1. Working with Children in Foster Care
Susan Spieker
Center on Infant Mental Health and Development
University of Washington
The traditional objectives of
the U.S. child welfare system have been to ensure safety and promote permanency for children.
Although improving child well-being has often been viewed as an implicit goal of the system, it
has only more recently, with the passage of the Adoption and Safe Families Act of 1997 (ASFA),
been made explicit (Wulczyn, Barth, Yuan, Harden & Landsverk, 2005). Indeed, since 2001
state CPS agencies have been required to undergo federal Child and Family Service Reviews
which assess and monitor their progress towards promoting child safety and permanency, as well
as meeting children’s educational, physical, and mental health needs.

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 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

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

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
AT has not been been supported by sparse research, but remains a topic of study for professional psychology and social work. State agencies and insurance companies have supported it.
Represent a basic cognitive error. For example, AT theory assumes that lack of eye contact is caused by failure of attachment, there for, forcing eye contact while holding will be corrective.