Will I Ever See You Again? Dr. Elizabeth Jacobs 1/27/2016

Important numbers… “It is now clear that human beings of all ages are found to be at their Will I Ever See How many children in foster care? happiest and to be able to deploy You Again? Ages 0-5 = 41.7% their talents to best advantage when Attachment Ages 0-3 = longest time in foster care2 they are confident that, standing challenges for Ages 0-3 = highest reentry rate3 behind them, there are one or more foster children Ages 0-3 less likely to be reunified4 trusted persons who will come to Elizabeth Jacobs, Ph.D. their aid should difficulties arise.” , 1973. 1CASA of AZ, 2015 2 Prepared for AFCARS Report, 2014 3Dicker and Gordon, 2004 2016 Northwest Arizona Symposium 4Jacobs, 2015

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The Cycle of Attachment Then brings these behaviors Attachment defined as... Infant/child feels has a need: hunger, fear, into foster care so… frustration & elicits the help of the caregiver displaying an “attachment behavior” to get  Children have difficulty forming attachments  “…reciprocal process by which an emotional his/her attention. to their foster parents because their needs connection develops…(Erikson) are not met. Caregiver correctly reads needs  Bio or foster parents have difficulty …between the child and his primary caregiver of child and tends to the need. responding correctly to the children because which occurs between 6 and 12 months. the behaviors seem odd.. Child is satisfied, returns to activity …so a new cycle is created... confident that help is there if needed. The child learns not to become attached… Will repeat this successful attachment behavior 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium David Pelzer

2016 Northwest Arizona Symposium 1 Will I Ever See You Again? Dr. Elizabeth Jacobs 1/27/2016

Insecurely Attached Research results were pretty simple… Secure Attachment Makes future secure attachments less likely (Risk factor) The emotional bond is positive and All children attach to Either: care is consistent. A sense of trust  Insecure-Resistant: child is uncertain. caregivers in one of two develops. Child may move away Vacillates between seeking and resisting ways: and explore knowing that the contact with caregiver. caregiver is available for help in Securely Or case of adversity or fear. Children Or  Insecure-Avoidant: child expects rejection learn from caregiver how to handle from caregiver. Actively avoid caregiver. Insecurely stress. Becomes a secure base. …or so they thought… (Protective factor.)

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100 billion neurons Until: A mid-1980’s Discovery at birth Researchers discovered an additional Insecure Attachment type : 700 - 1,000 “But wait, there’s more…” synapses per second

Disorganized/Disoriented Repeated = strengthened – child is confused, dazed, may subtly Not repeated = pruned try to hit caregiver…. Neurological development also affects a child’s ability to attach to • Abuse/neglect cause continuous (toxic) stress Common to children who had been abused… • Child’s alarm system remains activated. caregivers…. • Synapses for fear and stress strengthened Conclusion: Children who are neglected and • Synapses for learning and self-controlled pruned abused are more likely to have this type of • Body and brain set permanently on high alert . But not always… • Becomes the foundation of the child’s brain Some children are resilient… Conclusion: Time is of the essence… 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium

2016 Northwest Arizona Symposium 2 Will I Ever See You Again? Dr. Elizabeth Jacobs 1/27/2016

The unusual behaviors exhibited As a result of their neglect/abuse by traumatized children often lead foster children come into care with… to psychological diagnoses and are often treated with Psychotropic Medication further …unusual attachment behaviors they interfering with the child’s used to survive their abuse/neglect developing brain. which may be misunderstood. Classes of psychotropic medications: … and stress-related neural Anti-psychotics, Anti-depressants, connections which have interfered Anti-manic, Anti-seizure and Stimulants with normal brain development. Abuse/neglect affect brain development of young children. The younger the child, the better chance to • 41.3% > 4 different classes (Zito, J., et al., 2008) recover from this consequence • Long-term effects of these drugs are unknown. . (Littell, M., 2001) Conclusion:2016 Northwest Time Arizona is of Symposium the essence… 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium

