Developmental Problems of Maltreated Children and Early Intervention Options for Maltreated Children. Foster Care Therapeutic Interventions

04/23/2007

Maltreated infants and young children may need to be removed from their homes to increase safety. When this action is taken, a number of other concerns become prevalent. For example, child welfare workers must develop placements for children that will adequately address those children's needs (shown in Part 1 of this review to be quite substantial) and must mitigate the possibility that these children's preexisting developmental and behavioral problems might become worse in response to the combined trauma of abuse and removal from the home. Additionally, child welfare workers must begin permanency planning  a goal for stable, long-term residence. Nevertheless, many of these children have serious emotional and behavioral problems that make finding permanent homes and appropriate intervention programs difficult to attain.

Treatment foster care (TFC) has recently achieved more recognition for its potential role in assisting behaviorally troubled young children. Although TFC was once an intervention used only for older troubled children (Hahn et al., 2004), it is now a viable early intervention program for younger maltreated children with serious emotional, behavioral, and developmental problems (Fisher & Chamberlain, 2000; Fisher, Ellis, & Chamberlain, 1999). In the past, seriously disturbed and developmentally delayed preschoolers had limited residential options, including (a) restrictive, expensive institutions or (b) foster care that often resulted in multiple failed placements. Now, with TFC, these preschoolers can receive multidisciplinary therapeutic assistance for their developmental delays, emotion regulation difficulties, and behavioral problems while living in a family setting. Within TFC programs such as Oregon's Early Intervention Foster Care program, highly individualized and intensive treatment plans are created based on the in-depth assessments done during screening (Fisher et al., 1999). Each foster parent, trained in behavior modification, serves as a central and functional member of a multidisciplinary team, which includes a clinical team supervisor, an early interventionist, a family therapist, and a foster parent consultant. Children participate in weekly home visits from an early interventionist consultant and in weekly therapeutic play groups, and they receive services from a behavioral specialist in preschool to focus on remediating developmental delays and addressing emotional, behavioral, and social concerns. Foster parents receive support and guidance from a 24-hour, on-call crisis intervention system; weekly support group; and daily communication with the foster parent consultant. These services are needed to assess the child's level of functioning and progress toward goals and to make necessary changes in the child's treatment.

Long-term placement planning is also a goal of TFC. Fisher, Gunnar, Chamberlain, and Reid (2000) evaluated the effectiveness of an early intervention foster care program with respect to parenting skills of foster parents and children's behavioral adjustment. Using questionnaires, foster parents involved in the TFC reported that they engaged in more monitoring and more positive reinforcement than regular foster parents. Additionally, TFC parents engaged in less discipline and were less stressed over time. Despite having more troubled behavior at the beginning of the study, TFC preschoolers made improvement in behavioral functioning over 3 months (measured by parent report and cortisol levels) whereas the behavior of preschoolers in regular foster care evidenced more maladjustment over time. These findings suggest that Oregon's early intervention foster care is a beneficial program (Fisher Burraston, & Pears, 2005); however, dissemination and more research and program evaluation is needed to determine whether positive results can be replicated in other therapeutic foster care programs.

The Attachment and Biobehavioral Catch Up intervention is another treatment for maltreated infants and young children in foster care who display relational, behavioral, and biobehavioral dysregulation. In the intervention, which relies on foster parent diaries, infants placed after their first birthday engage in resistant-avoidant behavior with their new foster parent, and the foster parents  despite their optimal adult attachment style-begin to withdraw from the infant (Stovall & Dozier, 2000; Stovall-McClough & Dozier, 2004). The 10-session therapy, complete with manual, has been created to help foster parents engage in optimal sensitive parenting behavior (Dozier, Higley, Albus, & Nutter, 2002), which helps infants depend on external regulation assistance and learn self-regulation strategies. Under normal circumstances, demonstrating love and concern in response to an infant's (or toddler's or preschooler's) behavioral expression of a desire to be left alone can be considered insensitive. In this treatment, however, it is this insensitivity that helps infants learn how to trust and rely on the care of their foster parent. Thus, the treatment centers on teaching foster parents how to manage their own emotional reactions to infant rejection while continuing to provide love and support for the maltreated infant. Although an evaluation of the efficacy of this intervention is underway, several case illustrations have suggested that positive relational, emotional, and behavioral outcomes can be received through this intervention. Dozier and colleagues, however, have elucidated how multiple disruptions in foster placement (Dozier, Albus, Fisher, & Sepulveda, 2002) and foster parent's comfort with attachment issues (Dozier & Sepulveda, 2004) may negatively influence the effectiveness of the treatment. Thus, although a treatment manual has been disseminated for research and clinical purposes, the authors respectfully suggest that clinicians should use an individualized approach to treating maltreated infants in foster care.

Because an unstable home environment undermines development, especially during infancy, early intervention services are also used to help infants and young children achieve placement stability and permanency. Numerous interventions have been created specifically to help child welfare workers deal with the permanency issues of foster care. Although keeping children with their biological families (or reunifying them with biological parents) is the desired goal, intervention is usually needed to help parents remediate their own problems (e.g., drug dependency, serious mental illness, poor parenting skills) before either potential reunification or identification of alternative permanent living arrangements. Although all programs claim that safe placement is top priority, some programs such as intensive family preservation services (Kinney, Haapala, & Booth, 1991) favor preserving the family unit. Other programs such as family-focused, child-centered treatment intervention in child maltreatment (Swenson & Ralston, 1997) and family resolution therapy (Saunders & Meinig, 2000) are more open to alternative placements.

Recently, Zeanah and colleagues created an intervention program to help facilitate permanency decisions and arrangements for infants and toddlers (Larrieu & Zeanah, 1998; Zeanah et al., 2001). Intervention included behavioral, relational, and developmental assessment of the infant and intensive treatment for the parent that included following a court-ordered plan and helping parents accept responsibility for their child's maltreatment through individual psychotherapy, dyadic psychotherapy with parent and infant, medication, and crisis intervention. In comparisons of families involved in the permanency intervention with families receiving standard care, intervention infants were cleared for adoption more (control 20.7% vs. intervention 44.2%) but were reunified less (control 49% vs. intervention 34.7%) and experienced fewer subsequent maltreatment incidents than regular foster care infants (control 14.1% vs. intervention 5.2%). In a randomized study, Fisher et al. (2005) discovered that preschool children involved with early intervention foster care had fewer failed permanent placements when compared with children in regular foster care.

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