ENHANCING FOSTER CARE AS AN INTERVENTION

1. ENHANCING FOSTER CARE AS AN INTERVENTION Charles H. Zeanah, M.D. Tulane University School of Medicine

2. Continuum of Care for Orphaned, Abandoned and Maltreated Children Street children Institutions Smaller Group Care Foster Care High Quality Foster Care

3. John Bowlby …the quality of the parental care which a child receives in his earliest years is of vital importance for his future mental health. …essential for mental health is that an infant and young child should experience awarm, intimate and continuous relationship with his mother (or mother substitute…) in which both find satisfaction and enjoyment. --1952

4. Attachment • Infants are strongly biologically predisposed to form attachments to care-giving adults • Attachment develops graduallyover the first several years of life, based upon relationship experiences with caregivers • Under usual rearing conditions, infants develop “focused” or “preferred” attachments in the second half of the first year of life. • Separation protest • Stranger wariness

5. Attachment (cont.) • Healthy attachments protective. • Unhealthy attachments increase risk for maladaptive outcomes. • Disrupted attachments harmful.

6. Levels of discrimination between infants and caregivers It’s not just attached or not attached: Recognition/ familiarity Familiarity/ comfort Comfort/ pleasure Pleasure/ reliance Reliance/ preference

7. Challenges for foster care • From the child • From the foster parent • From the system

8. Young children in foster care challenging behaviors • Agitation • Constant Activity • Loudness • Aggression • Fears • Self-endangering • Stereotypies • Sleep disturbances • Hoarding, overeating, picky eating • Toileting problems • Delayed speech/language • Limited attention • Easily frustrated • Extreme withdrawal Bucharest Early Intervention Project

9. Can young children establish new attachments to foster parents? • Substantial number of maltreated children have significant signs of attachment disorders at the time they come into care. • Attachments begin to be evident within days to weeks in children in foster care. • Healthy attachments are far more likely in children in foster care if foster mothers are secure.

10. Challenges for foster parents • Isolation/lack of support • Repeated attachments and separation from children in their care • Problematic attachment histories • Insufficient or inadequate training • Motivation/commitment • Caring for children who have experienced attachment disruption(s) • Behavioral/emotional difficulties • Off putting behaviors • “He’s suffered enough” Syndrome

11. Challenges from the systems(Child protection and legal) • Failure to understand/apply science of development to “best interest” standards. • Foster care in early childhood must be conceptualized differently than in school aged children and adolescents • Failure to include foster parents as team members or professionals. • Decision making about young children influenced by “countertransference” (personal prejudices) rather than by careful consideration of best interest.

12. Quality Foster Care Exits

13. Four Examples • Attachment, Biobehavioral Catch-up • Dozier and colleagues • Multi-Treatment Foster Care • Fisher and colleagues • New Orleans Intervention • Zeanah and colleagues • Bucharest Early Intervention Project • Smyke and colleagues

14. Attachment and Bio-behavioral Catch-Up Targeted issue • Child alienates caregiver through challenging/ rejecting behavior • Caregiver does not act nurturing even if child elicits nurturance • Child exhibits biobehavioraldysregulation Intervention • Caregiver provides nurturance even if child doesn’t elicit it • Caregiver trained to provide nurturance even if it does not come naturally • Caregiver provides predictable environment

15. MTFC-P program components • Services to Foster Families • Initial training • 24 hour on-call staff availability • Support group • Daily phone check-in with parents • Services to Children • Therapeutic playgroup • Skills training • Preschool/school consultation • Services to Birth/Adoptive Parents • Family therapy • Training in Parenting • Aftercare consultation and support

16. New Orleans Intervention • Infant Mental Health Team is referred all children less than 60 months of age who are placed in foster care in Jefferson Parish. • Comprehensive assessments of child with foster and biological parents. • Intervene in relationships with all important caregivers • Facilitating primary attachments to foster parents • Reconstructing biological parent-child relationship • Assist with transition back to biological parents or transition to adoption

17. Bucharest Early Intervention Project • 3 social workers overseeing 68 children removed from institutional settings and placed in one of 56 homes • Visits to foster parents every 10 days • Intensive phone contact • Systematic inquiry regarding child behavior/adjustment • Foster parent support group • Education/support • Explicit efforts to facilitate attachments • Supervision/consultations from U.S. psychologists

18. Evaluations • ABC—RCT • Improved attachment and cortisol metabolism • MTFC—RCT • Enhanced stability (reduced disruptions), improved attachment and cortisol metabolism • New Orleans Intervention—Consecutive cohort study • Reduced recidivism and prevention of subsequent maltreatment • BEIP—RCT • Enhanced IQ, language, growth, emotional expression, attachment, EEG power, competence, and reductions in attachment disorders, internalizing disorders, and stereotypies

19. What is necessary to make foster care effective for young children? • Foster care is an intervention designed to protectand remediatechildren who have been abandoned, maltreated, or orphaned. • In order to protect young children adequately, foster parent must becomeprimary caregiver and primary attachment figure for child. • Safety, stabilityand consistent emotional availabilityare paramount. • Foster parents must psychologically invest/commitin child in order to become attachment figure.