Martin, Age 8 Now a few words about… (What we once called…) Then, once in care, foster children … Background: DV, Parental Drug use, 2nd grade. Reactive Attachment Disorder (RAD) Very aggressive, threatens to have his father kill people, sheriff called to school numerous times. experience multiple case managers, DSM V now divides into two disorders… Psychotropic meds: CASAs, judges, GALs, therapists, foster 1. Reactive Attachment Disorder: 1. Depakote (>10): Anti-seizure, off-label: mania homes… 2. Zoloft: Anti-depressant, SSRI*. 6-17: OCD - Withdraw/fearful of adults …experience frequent moves and/or - Insufficient care (at least one): 3. Intuniv: Guanfacine, reduces BP, off-label: ADHD placements. *Emotional needs not met 4. Risperidone: Anti-psychotic. off label: Mania *Repeated changes of primary caregiver *Limited opportunities to attach (e.g., *Black box warning: “SSRI’s may increase institutions. suicidal thoughts in children and adolescents.” …and their resistance/inability to Side effects (partial list): attach to others becomes an 2. Disinhibited Social Engagement Disorder 1. Breathing diff., bruising agitation, insomnia, liver damage Indiscriminately social toward adults 2. Agitation, anxiety, diarrhea, dizziness, dry mouth, gas expected outcome… Same “insufficient care” as RAD 3. Dizziness; drowsiness; dry mouth; headache; tiredness.. 4. Insomnia, rapid HR, hallucinations,, TARDIVE DYSKINESIA 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium Extreme2016 Northwest andArizona Symposiumrare…

2016 Northwest Arizona Symposium 3 Will I Ever See You Again? Dr. Elizabeth Jacobs 1/27/2016

Attachment (Bonding) Assessment Attachment disorder symptoms may Links to Psychopathology/criminality: include the following behaviors... Evaluates the quality of the caregiver-child relationship through: (developed by clinicians)  “Insecure attachment patterns in infancy and early childhood are strong predictors of psychopathology and maladaptive  Superficially charming  Learning deficits behavior in adolescence and adulthood.” (Genuis, 1995). • Single or multiple interviews. • Video-taped caregiver-child observations  Lack of eye contact  Lacks cause/effect thinking*  Foster children are almost 9 times more likely than home ( – )  Overly affectionate  Lack of conscience* reared children to evidence psychological disturbance. • Observations in the home  Not cuddly  Abnormal eating patterns (McIntyre & Kessler, 1986). • Courts docs  Control problems*  Poor peer relationships*  Within the first year, 68% of children who age out of foster • Psychological testing  Destructive  Preoccupied with fire, blood, care system are in jail or dead. (Dr. Bruce Perry 2006) • Mental Health Assessment  Cruel to animals* gore*  Chronic lying*  Nonsense questions/chatter  80% of prison inmates in Illinois have been through the …of children 0-6 years old. (0-12 mo: later  Demanding foster care system (National Association of Social Workers)  No impulse control* attachment is predicted by the mother’s  Abnormal speech patterns sensitivity to the infant.  As well as dependent, histrionic, borderline, and schizoid *also symptoms of ODD* and Conduct Disorder* personality disorder (Mikulincer & Shaver, 2012) Answers: “Who can best provide a secure base for this child by being predictable, consistent, No current therapy for attachment disorder 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium and emotionally available?” so use therapy for ODD/CD.

