1. Understanding the Social and Emotional Development of Young Children in Foster Care Vanessa R. Lapointe Megan Tardif May 11, 2006

2. Goals Risk associated with identification as a child in foster care –Issues predating placement in care –Issues arising from placement in care Related literature Clinical snapshot of population Implementation of a developmental screening and surveillance program

3. Early Development – Key Points Interrelatedness of domains Establishment of internal working models of attachment (first 2 years) Resilience (Schofield & Beek, 2005) Matthews’ Principle

4. Matthews Principle What makes a difference for kids? Early intervention is key Typically developing Challenges The more time that elapses, the further behind the child that faces developmental challenges falls Time Development

5. Some statistics Very little Canadian research on this population Approximately 50 000+ foster children in Canada Approximately 500 000+ foster children in USA, with 230 000 entering foster care every year (Antoine & Fisher, 2006) Young children are the largest group of children living in out-of-home care In USA, 30% of foster children in 0-5 age range

6. Issues predating placement in care Prenatal history –Poor prenatal care –Prenatal exposure Genetic conditions –Transmission of parental challenges –Genetic component of mental health –Developmental disabilities and other exceptionalities –More difficult children to engage –Less responsive –Less regulated

7. Issues predating placement in care Abuse and/or Neglect –Physical, emotional, sexual More likely to receive mental health services (Pears & Fisher, 2005) –Neglect - Standard of care is not met –Suggestion that in terms of development, neglect can be more detrimental (Pears & Fisher, 2005)

8. Issues predating placement in care Abuse and/or Neglect –Maltreated children have poorer skills in: Initiating interactions with peers Responsibility Maintaining self-control Internalizing behaviors Hyperactivity Reduced quality of play (Veloz & Fordham, 2005)

9. Issues predating placement in care Abuse and/or Neglect –After accounting for socioeconomic and foster family characteristics, these family of origin issues hold the most causal weight in terms of foster children’s challenges (Buehler et al., 2000) –Children birth to 3 highest victimization rate of child maltreatment (US Department of Health and Human Services)

10. Issues predating placement in care Placement in care of a relative –Continuation of kinship ties –Lack of significant relationship with child prior to child entering care –Preparedness to parent Life stage Pre-existing issues Substance abuse –Parental substance abuse (biological parent) is one of the strongest predictors of foster care placement instability (5- 9x)– this instability exacerbates existing behavioral difficulties (Holland & Gorey, 2004)

11. Issues predating placement in care Experience of poor parental strategies –Deficient family management skills –Harsh and inconsistent discipline –Low levels of supervision and involvement in child’s life –Lack of appropriate prosocial reinforcement Leads to increased risk for mental health problems (Leslie et al., 2005)

12. Issues arising with placement in care Loss/trauma –Birth parent(s) –Siblings (Leathers & Addams, 2005) Consideration of age at placement –Change in attachment classification (to secure) more likely and more quickly in younger children (Stovall-McClough & Dozier, 2004)

13. Issues arising with placement in care Frequent changes in care providers –# of transitions directly impacts development (Pears & Fisher, 2005) –Exacerbates existing social and emotional concerns (Newton et al., 2000) –Social skills (cooperation, assertion, and responsibility) positively correlated with length of foster care placement (Veloz & Fordham, 2005)

14. Issues arising with placement in care “Children in [foster care] often experience multiple placements and varied degrees of service provision. This can be devastating to a child already struggling to piece together a life subjected to abuse and neglect by his or her immediate family” (McMillan, 2005)

15. Issues arising with placement in care Frequent changes in care providers –“…most any child who has already experienced a number of lifespan traumas and then the loss of their family of origin will only be further harmed by going through a series of developed and then lost relationships with foster parents and siblings.” (p. 117-188, Holland & Gorey, 2004)

16. Issues arising with placement in care Quality of care –“When victims of child abuse and neglect are placed in inadequately prepared foster homes, the state implicitly colludes in continuing their maltreatment” (Rich, 1996 as cited in Pasztor, 2006) Discontinuity in or lack of service provision (Pasztor et al., 2006) –Physician –Early Intervention Services –Education

17. Clinical Snapshot “The population of abused and neglected children who go on to enter foster care may have significantly more health problems, and especially mental health problems, than other poor children” (Bilaver et al., 1999)

18. Clinical Snapshot While up to 50% of children in one study reportedly had mental health needs, very few of them actually accessed the appropriate services due to lack of identification and/or barriers to service accessibility within the system (Leslie at al, 2000)

19. Clinical Snapshot Placement in foster care associated with higher rates of behavior issues/disorders (Flynn & Biro, 1998) Decreased levels of educational success –41% repeat grade –43% in Special Education (3-4x) –Frequent changes in educational setting (2x) (Flynn & Biro, 1998)

20. Clinical Snapshot Placement in foster care associated with significantly worse emotion understanding and theory of mind capabilities, even after age, intelligence and executive function are accounted for (Pears & Fisher, 2005) Mental health services are typically more difficult to access than physical health services (Pasztor et al., 2006)

