Goals: EARLY RELATIONAL HEALTH & Consider relational health in - - PDF document

EARLY RELATIONAL HEALTH & CHILD WELFARE

Baby LLC 2019

Kate Rosenblum, PhD

Professor Departments of Psychiatry and OB/Gyn University of Michigan katier@med.umich.edu

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Goals:

• Consider relational health in the context of child welfare
• Begin considering opportunities and strategies for

enhancing relational health in child welfare

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Wulczyn, Chen, Hislop, 2007

3 When we consider how to address relational health in the context of child welfare- we have to consider the unique experiences of infants and toddlers in the system 4 Infants and young children are unique. To illustrate– two sides of risk assessment:

• Full risk assessment of infants in terms of their fragility

and unique developmental needs

• Full risk assessment in terms of harm in just removing

from care

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Young children at serious risk for harm

• Children < 48 mos old account for 79% of child

maltreatment fatalities

• Infants < 12 months account for 44 % of deaths

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Yet removing may also be to do harm…

• Centrality of attachment relationships
• Foundation for multiple aspects of development
• Biobehavioral shifts– organizing the emerging self in

relational context over first several years

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Limitations inherent to framing potentially conflicting goals of “family preservation versus child protection” Iatrogenic Effects:

A (not infrequent) child welfare dilemma… What we do to be helpful may also cause harm

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Just as the removal of a child from their biological family is associated with a host of changes in a child’s life, so too is the subsequent reunification to that family of origin

Lau et al, 2003

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Even with time to prepare and support… separations (and reunions) are associated with heightened vulnerability for families with young children

10 For example, despite very good intentions, foster care can be harmful to children

• Children in foster care developed more significant

behavioral problems than similarly-maltreated children who remained at home (e.g., Lawrence et al, 2006)

• An MIT economist studied 15,000 kids and found that

children taken from their families and placed in foster care fared worse in life than similarly-maltreated children who were simply left with their families. (Doyle et al., 2007)

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Developmental Considerations

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Developmental considerations

• Developmental Perspective
• Cognitive, social-emotional development
• Relational Perspective
• Attachment relationships
• Future relationships: Partners, peers, teachers, lawyers, judges,

employers

• Biobehavioral Perspective
• Regulation/Dysregulation

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Aberrations early in development have greater impacts Normative Developmental Path Events Time (Age)à

Distance from path

e.g., see Shonkoff, 2000

Developmental Perspective

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Development & Attachment

• Infants are dependent on others for survival (Bowlby, 1962)
• Developing attachment bond
• 1- to 4- months: recognition and emerging preferences
• By 4 months: communicating preference for primary caregiver

(e.g., more easily soothed, smiling more often)

• By 7- months: the onset of focused attachment
• Typically with one primary attachment figure
• With mobility– seeking proximity in times of danger or threat
• Crying or protest when separated from attachment figure

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Relationship Recognition/Familiarity Attachment

Building Attachments

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What are the Implications?

• Babies can’t wait
• Attachment is with the person who provides their day-to-

day (night-to-night) care

• No “long distance” attachment
• Familiarity and relationships can be maintained

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The good news: Prevention and/or intervention can ameliorate risks and lead to better brain and behavior developmental

• utcomes

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Biobehavioral Perspective: Evidence for the power of caregiving

• Cross-fostering studies in

rodents

• Genetic engineering: breed

“high” and “low” stress rats

• “High stress” mother rats

show poor caregiving, and vice versa

• Stress vulnerability trait AND

caregiving quality are passed

• n to pups

Meaney and Szyf, 2005; Francis, Dioro, Plotsky and Meaney, 2002

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High “stress” breed Low “stress” breed

Caregiving

Poor quality High quality

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Cross-fostering studies

High quality High “stress” breed Low “stress” breed Poor quality High quality caregiving can turn “stress” genes off.

