Susan Spieker Center on Infant Mental Health and Development University of Washington.
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Transcript Susan Spieker Center on Infant Mental Health and Development University of Washington.
Susan Spieker
Center on Infant Mental Health and Development
University 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 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)
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
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
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-today 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
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
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
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
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)
Two Pathways of Fear
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
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
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
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
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.
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 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?
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
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
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
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