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J O H A N N A B I C K , P H D
Y A L E U N I V E R S I T Y
C H I L D S T U D Y C E N T E R
M A R Y D O Z I E R , P H D
U N I V E R S I T Y O F D E L A W A R E
Infants in Foster Care: Social Emotional Needs and Effective
Interventions
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Infants in Foster Care
400,000 children in foster care to date
Children younger than 5 are twice as likely to be placed in foster care
www.childwelfare.gov, 2010
Spend longer time in out-of-home care
George & Wulczyn, 1998
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Foster Care
Designed to be an intervention
Removal from unsafe conditions
Developed as alternative to institutional care
Children thrive in family setting
Foster parents have an important job!
Key position to help enhance
positive outcomes!
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Topics for Today: Infants in Foster Care
Part 1: Developmental stage of infancy
Why is foster care challenging for infants?
Part 2: What areas of development are affected?
Part 3: What can be done to promote positive outcomes?
Attachment and Bio-behavioral Catch-up Program
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Infants in Foster Care
Part 1: Developmental Stage of Infancy
Why is foster care challenging for infants?
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What are the Developmental Needs of Infants
Human infants are biologically prepared to form
attachments to caregivers
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Infant Attachment
Salient tasks in infancy become “selective” especially during the second half of the first
year of life • once infants can “move away” from
caregiver, an attachment is in place
primary caregiver(s) • Not just any adult will do: “stranger” will
not work
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Infant Attachment
Associated with children’s social emotional development and functioning Caregiver regulates emotions of infant Internalized and eventually learned on
own
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Challenge 1: Losing Attachment Caregiver(s)
Loss of caregiver challenges a core developmental process
Placed in care of adult with whom they often have no relation
Occurs at a developmental point in which they would otherwise have fully developed attachments
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Challenge 2: Multiple Placements
Multiple losses and multiple attachment reformations
Undermines potential to form healthy relationships
Associated with increased emotional and behavioral difficulties
Gean, Gillmore, Dowler, 1985
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Challenge 2: Multiple Placements (cont.)
Compromised Cognitive Performance/Attention Day-night Stroop task and Working memory control task
(Gerstadt et al., 1994)
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Placement Instability: Lewis et al., 2007
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Challenge 2: Multiple Placements (cont.)
Circular problem
Behavioral and emotional difficulties
Primary reason that children disrupt
• Oosterman, Schuengel, Slot, Bullens, & Doreleijers, 2007
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Challenge 3: Prior Trauma
Histories of problematic caregiving
neglect (parental substance abuse)
physical maltreatment
abandonment
sexual abuse
exposure to violence in the home, etc.
“Carry this trauma with them” to next placement
Behave in ways that alienate caregivers
Push caregivers away at times of need
Makes new relationship formation even more difficult
• Stovall & Dozier, 2002
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Summary of Challenges for Infants
Challenge 1: Disrupt of Attachment Bond
Challenge 2: Often repeated separations, disruptions
Challenge 3: Prior traumatic experiences
Collectively places infants at risk for attachment difficulties and behavioral dysregulation
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Infants in Foster Care
Part 2: What areas of development are affected?
(and how can we measure them?)
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Attachment Security in Infancy
When infants have caregivers that are available and responsive to their needs, they develop secure attachments
Behaviorally:
Seek out caregivers for comfort (safe haven)
Confidently explore their world, knowing they can rely on their caregiver as a “secure base” (when not distressed)
Develop a “confident expectation” that their caregiver will respond to their needs
(Sroufe, 1989; Ainsworth, Blehar, Waters, & Wall, 1978).
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Insecure attachment
What happens when caregivers are not sufficiently responsive to infants needs?
Cannot be “confident” that their caregiver will be available to them when they need them
Develop alternative behavioral strategies to manage distress when in their caregivers presence
Ainsworth et al., 1978
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Avoidant
In response to caregivers that “minimize” infant distress, do not respond sensitively
Develop an Avoidant Attachment turn away from their caregivers at times of need behave like they don’t need their caregiver’s nurturance
Why? not used to getting responded to, so “learn” not to turn to caregivers
How do we know they “aren’t fine?”
Even though they show heightened physiological arousal, and subtle behavioral signs of stress • Sroufe & Waters, 1977
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Ambivalent/Resistant
In response to “inconsistent” caregiver availability
Develop a Resistant attachment
alternate between avoiding their caregiver and seeking contact when distressed
remain fussy, inconsolable even when caregivers try to soothe
Why?
don’t “learn” that they can effectively use caregiver as a safe haven
“sometimes s/he’s there and sometimes not”
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Disorganized
In addition to being classified as secure or insecure, babies can receive a secondary classification of Disorganized breakdown in their behaviors when they are distressed and in their
caregivers presence. lapse in organized strategy
freezing, signs of fear, or atypical behaviors when they should be turning to their caregiver for safety!