21. Clinical Snapshot Prevalence of developmental delay 13-80 % compared to 4%-10% in general population (Halfon et al., 1995; Horowitz, Simms & Farrington, 1994; Leslie et al., 2002) Decreased language development across all ages but worsens as as enter preschool years (up to 63% will have delays) (Halfon et al, 1995; Silver et al, 1999) 63% cognitive delays and 46% motor delays (Leslie et al, 2002)

22. Clinical Snapshot Early Interventionist Perspective –Often start with regulation difficulties; possibly related to prenatal factors –Difficulty with self-soothing –More likely to have extreme and sudden changes in their emotional state (++ “unexplained” crying, tantrums) –Catch up may happen with developmental delays but social and emotional difficulties often last

23. Developmental Screening and Surveillance Program In US, The Child Welfare League of America, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry have issued policy statements calling for mandatory developmental assessments of children within 1 month of entering foster care as well as periodic re- screening over-time

24. Developmental Screening and Surveillance Program Screening Measures –Challenge – harder to identify younger children (Leslie et al, 2002) –First-level screen versus more in-depth assessment –Goal of universality - need to be able to administer a large number of assessments with minimal cost –Parent-completed screening questionnaires Foster parents are reliable informants, particularly of externalizing disorders (Tarren-Sweeney et al., 2004).

25. Developmental Screening and Surveillance Program Selecting a screening measure –Capacity for parent respondent –Consider minimal amount of time child must live with parent before measure is reliable and valid –Consider length of time to complete –Ideal to screen for multiple domains, including social and emotional well-being

26. Developmental Screening and Surveillance Program Selecting a screening measure –Consider sensitivity and specificity of the tool –Sensitivity = The ability of the test to correctly identify children with developmental delays (true positives) –Specificity = The ability of the test to correctly identify children without developmental delays (true negatives) –Gold standard Both specificity and sensitivity should be around 0.70 to 0.80 (Meisels, 1989)

27. Developmental Screening and Surveillance Program Screening Tool Target Ages Time to Complete Domains Covered Languages available Publisher ASQ – 2 nd Edition 4-60 months 10-15 minutes language, personal- social fine motor gross motor cognition English, Spanish, French and Korean Paul H. Brookes Publishing Co., ASQ SE6-60 months 10-15 minutes social and emotional Paul H. Brookes Publishing Co., Child Development Inventory 0-78 months (6 ½ years) “Very quick” social, self help, motor, language; General Development Scale and 30 items to identify parent's other concerns English Ellsworth & Vandermeer Press, Ltd., PEDS – Parents Evaluation of Development al Status Birth – 8 years 2 minutesa wide range of developmental issues including behavioural and mental health problems English, Spanish and Vietnamese, additional translations including Hmung, Somali, Chinese, and Malaysian can be licensed by emailing the publisher Ellsworth & Vandermeer Press, Ltd.,

28. Developmental Screening and Surveillance Program Service Provision/follow-up –Identify community/provincial partners and agencies and establish collaborative system –Scope – to assess children and link with effective intervention services

29. Developmental Screening and Surveillance Program 1.Screening 2.Access to services 3.Management of information 4.Coordination of care 5.Collaboration among systems 6.Family participation 6.Attention to cultural issues 7.Monitoring and evaluation 8.Training and Education 9.Funding 10.Designing managed care to fit needs of children (Wolverton, 2002)

30. Broader Program Embedded in a more holistic approach to foster care that recognizes the systemic influences on young children’s lives Especially relevant is the role of foster parent in improving outcomes Need to consider role of existing programs and agencies: e.g. IDP, Safe Babies, Supported Child Development, MCFD (Child Protection and Mental Health)

31. Broader Program e.g. Multidimensional Treatment Foster Care Program for Preschoolers –Clinical support to address behavioral and developmental concerns –Emotional support –On-going training –Weekly group support meetings –Identification of emotional needs of caregivers and children –Foster home consultant, foster parents, and coordinating supervisor –Weekly therapeutic playgroup for children Social skill development Preparing children for social experience of school (Antoine & Fisher, 2006)

32. Developmental Screening and Surveillance Program Challenges –Resources Administrative Tools (minor) Early Interventionists –Shortage! –Defining “delay”

33. Developmental Screening and Surveillance Program Benefits –Early identification (Matthews’ Principle) –Building capacity Raising awareness of importance of early development Increasing knowledge of key early development milestones For social workers, birth parents, foster parents A lack of awareness contributes to adverse outcomes

34. Conclusions “Children in foster care, as a result of exposure to risk factors such as poverty, maltreatment, and the foster care experience, face multiple threats to their healthy development, including … attachment disorders, … inadequate social skills, and mental health difficulties” (Harden, 2004)

35. Conclusions “Developmentally sensitive policies and practices designed to promote the well-being of the whole child, such as ongoing screening and assessment and coordinated systems of care, are needed to facilitate the healthy development of children in foster care.” (Harden, 2004)

36. Questions/Comments