenter on Infant Mental Health and DevelopmentUniversity of Washington

Why do Young Children Enter Foster Care?

Children under 3 years are 30% of the maltreated population

73% of children under 3 years experience neglect

Infants are more likely to be maltreated than any other age group (3-5x)

Substantiated cases in young children are more likely to result in foster placement

Infants are more likely to experience a recurrence of maltreatment

Who are the Young Children in Foster Care?

Compromised prenatal coursePrenatal malnutritionPoor maternal mental and physical health, stress, HIVTeratogens (lead, substances, cigarettes, alcohol)

Genetic vulnerabilitiesNeglect or abuse after birthChild welfare experience Early care experiences

Multiple placementsQuality of foster parentingEmotional quality of placementVisitation with birth familyOther care/educational settings (Head Start/Early Head

Start)

Who are the Young Children in Foster Care?

• Higher rates of prematurity• Higher rates of poor physical health, childhood

illnesses, untreated health problems, acute and chronic conditions

• Trauma, failure to thrive• Cognitive delays (~53%, ACF, 2005)• Language delays• Expressive delays• Inability to communicate emotion

• Internalizing and externalizing, difficulty with self-regulation, 20-30% of toddlers (ACF, 2005)

Child Abuse Prevention and Treatment Act of 2003 (CAPTA); Keeping Children and Families Safe Act of 2003 AmendmentsRequired referral to Part C for all children in

child welfare under 3 for screeningApart from this law, child welfare policy has

not addressed the unique needs of infants and young children in child welfare

For example, generic timelines for permanency decisions (18-20 months after entry) don’t take into account the very young child’s sense of time, or need to develop and maintain a focused attachment relationship

Does Foster Care Have an Additional Negative Impact?

Research suggests, for children 4-17, the answer is ‘No’.

Once we control for selection effects, the reasons why some children are in foster care and others not, it appears that placement per se has little effect on cognitive skills or behavior problems (Berger et al., 2009).

The implications for working with older preschool children in foster care are that practices would be similar across children with particular behavior and learning issues, regardless of whether or not they were in foster care or not

Does Foster Care Have an Additional Negative Impact for Infants or Toddlers?

Attachment: There is a sensitive period in the first two years of life

Selective attachments are based on ongoing, day-to-day interactions with caregivers

Attachments become consolidated during 6-12 months of ageAttachment figures internalized after ~30

monthsIdeally, no transitions in and out of foster

care between 6 and 30 months

Does Foster Care Have an Additional Negative Impact for Infants or Toddlers?

Self development: dependent upon early caregiving relationship

Sense of identityAutonomy from preferred caregiver

Regulatory capacityModulate emotion, state, & physiological

processesLanguage as facilitator of self understanding

Does Foster Care Have an Additional Negative Impact for Infants or Toddlers?

Exponential growth of brain in infancy and early childhood25% of adult weight at birth75% at 3 years90% at 5 years

Infancy/early childhood is a sensitive period for many functions/processes

Plasticity of the brain in the early yearsImportance of early experience for brain’s

support of learning, regulation, emotion, and even physical growth

Maltreatment Affects the Architecture of the Brain

Lack of touch –smaller brainsLack of sensory stimulation –asocial behavior,

language/cognitive delay (less dense corpus callosum)

Maternal depression—reduced frontal lobe activity

Maternal stress –slower fetal brain growthMaternal drug use—Perturbed CNSDeprivation (orphanages)—poor growth, lower

DQ/IQ, sterotypies, dampening of brain functioning

Maltreatment Affects the Architecture of the Brain

Impact of traumaFight/flight (amygdala, etc)Hyperarousal (cingulate gyrus, etc)Distractibility (prefrontal regions)Dissociation (hippocampus)Impaired memory (hippocampus)Poor self regulation (frontal regions)Emotional processing difficulties (stress

hormone imbalances, cortisol)Cognitive delays (frontal lobe, corpus callosum)

Foster Care and Cognitive Delays30% show developmental delaysEffects of maltreatmentPlacement type and stability influence delayCognitive delay influences type and stability

of placementLess likely to be in Early Intervention

Foster Care and Social-Emotional Development

Effects of maltreatmentGenetic variablesBehavior problemsAttachment disordersSocial and adaptive skills deficitsMental health and early intervention usagePlacement type and stability influence social

emotional status, andSocial-emotional status influences placement

type and stability

Attachment and Young Children in Foster Care

The concept of ‘attachment’ pervades all aspects of foster/adoptive culture

However, the popular foster/adoptive meaning of ‘attachment’ differs from it’s academic, empirical meaning

Many foster parents and even social workers have received trainings or hold viewpoints based on popular literature

In the popular version, almost any behavior or relationship problem can be construed as an attachment issue

Popular Version of Attachment (RAD): Framework for Understanding Maltreated Children

Superficially charming and engaging, particularly around strangers or those who they feel they can manipulate

Indiscriminate affection, often to strangers; but not affectionate on parent’s terms Problems making eye contact, except when angry or lying A severe need to control everything and everyone; worsens as the child gets older Hypervigilant Hyperactive, yet lazy in performing tasks Argumentative, often over silly or insignificant things Frequent tantrums or rage, often over trivial issues