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Protective Role of Caregiver

• Cortisol inhibits brain growth (neurotoxic), and thus needs

to be kept low

• Infant’s stress response is buffered by responsive and

sensitive caregiver

• Interventions with foster parents can positively impact

cortisol patterns (Dozier et al, 2006 ;Fisher et al, 2007)

22 Implications: The power of parenting

• Data underscore ways that early nurturance can ameliorate

early risks and disruptions

• Often the focus of attention and intervention is high risk

parenting and/or problematic child behavior, but…

• The absence of a responsive, highly engaged parent may

have the greatest consequences for the child

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Power of Parenting cont’d

• Infants need for us to take their perspective..
• Who is a parent?
• What is a separation and what is a loss?
• When is a move disruptive?
• What can be done to mitigate losses?

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Power of Parenting (cont’d)

Taking the Parent’s Perspective…

• Parenting a traumatized child is likely to pose

new challenges even for experienced parents

• Child “miscues” based on earlier experience
• Offer nurturance
• Follow child’s need (not just their lead)
• Heightened need for active parenting
• “Time in” versus “Time out”
• Verbal and physical engagement– pick up the baby, talk

to the baby

25 The role of investment (Ackerman & Dozier, 2005)

• Foster parent investment includes:
• Acceptance of and commitment to parenting the child,
• Sense of efficacy regarding positively impacting child
• Foster parents and kin vary in investment
• Higher levels of investment linked with more

supportive and nurturing interactions

26 Factors that may contribute to lower investment:

• Distress around having been previously invested in a

child that was removed from care– especially if lack

• f on-going contact
• Anticipating instability in the placement – some foster

parents may minimize investment & remain guarded

• Some parents are warned not to become too

invested

• Kin may experience loyalty conflicts

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All parents need support…

• Biological parents need supports, resources, and treatment
• to address problems interfering with their caregiving capacity
• to understand the needs of traumatized infants and young

children, including typical responses to separation and loss

• Foster parents need support
• To understand the needs of traumatized infants and young

children, including typical responses to separation and loss

• To invest in parenting the child
• To consider the potential for a mentoring role

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Safe and Secure Baby Court

• Informed by ZERO TO THREE’s national SBCT project
• Collaboration of Rhode Island Association for Infant

Mental Health, Department of Health, and court staff

• Special features:
• Voluntary participation
• Immediate referral to Brown Center for Infant/Parent Assessments
• Incremental and flexible case plans tailored to family
• Court reviews every two weeks
• Minimum of 3 visits/week for parents and babies
• Care coordinators provided by court to support family stabilization
• Foster parent invitations to attend court hearings, host visits, and

serve as mentors

• Dedicated staffing
• Judicial leadership

29 Minimizing Iatrogenic Effects–

Thinking “outside the box” to improve child outcomes eg Foster Parents/Kin as Collaborators

• Aim to reduce re-traumatization through repeated

relationship disruptions

• Consider the possibility of foster parents as

supervisors of visitation

• Foster parents as mentors
• Parents have opportunities to observe, learn new ways of

being with the baby, get involved in caretaking routines.

• Foster parents can stay connected to the child post-

reunification

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Services

• Focus on prevention- Family First Preservation Services Act
• Limited evidence-base to many parenting programs
• Yet evidence-based treatments do exist– challenge is

connecting clients to quality services

• Knowing the resources in your community:
• Part C Early Intervention
• Infant Mental Health Services (e.g., Infant Parent Psychotherapy)
• Substance Use Treatment (MAT, therapy/recovery oriented

treatments, case management e.g., Project Bright)

• Trauma treatment for parents and young children
• Prevention Services
• Wrap-Around or Intensive Home Based

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Baby Court Works…

32 And in Rhode Island… Court Team Impact

• As of March 2018, 38 cases referred, 26 intakes

completed, 19 parents enrolled

• As of Nov 2018, all cases that successfully closed

had not had any further DCYF involvement

• Expanded eligibility

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Evidence based treatments- work!

• Examples:
• Child Parent Psychotherapy (CPP)
• Infant Parent Psychotherapy (IPP)
• Parent-Child Interaction Therapy (PCIT)
• Attachment & Biobehavioral Catch Up (ABC)
• See also:
• National Child Traumatic Stress Network (nctsn.org)
• California Clearninghouse for Evidence Based Practice in Child

Welfare (cebc4cw.org)

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