Why?
Trauma, frightening parental behavior once source Van Ijzendoorn et al., 1999
Infants in foster care at especially high risk
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Why Do We Care About Attachment Security?
Secure toddlers relative to insecure:
More competent problem solving as toddlers (Matas, Arend, & Sroufe, 1978)
More independent and confident with teachers at preschool (Sroufe, 1983)
More competent interactive behaviors with peers at school (Elicker, Englund, Sroufe, 1992
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Disorganized Attachment a Serious Risk
Long term risk for a host of problematic outcomes Decreased cognitive performance
(mental development scores on assessment during toddlerhood)
Lyons-Ruth et al., 1991
Aggressive behavior with peers
(Lyons-Ruth, Alpern, & Repacholi, 1993; Lyons-Ruth, Easterbrooks, & Cibelli, 1997)
Dissociative symptomatology, psychopathology throughout childhood
(Carlson, 1998)
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Attachment Organization and Foster Infants
Under responsive conditions, foster infants can develop secure attachments
Show “secure” behavior and less avoidant behavior with first two months
Develop clear, coherent strategies in the first few months of placement
But! if do not receive nurturing, responsive care, show high levels of avoidant and resistant behavior
(Chase-Stovall, Dozier, 2004)
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Disproportionate Disorganization
In general, at higher risk for developing disorganized attachments
When not cared for by highly nurturing caregivers
Possible Reason? Placement disruption is likely so disorganizing, difficulty with developing secure attachment unless in the most responsive environments
Important considering long term risks associated with disorganized attachment classifications!
Dozier et al., 2006
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Additional Dysregulation Among Foster Infants
What if we look beyond the surface?
Bio-behavioral dysregulation Children can “look fine” behaviorally, but show physiological signs
of stress
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HPA Axis
Hypothalamus Pituitary Adrenal (HPA) axis
Physiological system associated with response to stress, sleep, and ability to fight infections
2 orthogonal functions
Stress reactive function
Body’s mounting a stress response
Diurnal function
Circadian rhythm, Immune system
More discrepancies in this system
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How Does This System Work?
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How Can We Measure It?
The end product: cortisol
Easily measured in saliva (good for babies!)
An index for how system is functioning
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When do We Measure the HPA axis?
Look at patterns across the day
Typical diurnal pattern established during the first year of life
Sharp increase at wake up
Sharp decrease until mid morning, steady decrease until bedtime
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Cortisol and Young Foster Children
• Infants in Foster Care Showed Atypical Daily Rhythms, Dozier et al., 2006
• Infants: Atypically High
• Toddlers; Atypically Low
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Cortisol Values Across the Day
Less change from morning to evening Dozier et al., 2006
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Infants in Foster Care
Part 3: What Programs Promote Positive Outcomes?
One example: ABC
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Attachment and Bio-behavioral Catch up (ABC)
Mary Dozier and Infant Caregiver Lab
University of Delaware
10 session, home-based intervention for foster parents and infants at risk for neglect
Targets 3 critical needs of at-risk infants
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Overview of ABC
Critical Need Intervention Target Outcome
1. Infants push caregivers away
Re-interpret
infants' signals
Attachment Security
2. Nurturing care may not come naturally
Over-ride issues that interfere with nurturance
Attachment Security
3. Difficulty regulating behavior and physiology
Predictable, controllable world
Bio-behavioral regulation
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Overview of ABC
Critical Need Intervention Target Outcome
1. Infants push caregivers away
Re-interpret
infants' signals
Attachment Security
2. Nurturing care may not come naturally
Over-ride issues that interfere with nurturance
Attachment Security
3. Difficulty regulating behavior and physiology
Predictable, controllable world
Bio-behavioral regulation
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First Critical Need
Infants who experience early adversity push caregivers away Fail to elicit nurturance
Concern: Caregivers respond in complementary ways Diary Study
“Baby looks like he doesn’t need me, I’ll leave him alone”
Stovall & Dozier, 2000
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Intervention Target 1
Targeting what infant brings to relationship
“Babies need you, even though they push you away”
Caregivers are helped to re-interpret infants’ signals
Get feedback “en-vivo” and through video feedback at the end of session
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Overview of ABC
Critical Need Intervention Target Outcome
1. Infants push caregivers away
Re-interpret
infants' signals
Attachment Security
2. Nurturing care may not come naturally
Over-ride issues that interfere with nurturance
Attachment Security
3. Difficulty regulating behavior and physiology
Predictable, controllable world
Bio-behavioral regulation
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Second Critical Need
Nurturing care may not come naturally to some caregivers
“You’re fine, you’re not hurt”
Ignore bids for attention
Address personal issues that may be getting in the way
Trouble developing organized attachments with non-nurturing caregivers Dozier, Stovall, Albus, & Bates (2001)
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Intervention Target 2
Targeting what caregiver brings to relationship
Over-riding parents’ own tendencies to minimize children’s needs
Provide nurturing care even if it does not come naturally
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Overview of ABC
Critical Need Intervention Target Outcome
1. Infants push caregivers away
Re-interpret
infants' signals
Attachment Security
2. Nurturing care may not come naturally
Over-ride issues that interfere with nurturance
Attachment Security
3. Difficulty regulating behavior and physiology
Predictable, controllable world
Bio-behavioral regulation
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Third Critical Need
Infants have difficulty regulating behavior and physiology Early adversity is associated with atypical diurnal
patterns of cortisol Dozier et al., 2006
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Intervention Target 3
Helping Children Develop Better Regulatory Capabilities
Following the child’s lead (Barnard, 1998; Van den Boom, 1994)
Predictable, controllable environment, sense of mastery and control
Touching, holding
(Field, 1994)
Expression of emotions
(Izard, 2003)
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How do we know it “works”?