In summary, then, “Best Interest” requires Case Study - Rosie Miranda (As of 5/15/2015) that we consider: Event Case Plan Age Date Time 16 ½; came into care in 2004 at age 5 -- Neglect/Abuse Problem Amelioration Birth Sibs reunified 0 1/20/12 Home – 9 mo. Sexually molested by father and mother’s BFs Removed Family Reunification 9 mo. 10/20/12 Foster – 4 mo. All children TPRed; Miranda’s four sibs adopted Length of abuse/neglect results Time is of the essence. (Neglect) in neurodevelopment Expedite case plan 0-5. M. displays sexualized behaviors and aggression Reunified 13 mo. 2/22/13 Home – 5.5 mo. problems. Concurrent of S & A, if doubt. “Denial of placement in Maricopa Co.’s TGH” (5/15) Removed Family Reunification 19 mo. 8/5/13 Foster – 19.5 Odd, unique, survival behaviors Educate foster parents ( & as All requests outside of Maricopa Co. also declined (beaten) -- so far (from home or misinterpretation of problems arise). Involve high 10.7 years in care; 24 placements events.) Parents: level therapist Several potential adoptions; all incomplete. (www.apa.org/practice/refer.html) -- Mother mentally ill, both parents: drug users, missed/positive UAs, inconsistent/no show visits, not participating in services. As adoption gets close; Miranda behaves in such a way Multiple people (CMs, homes, Move only reluctantly/ Had CPS involvement with older children before Rosie was born. that the adoption is cancelled or potential adoptive parents therapists, etc.) What does placement need? backs out after receiving her information. Let’s: New placement Continuity with previous home • Compare amount of time at home vs. in foster home. FCRB reviewed notes back to 2004. • Emotional (attachment) consequences of moving back and forth. Psych diagnosis/Psychotropic Re-evaluate w/ new Psych • What is stressful for Rosie? Miranda has never had anyone – ever! meds (not “by report”) evaluation • Is the Case Plan appropriate? Loss of bond with parents Is visitation adequate? • What is in the best interest2016 Northwest of Rosie? Arizona Symposium 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium

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Recommended Reading “Best Interest” requires that we consider: Recommended Reading (2) (Page 2) Cournos, F. (1999). City of one: A memoir. New York: W. W. Norton and Jacobs, E. (2015). Will I ever see you again? Attachment challenges for foster Problem Amelioration Company. children. (Amazon.com) No consistent person Look for previous foster, teacher, Courter, G. (2001). I speak for this child: True stories of a child advocate. Mercer, J., Sarner, L., & Rosa, L. (2003). on trial: The scout leader, CASA, brother Lincoln, Ne: iUniverse.com. (Ebook) torture and death of Candace Newmaker. Westport CT: Praeger Dyer, F. (1999). Psychological consultation in parental rights case. New Publishing. If any reason to doubt RTP Concurrent of S & A and place in York: Guildford Press. Pelzer, D. (1995). A child called "It": One child's courage to survive. Foster/Adopt Home Dyer, F. (2004). Termination of parental rights in light of : Deerfield Beach Florida: Health Communications, Inc. The Case of Kaylee. Psychology, Public Policy, and Law, 10, 5-30. Pelzer, D. (1997). The lost boy: A foster child’s search for the love of a family. Attachment to foster home vs. Bonding assessment will help Diffenbaugh, V. (2011.) The Language of Flowers. New York: Random Deerfield Beach Florida: Health Communications, Inc. RTP determine best placement House. Perry, B. (2005). Bonding and attachment in maltreated children. Available Foster Club (2010). Fosterclub.com -- The national network for young people online: ww.childtraumaacademy.com Re-entry into foster care Confidence that parents’ progress in foster care. Perry, B. (2006). The boy who was raised as a dog and other stories from a will continue Greenberg, M., Cicchetti, D., & Cummings, E. (1990). Attachment in the child psychiatrist’s notebook: What traumatized children can teach Inadequate foster parent training All foster parent training should be preschool years. Chicago: University of Chicago Press. us about loss, love, and healing. New York: Basic Books. “therapeutic.” Heineman,T. & Ehrensaft, D. (2006). Building a home within: Meeting the Rhodes-Courter, A. (2007). Three Little Words. New York: Simon & No kinship foster parent training Require (50% returned to parent) emotional needs of children & youth in foster care. Baltimore, Schuster. Systemic problems… New programs: Hope Meadows MD: Brookes. Smith, Wes. (2001). Hope Meadows: Real-life stories of healing and caring from an inspiring community. New York: Berkley Publishing. 2016 Northwest ArizonaOne Symposium therapist, one child 2016 Northwest Arizona Symposium 2016 Northwest Arizona Symposium

Contact Information

Elizabeth Jacobs, Ph.D. Faculty Emeritus, Maricopa Colleges 623.680.7606 (Cell) [email protected]

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