20. Premise #1 • Foster care is an intervention designed to protectchildren and remediatewho have been maltreated. • Interventions can be helpful or harmful. • alternatives are institutional care and family preservation • Should place psychological safetyon par with physical safety. • Developmental capacities and needs must be considered in every aspect of decision making.

21. Foster Care vs. Institutional Care Author Foster Care Institution Country • Goldfarb (1943) 20 20 US • Goldfarb (1944) 40 40 US • Goldfarb (1945a) 15 15 US • Goldfarb (1945b) 70 70 US • Levy (1947) 129 101 US • Dennis &Najarian (1957) 41 49 Lebanon • Provence & Lipton(1962) 75 75 US • Roy et al. (2000) 19 19 UK • Harden et al. (2002) 30 35 US • Ahmed et al. (2005) 48 94 Iraqi Kurdistan • Nelson et al. (2009)* 68 68 Romania *RCT

22. Continuum of care-giving approaches:Alternatives • Overwhelmingly consistent evidence favoring foster care over institutional care • Family preservation has generally dismal results (other than Homebuilders model which is more encouraging) • Family preservation will never replace foster care • Emphasis should be on improving the availability and quality of foster care.

23. Premise #2 • In order to protect young children adequately, foster parent mustbecome primary caregiver and attachment figurefor child. • The young child cannot wait. • The young child needs literal physical contact to sustain attachments. • Emotional availability and dependability are crucial. • If reunification is possible, transition can be conducted in a way that protects the child.

24. MFTC attachment related-behaviors (Fisher & Kim, 2005) Increased secure behavior Decreased insecure behavior

25. ABC: Disorganized attachment among foster and intact dyads 73 31 18 9 Dozier, 2006

26. BEIP attachment at 42 months 83 66 51 49 34 17 CAUG< FCG = NIG

27. Premise #3 • Safety, stability and emotional availability are paramount for the young child. • Until the threat is removed, trauma cannot be treated.

28. Disruptions in Foster Care • Disruptions are harmful after attachments are established (7-9 months) • After 12 months are even more harmful than disruptions before 12 months. • From child’s perspective, impossible to understand.

29. Number of Disruptions by Type of Care 65 42 36 36 23 2

30. Premise #4 • Foster parents must psychologically commit to in child in order to become attachment figure. • Child must have a mother-- not a babysitter or placeholder or committee.

31. Inherent contradiction of foster parenting • Psychological Ownership • Love the child as their own—extended respite versus attachment figure • Advocate for child • Become the child’s “go – to” person—usurping parental role • Uncertainty • Child can be removed at any time • Progress of biological parents

32. What predicts commitment? • Number of children fostered • Kin vs. non-kin

33. Number of children fostered • The more children fostered in the past, the lower the commitment to the current child, r(102) = -0.47, p< .01. • Commitment should be valued over experience.

34. Signs of indiscriminate behavior and foster parent type Professional > Family Building/Kin (p= .005)

35. Barriers to attachment in foster parents

36. Relationship with foster child Norwood et al., 2009

37. What is the evidence that commitment is important? • Child representations of self and other • When caregivers are lower in commitment, relationship with child is more likely to disrupt than when higher in commitment. • Dozier &Lindhiem, 2005

38. A model of child centered, healthy foster parenting Sensitive Caregiving • Safe • Securely Attached • Socially Competent • Emotionally Well- • Regulated Psychological Investment/ Commitment Valuing Child as An Individual Placing Needs of Child First Parent Behaviors Child Outcomes

39. Conclusions • Foster care is a better form of care for abandoned and maltreated young children than other approaches (institutional care or family preservation). • Models of quality foster care exist and have been demonstrated to be better for young children than business as usual foster care. • Foster care for young children must be different than foster care for older children because of the urgency of attachment needs of young children.

40. Conclusions: Are we ready for systems change? • Foster care for young children different than foster care for older children because of the urgency of attachment needs of young children. • Child Protection efforts may be arrayed along a continuum from lack of protection to high quality foster care—there is no approach that cannot improve. Street children Institutions Smaller Group Care Foster Care High Quality Foster Care