Randomized clinical trial
Control Treatment: Developmental Education for Families
Ten 1-hour sessions(weekly) with caregiver and child Enhance cognitive and linguistic abilities
Ramey et al., 1982; 1984 Prior success in improving intellectual functioning when provided
intensively in day care settings Brooks-Gunn et al., 1993
Comparison group of children from intact families
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Foster Mothers Become More Sensitive
Compared Foster Mothers’ Interactions with Infants during a Play interaction following intervention 44 Foster Mothers in ABC
52 Foster Mothers in DEF
Foster mothers who received ABC responded more sensitively to infants’ cues during play than those who received DEF
Bick, Dozier, & Moore, 2012
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Outcome: Strange Situation Attachment Classification
Children in Attachment and Biobehavioral Catch-up intervention developed secure attachments more than children in control intervention, 2=4.14, p < .05.
0
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secure attachment
Attachment and Biobehavioral Catch-
up (n=41)
Control intervention (n=45)
Group
Dozier et al., 2009: Foster parents who received ABC report that children display less avoidance in daily reports
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Percentage Disorganized Attachment Among Children in ABC and DEF Interventions
Disorganized (32%)
Disorganized (57%)
Organized (68%)
Organized (43%)
0%
20%
40%
60%
80%
100%
ABC Control
Perc
en
t o
f C
hil
dre
n w
ith
Org
an
ized
vs
. D
iso
rgan
ized
Att
ach
me
nt
Cla
ssif
icati
on
s
Intervention Group
Bernard, Dozier et al., Child Development, 2012
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Negative Affect Among Children in ABC and DEF Interventions
0
1
2
3
4
Anger Anger towards CG Negative Affect
ABC
DEF
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Outcome: Bio-behavioral Regulation
Children from Attachment and Bio-behavioral Catch-up intervention show significantly lower cortisol than children from DEF group, F (1,80) = 4.55, p < .05.
Dozier et al., 2006
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
AM PMTime of Day
Co
rtis
ol u
g/d
l
ABC
DEF
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Which pattern most resembles that of typically developing children?
Children who had never been in care differed from DEF intervention children but not from Attachment and Bio-behavioral Catch-up intervention children, F (3, 198)=5.24, p < .002.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
AM PM
Time of Day
Co
rtis
ol
ug
/dl
ABC
DEF
Comparison
*
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Summary of Effectiveness of ABC
Improves foster mother-child interactions
Improves attachment Attachment Security
Reduces Disorganization
Regulates HPA axis
Exciting thing: this starts in home! No other more important relationship for these young children
Especially at this critical stage of development
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Overall Summary
Challenges Faced by Foster Infants
Development challenge
Multiple placements
Prior trauma
What becomes perturbed in these children?
Attachment
Bio-behavioral: HPA axis
What can help promote positive outcomes?
One example: Attachment and Bio-behavioral Catch up
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Additional Interventions: Improving Foster Parent Infant Relationships
In past decade: Significant progress in identifying interventions that improve foster parents’ abilities to respond to attachment and mental health needs of foster infants
Multidimensional Treatment Foster Care for Preschoolers (MTFC-P)
Fisher et al., 2007
http://www.mtfc.com/
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Acknowledgements
M A R Y D O Z I E R A N D I N F A N T C A R E G I V E R L A B
U N I V E R S I T Y O F D E L A W A R E
http://abcintervention.com/equipment.html
Delaware Division of Family Services, Parents and Children
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Questions