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
Top Related