enhancing foster care as an intervention charles h. zeanah, m.d. tulane university school of...

ENHANCING FOSTER CARE AS AN INTERVENTION

Charles H. Zeanah, M.D.Tulane University School of Medicine

Continuum of Care for Orphaned, Abandoned and Maltreated Children

Street children

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CareInstitutions Foster Care High Quality

Foster Care

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

• 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

Attachment

• Healthy attachments protective.• Unhealthy attachments increase risk for

maladaptive outcomes.• Disrupted attachments harmful.

Attachment (cont.)

Levels of discrimination between infants and caregivers

Recognition/familiarity

Comfort/pleasure

Familiarity/comfort

Pleasure/reliance

Reliance/preference

It’s not just attached or not attached:

• From the child• From the foster parent• From the system

Challenges for foster care

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

• 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.

Can young children establish new attachments to 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

Challenges for foster parents

• 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.

Challenges from the systems(Child protection and legal)

Quality Foster Care Exits

• 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

Four Examples

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

• 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

MTFC-P program components

• 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

New Orleans Intervention

• 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

Bucharest Early Intervention Project

• 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

Evaluations

• 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.

What is necessary to make foster care effective for young children?

• 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.

Premise #1

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

Foster Care vs. Institutional Care

*RCT

• 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.

Continuum of care-giving approaches:Alternatives

• 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.

Premise #2

MFTC attachment related-behaviors (Fisher & Kim, 2005)

Increased secure behavior

Decreased insecure behavior

ABC: Disorganized attachment among foster and intact dyads

Dozier, 2006

18

73

9

31

BEIP attachment at 42 months

CAUG< FCG = NIG

17

34

66

51

83

49

• Safety, stability and emotional availability are paramount for the young child.

• Until the threat is removed, trauma cannot be treated.

Premise #3

• 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.

Disruptions in Foster Care

Number of Disruptions by Type of Care

65

2

23

42

3636

• 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.

Premise #4

• 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

Inherent contradiction of foster parenting

• Number of children fostered

• Kin vs. non-kin

What predicts commitment?

• 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.

Number of children fostered

Signs of indiscriminate behavior

and foster parent type

Professional > Family Building/Kin (p= .005)

Barriers to attachment in foster parents

Kin Non-Kin

Own attachment history + +

Misperceiving child behavior + +

Fear of loss of child + +++

Family loyalty conflicts +++ _

Stresses and supports + +

Relationship with foster child

Norwood et al., 2009

• 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

What is the evidence that commitment is important?

A model of child centered, healthy foster parenting

SensitiveCaregiving

Valuing Child as An Individual

Placing Needs of Child First

Psychological Investment/Commitment

•Safe•Securely Attached•Socially Competent•Emotionally Well-Regulated

Child OutcomesParent Behaviors

• 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.

Conclusions

• 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.

Conclusions: Are we ready for systems change?

Street children

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CareInstitutions Foster Care High Quality

Foster Care