Working with Children in Foster Care

1. Working with Children in Foster Care Susan Spieker Center on Infant Mental Health and Development University of Washington

2. 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

3. Who are the Young Children in Foster Care? • Compromised prenatal course • Prenatal malnutrition • Poor maternal mental and physical health, stress, HIV • Teratogens (lead, substances, cigarettes, alcohol) • Genetic vulnerabilities • Neglect or abuse after birth • Child welfare experience • Early care experiences • Multiple placements • Quality of foster parenting • Emotional quality of placement • Visitation with birth family • Other care/educational settings (Head Start/Early Head Start)

4. 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)

5. Child Abuse Prevention and Treatment Act of 2003 (CAPTA); Keeping Children and Families Safe Act of 2003 Amendments • Required referral to Part C for all children in child welfare under 3 for screening • Apart 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

6. 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

7. 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 age • Attachment figures internalized after ~30 months • Ideally, no transitions in and out of foster care between 6 and 30 months

8. Does Foster Care Have an Additional Negative Impact for Infants or Toddlers? • Self development: dependent upon early caregiving relationship • Sense of identity • Autonomy from preferred caregiver • Regulatory capacity • Modulate emotion, state, & physiological processes • Language as facilitator of self understanding

9. Does Foster Care Have an Additional Negative Impact for Infants or Toddlers? • Exponential growth of brain in infancy and early childhood • 25% of adult weight at birth • 75% at 3 years • 90% at 5 years • Infancy/early childhood is a sensitive period for many functions/processes • Plasticity of the brain in the early years • Importance of early experience for brain’s support of learning, regulation, emotion, and even physical growth

10. Maltreatment Affects the Architecture of the Brain • Lack of touch –smaller brains • Lack of sensory stimulation –asocial behavior, language/cognitive delay (less dense corpus callosum) • Maternal depression—reduced frontal lobe activity • Maternal stress –slower fetal brain growth • Maternal drug use—Perturbed CNS • Deprivation (orphanages)—poor growth, lower DQ/IQ, sterotypies, dampening of brain functioning

11. Maltreatment Affects the Architecture of the Brain • Impact of trauma • Fight/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)

12. Two Pathways of Fear

13. Foster Care and Cognitive Delays • 30% show developmental delays • Effects of maltreatment • Placement type and stability influence delay • Cognitive delay influences type and stability of placement • Less likely to be in Early Intervention

14. Foster Care and Social-Emotional Development • Effects of maltreatment • Genetic variables • Behavior problems • Attachment disorders • Social and adaptive skills deficits • Mental health and early intervention usage • Placement type and stability influence social emotional status, and • Social-emotional status influences placement type and stability

15. 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

16. 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 issuesDemanding 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

17. 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

18. 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.

19. 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).

20. 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

21. RAD (DSM-IV) is a very rare diagnosis • A 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

22. Young children in foster care • Children 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.

23. 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

24. Notes on ‘indiscriminant friendliness’ • Foster children exhibit higher levels than non-maltreated children • Inhibitory 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?

25. In Summary • Children 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

26. 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 supervision • Weekly foster parent support group mtgs • 24 hour on call staff • Behavior specialist worked with child’s preschool/daycare • Child attended weekly therapeutic playgroup sessions where clinicians received weekly supervision

27. Approaches that work with foster children • Reframe child difficult behaviors • Child problems attributed to a problematic learning history, not a defect in child or parent • Appropriate limit setting • Increase positive interactions

28. Approaches that don’t work • ‘Attachment Therapy’ ‘Holding Therapy’ ‘Rage-reduction therapy’ ‘z-process therapy’ • Originally presented as a treatment for autistic children • Now 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