Presentation on theme: "Working with Children in Foster Care"— Presentation transcript:
1 Working with Children in Foster Care Susan SpiekerCenter on Infant Mental Health and DevelopmentUniversity of WashingtonThe traditional objectives ofthe 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, ithas 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 2001state CPS agencies have been required to undergo federal Child and Family Service Reviewswhich assess and monitor their progress towards promoting child safety and permanency, as wellas 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 population73% of children under 3 years experience neglectInfants 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 placementInfants are more likely to experience a recurrence of maltreatment
3 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 experienceEarly care experiencesMultiple placementsQuality of foster parentingEmotional quality of placementVisitation with birth familyOther care/educational settings (Head Start/Early Head Start)
4 Who are the Young Children in Foster Care? Higher rates of prematurityHigher rates of poor physical health, childhood illnesses, untreated health problems, acute and chronic conditionsTrauma, failure to thriveCognitive delays (~53%, ACF, 2005)Language delaysExpressive delaysInability to communicate emotionInternalizing 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 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 welfareFor 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 lifeSelective attachments are based on ongoing, day-to-day interactions with caregiversAttachments 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
8 Does Foster Care Have an Additional Negative Impact for Infants or Toddlers? Self development: dependent upon early caregiving relationshipSense of identityAutonomy from preferred caregiverRegulatory capacityModulate emotion, state, & physiological processesLanguage 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 childhood25% of adult weight at birth75% at 3 years90% at 5 yearsInfancy/early childhood is a sensitive period for many functions/processesPlasticity of the brain in the early yearsImportance 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 brainsLack of sensory stimulation –asocial behavior, language/cognitive delay (less dense corpus callosum)Maternal depression—reduced frontal lobe activityMaternal stress –slower fetal brain growthMaternal drug use—Perturbed CNSDeprivation (orphanages)—poor growth, lower DQ/IQ, sterotypies, dampening of brain functioning
11 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)
13 Foster Care and Cognitive Delays 30% show developmental delaysEffects of maltreatmentPlacement type and stability influence delayCognitive delay influences type and stability of placementLess likely to be in Early Intervention
14 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
15 Attachment and Young Children in Foster Care The concept of ‘attachment’ pervades all aspects of foster/adoptive cultureHowever, the popular foster/adoptive meaning of ‘attachment’ differs from it’s academic, empirical meaningMany foster parents and even social workers have received trainings or hold viewpoints based on popular literatureIn 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 manipulateIndiscriminate affection, often to strangers; but not affectionate on parent’s termsProblems making eye contact, except when angry or lyingA severe need to control everything and everyone; worsens as the child gets olderHypervigilantHyperactive, yet lazy in performing tasksArgumentative, often over silly or insignificant thingsFrequent tantrums or rage, often over trivial issues Demanding or clingy, often at inappropriate timesTrouble understanding cause and effectPoor impulse controlLacks morals, values, and spiritual faithLittle or no empathy; often have not developed a conscienceCruelty to animalsLying for no apparent reason
17 Popular Version of Attachment (RAD): Framework for Understanding Maltreated Children False allegations of abuseDestructive to property or selfStealingConstant chatter; nonsense questionsAbnormal speech patterns; uninterested in learning communication skillsDevelopmental / Learning delaysFascination with fire, blood and gore, weapons, evil; will usually make the bad choiceProblems with food; either hoarding it or refusing to eatConcerned with details, but ignoring the main issuesFew or no long term friends; tend to be lonersAttitude of entitlement and self-importanceSneaks things without permission even if he could have had them by askingTriangulation of adults; pitting one against the otherA 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 attachmentHowever, 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 himThe attachment may be insecure or disordered or disrupted, howeverThe 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 focusThey may have multiple symptoms due to comorbid conditions, not attachment, per seThis 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 modelsTeachers 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 difficultiesThe 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 childrenInhibitory control closely related to indiscriminant friendliness (controlling for age and cognitive ability)More foster placements poorer inhibitory control greater indiscriminant friendlinessEven when new attachments seem secure and stable, poor inhibitory control and indiscriminant friendliness persistTied to larger pattern of dysregulation related to quality of early caregiving?
25 In SummaryChildren in foster care may be oppositional and aggressive, whether or not they have a RAD diagnosisTheir challenging behaviors often result in failed placements and school expulsionThese 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 parentsFoster parents received 12 hrs intensive trainingDaily 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
27 Approaches that work with foster children Reframe child difficult behaviorsChild problems attributed to a problematic learning history, not a defect in child or parentAppropriate limit settingIncrease 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 childrenNow used for children considered to be emotionally disturbed as a consequences of difficulty with early attachmentChild is restrained, and held, in extreme form, has resulted in deathAT 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.