Demanding or clingy, often at inappropriate times Trouble understanding cause and effect Poor impulse control Lacks morals, values, and spiritual faith Little or no empathy; often have not developed a conscience Cruelty to animals Lying for no apparent reason

Popular Version of Attachment (RAD): Framework for Understanding Maltreated Children

False allegations of abuse Destructive to property or self Stealing Constant chatter; nonsense questions Abnormal speech patterns; uninterested in learning communication skills Developmental / Learning delays Fascination with fire, blood and gore, weapons, evil; will usually make the bad

choice Problems with food; either hoarding it or refusing to eat Concerned with details, but ignoring the main issues Few or no long term friends; tend to be loners Attitude of entitlement and self-importance Sneaks things without permission even if he could have had them by asking Triangulation of adults; pitting one against the other A darkness behind the eyes when raging

www.radkid.org

In other words, almost any problem behavior can be seen within this framework as a symptom of faulty attachment

However, RAD is first a clinical hypothesis and then a diagnosis that requires careful assessment.

DSM-IV 313.89: Reactive Attachment Disorder of Infancy or Early Childhood Beginning before age 5 and occurring in most situations, the patient’s social

relatedness is markedly disturbed and developmentally inappropriate. This is shown by either of:

Inhibitions. In most social situations, the child doesn’t interact in a socially appropriate way. This is shown by responses that are excessively inhibited, hypervigilant or ambivalent and contradictory. For example, the child responds to caregivers with frozen watchfulness or mixed approach-avoidance and resistance to comforting.

Disinhibitions. The child’s attachments are diffuse, as shown by indiscriminate sociability with inability to form appropriate selective attachments. For example, the child is overly familiar with strangers or lacks selectivity in choosing attachment figures.

This behavior is not explained solely by a developmental delay (such as Mental Retardation) and it does not fulfill criteria for Pervasive Developmental Disorder.

Evidence of persistent pathogenic care is shown by one or more of: The caregiver neglects the child’s basic emotional needs for affection, comfort

and stimulation. The caregiver neglects the child’s basic physical needs. Stable attachments cannot form because of repeated changes of caregiver (such

as frequent changes of foster care). It appears that the pathogenic care just described has caused the disturbed

behavior (for example, the behavior began after the pathogenic behavior).

DSM-IV 313.89: Reactive Attachment Disorder of Infancy or Early Childhood

Specify type, based on predominant clinical presentation:

Inhibited Type. Failure to interact predominates.

Disinhibited Type. Indiscriminate sociability predominates.

-- American Psychiatric Association DSM-IV Sourcebook, Volume III

RAD (DSM-IV) is a very rare diagnosisA young child in foster care may have

developed a selective attachment to a parent who also abused or neglected him

The attachment may be insecure or disordered or disrupted, however

The DSM-IV diagnosis of RAD would exclude that child

Young children in foster careChildren who have experienced multiple

placements after early problematic attachment relationships due to abuse and neglect have received relatively little research focus

They may have multiple symptoms due to comorbid conditions, not attachment, per se

This complicates the diagnosis, but broadens repertoire of available treatment,

These could be, ADHD, PDD, ODD, learning problems, trauma, mood disorders, etc.

Regardless of whether or not there is a diagnosis of RAD, children in foster care may have other common behavioral difficulties that may be better conceptualized, and addressed, by behavioral or social learning theory models

Teachers who understand this can be very helpful to foster parents who may have decided that ‘attachment’ or RAD is the source of all their child’s difficulties

The child will benefit if parents and teachers have a shared perspective on the child and his challenging behavior

Notes on ‘indiscriminant friendliness’Foster children exhibit higher levels than non-

maltreated childrenInhibitory control closely related to

indiscriminant friendliness (controlling for age and cognitive ability)

More foster placements poorer inhibitory control greater indiscriminant friendliness

Even when new attachments seem secure and stable, poor inhibitory control and indiscriminant friendliness persist

Tied to larger pattern of dysregulation related to quality of early caregiving?

In SummaryChildren in foster care may be oppositional and

aggressive, whether or not they have a RAD diagnosis

Their challenging behaviors often result in failed placements and school expulsion

These behaviors derive more from a history of abuse and trauma than inability or no opportunity to form attachments, per se.

Even after developing secure attachments, foster children can continue to show emotional and behavioral dysregulation

Multidimensional Treatment Foster Care Program for Preschoolers (MTFC-P) (P.A. Fisher et al.)

Team approach to children, foster parents, and potential permanent placement parents

Foster parents received 12 hrs intensive training Daily telephone support and supervisionWeekly foster parent support group mtgs24 hour on call staffBehavior specialist worked with child’s

preschool/daycareChild attended weekly therapeutic playgroup

sessions where clinicians received weekly supervision

Approaches that work with foster childrenReframe child difficult behaviorsChild problems attributed to a problematic

learning history, not a defect in child or parent

Appropriate limit settingIncrease positive interactions

Approaches that don’t work‘Attachment Therapy’ ‘Holding Therapy’

‘Rage-reduction therapy’ ‘z-process therapy’Originally presented as a treatment for

autistic childrenNow used for children considered to be

emotionally disturbed as a consequences of difficulty with early attachment

Child is restrained, and held, in extreme form, has resulted in death