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
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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
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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
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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
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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