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

Baby LLC Nov 7th and 8 th, 2019 Goals: EARLY RELATIONAL HEALTH & • Consider relational health in the context of child welfare CHILD WELFARE • Begin considering opportunities and strategies for enhancing relational health in child welfare Baby LLC 2019 Kate Rosenblum, PhD Professor Departments of Psychiatry and OB/Gyn University of Michigan katier@med.umich.edu 1 2 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 Wulczyn, Chen, Hislop, 2007 3 4 Young children at serious risk for Infants and young children harm are unique. To illustrate– two sides of risk assessment: • Children < 48 mos old account for 79% of child maltreatment fatalities • Full risk assessment of infants in terms of their fragility and unique developmental needs • Infants < 12 months account for 44 % of deaths • Full risk assessment in terms of harm in just removing from care 5 6

Baby LLC Nov 7th and 8th, 2019 Yet removing may also be to do harm… Limitations inherent to framing potentially conflicting goals of “family preservation versus child protection” • Centrality of attachment relationships • Foundation for multiple aspects of development • Biobehavioral shifts– organizing the emerging self in Iatrogenic Effects: relational context over first several years A (not infrequent) child welfare dilemma… What we do to be helpful may also cause harm 7 8 Even with time to prepare and support… separations (and reunions) are associated with Just as the removal of a child from their heightened vulnerability for biological family is associated with a host of families with young children changes in a child’s life, so too is the subsequent reunification to that family of origin Lau et al, 2003 9 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 Developmental Considerations 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) 11 12

Developmental Perspective Developmental considerations • Developmental Perspective • Cognitive, social-emotional development • Relational Perspective Distance from path • Attachment relationships Events • Future relationships: Partners, peers, teachers, lawyers, judges, employers • Biobehavioral Perspective Normative Developmental Path • Regulation/Dysregulation e.g., see Shonkoff, 2000 Time (Age) à Aberrations early in development have greater impacts 13 14 Development & Attachment Building Attachments • Infants are dependent on others for survival (Bowlby, 1962) Attachment • Developing attachment bond • 1- to 4- months: recognition and emerging preferences Relationship • By 4 months: communicating preference for primary caregiver (e.g., more easily soothed, smiling more often) • By 7- months: the onset of focused attachment Recognition/Familiarity • Typically with one primary attachment figure • With mobility– seeking proximity in times of danger or threat • Crying or protest when separated from attachment figure 15 16 What are the Implications? The good news: Prevention and/or intervention • Babies can’t wait can ameliorate risks and • Attachment is with the person who provides their day-to- day (night-to-night) care lead to better brain and behavior developmental • No “long distance” attachment outcomes • Familiarity and relationships can be maintained 17 18

Baby LLC Nov 7th and 8th, 2019 Biobehavioral Perspective: High “ stress ” breed Low “ stress ” breed Evidence for the power of caregiving • Cross-fostering studies in rodents Poor High Caregiving quality quality • Genetic engineering: breed “ high ” and “ low ” stress rats • “ High stress ” mother rats show poor caregiving, and vice versa Meaney and Szyf, 2005; Francis, Dioro, Plotsky and Meaney, 2002 • Stress vulnerability trait AND caregiving quality are passed on to pups 19 20 Cross-fostering studies Protective Role of Caregiver High “ stress ” breed Low “ stress ” breed • Cortisol inhibits brain growth (neurotoxic), and thus needs to be kept low • Infant ’ s stress response is buffered by responsive and High Poor sensitive caregiver quality quality • Interventions with foster parents can positively impact cortisol patterns (Dozier et al, 2006 ;Fisher et al, 2007) High quality caregiving can turn “ stress ” genes off. 21 22 Implications: Power of Parenting cont’d The power of parenting • Infants need for us to take their perspective.. • Data underscore ways that early nurturance can ameliorate early risks and disruptions • Who is a parent? • What is a separation and what is a loss? • Often the focus of attention and intervention is high risk • When is a move disruptive? parenting and/or problematic child behavior, but… • What can be done to mitigate losses? • The absence of a responsive, highly engaged parent may have the greatest consequences for the child 23 24

Baby LLC Nov 7th and 8th, 2019 Power of Parenting (cont’d) The role of investment (Ackerman & Dozier, 2005) Taking the Parent’s Perspective… • Parenting a traumatized child is likely to pose • Foster parent investment includes: new challenges even for experienced parents • Acceptance of and commitment to parenting the child, • Sense of efficacy regarding positively impacting child • Child “ miscues ” based on earlier experience • Offer nurturance • Foster parents and kin vary in investment • Follow child ’ s need (not just their lead) • Higher levels of investment linked with more • Heightened need for active parenting supportive and nurturing interactions • “ Time in ” versus “ Time out ” • Verbal and physical engagement– pick up the baby, talk to the baby 25 26 Factors that may contribute to lower All parents need support… investment: • Biological parents need supports, resources, and treatment • Distress around having been previously invested in a • to address problems interfering with their caregiving capacity child that was removed from care– especially if lack • to understand the needs of traumatized infants and young of on-going contact children, including typical responses to separation and loss • Anticipating instability in the placement – some foster • Foster parents need support parents may minimize investment & remain guarded • To understand the needs of traumatized infants and young • Some parents are warned not to become too children, including typical responses to separation and loss invested • To invest in parenting the child • Kin may experience loyalty conflicts • To consider the potential for a mentoring role 27 28 Safe and Secure Baby Court Minimizing Iatrogenic Effects– Thinking “outside the box” to improve child outcomes • Informed by ZERO TO THREE’s national SBCT project eg Foster Parents/Kin as Collaborators • Collaboration of Rhode Island Association for Infant Mental Health, Department of Health, and court staff • Aim to reduce re-traumatization through repeated relationship disruptions • Special features: • Voluntary participation • Consider the possibility of foster parents as • Immediate referral to Brown Center for Infant/Parent Assessments supervisors of visitation • Incremental and flexible case plans tailored to family • Court reviews every two weeks • Foster parents as mentors • Minimum of 3 visits/week for parents and babies • Parents have opportunities to observe, learn new ways of • Care coordinators provided by court to support family stabilization being with the baby, get involved in caretaking routines. • Foster parent invitations to attend court hearings, host visits, and • Foster parents can stay connected to the child post- serve as mentors reunification • Dedicated staffing • Judicial leadership 29 30

Baby LLC Nov 7th and 8th, 2019 Baby Court Works… 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 31 32 And in Rhode Island… Evidence based treatments- work! Court Team Impact • Examples: • As of March 2018, 38 cases referred, 26 intakes • Child Parent Psychotherapy (CPP) completed, 19 parents enrolled • Infant Parent Psychotherapy (IPP) • Parent-Child Interaction Therapy (PCIT) • As of Nov 2018, all cases that successfully closed had not had any further DCYF involvement • Attachment & Biobehavioral Catch Up (ABC) • See also: • Expanded eligibility • National Child Traumatic Stress Network (nctsn.org) • California Clearninghouse for Evidence Based Practice in Child Welfare (cebc4cw.org) 33 34