Attachment and Child Welfare Practice To succeed in Volume 19, Number 3 Parent-child attachment has a powerful influ- To successfully ensure child welfare July 2014 ence on child welfare work. Healthy attach- the safety, permanence, practice, it helps to be ment gives children a solid foundation for and well-being of chil- This publication for child “attachment welfare professionals is their cognitive, social, and emotional devel- dren it really helps to be literate.” produced by the North opment. When attachment is secure, often “attachment literate.” This Carolina Division of Social things are much easier. means knowing what attachment is, how it Services and the Unfortunately, secure attachment isn’t works, and how to respond effectively to and Children’s Resource all we see in our work. Because and attachment problems. Program, part of the Jordan neglect interfere with attachment, we fre- We hope this issue of Practice Notes will Institute for within quently encounter children and families be a helpful resource in your ongoing study the School of struggling with attachment security. of this important topic.  at the University of North Carolina at Chapel Hill. Why Attachment Matters In summarizing research, we Most of us are aware try to give you new ideas for Benefi ts of Secure Attachment refining your practice. How- attachment is an impor- Secure attachment has been linked to many ever, this publication is not tant part of healthy devel- positive child outcomes, including: intended to replace child opment. Yet we may not Brain Development. The brain grows welfare training, regular su- know exactly why attach- rapidly during the first three years of life. pervision, or peer consulta- ment is so important or Experiences shape how the brain grows. tion—only to enhance them. understand how secure attachment occurs. When it is stimulated in positive ways, the Secure Attachment brain forms connections related to those Let us hear from you! Attachment occurs when a child has a secure, experiences. For example, talking, singing, To comment about some- and reading to children help form brain thing that appears in Prac- consistent, reciprocal relationship with a pre- tice Notes, please contact: ferred person—typically the child’s primary pathways related to language. John McMahon caregiver. When the caregiver is sensitive to Attachment affects brain development in Jordan Institute for Families the child’s needs and responds in ways that two important ways. First, because the child School of Social Work are warm, nurturing, and make the child feel feels safe and cared for, the brain can use its UNC–Chapel Hill safe, the child begins to use this person as energy to develop pathways crucial for higher Chapel Hill, NC 27599-3550 a secure base from which to explore and, level thinking. Secure attachment is particu- [email protected] when necessary, as a haven of safety and larly related to the development of the fron- Newsletter Staff comfort (Waters & Cummings, 2000 cited in tal cortex, which is responsible for decision Mellicent Blythe Benoit, 2004; Moulin, et al., 2014). making, judgment, and reasoning (DeBellis Sarah Marsh If a caregiver is consistently available, & Thomas, 2003; Dozier, et al., 2008). John McMahon responsive, and nurturing, by the final Second, by providing a “home base” Laura Phipps months of the first year the child’s attach- from which a child can safely explore the Visit Our Website ment to that person is very likely to be world, secure attachment allows the child to www.practicenotes.org “secure,” meaning the child is confident the have more varied experiences and therefore caregiver will always be available to help or build more connections in the brain. save them (Bowlby, 1982; Wolpert, 1999). Social & Emotional Development. Attachment matters. Although it’s most Attachment to a primary caregiver is the obvious when we’re young, its powerful foundation of all future relationships. When influence is felt throughout our lives. there is a secure attachment, cont. next page Why Attachment Matters continued from the previous page you learn how to trust others, how to respond emotionally, and how others Some Indicators of Secure Attachment will respond to you (Bowlby, 1982). Child’s behavior Parent’s behavior In addition, secure attachment leads 1 to 18 months to the development of empathy. If a • Signals needs; relaxes when need is met • Responds to baby’s signal; identifies child sees herself as worthwhile and • Responsive; has full range of emotions needs most of the time deserving of care, she is also able to • Checks back to parents for reassurance • Returns to relaxation along with baby; when strangers are present feels good about self and child see others that way. Only when a child • Exhibits anxiety, anger, or flattened • Offers nurturing, soothing responses believes her own basic needs will be affect when parents leave • Woos child, initiates positive interac- met can she attend to others’ needs. • Pleased when reunited with parents tions, calls baby by name The child works first to please her pri- • Checks in to feel safe when exploring • Makes frequent eye contact with child • Turns to parents for comfort • Encourages safe exploration mary caretaker and over time extends 18 Months to Five Years her concerns to siblings, friends, class- mates, community members, and, as • Can handle longer periods of • Responsive to child’s needs and cues separation (in hours) without anxiety • Encourages growing autonomy and her moral development continues, to • Increasing ability to accept redirection, praises accomplishments people she has never met. discipline, and authority • Redirects/sets limits when needed Self-Regulation. When caregivers • Shows empathy, remorse, and guilt without overreacting to bad behavior respond to them, learn to man- • Uses “wooing” and “coercion” to try to • Enjoys reciprocal affection and influence parents interaction with child age their own feelings and behavior. Grade School When infants are overwhelmed, stress hormones are released in the brain. • Behaves as though he likes himself • Interested in child’s school performance • Shows pride in accomplishments • Accepts expression of negative feelings When caregivers respond with sooth- • Exhibits confidence in own abilities • Responds to child’s needs and fears ing behaviors, they help the child • Accepts limits imposed by adults • Initiates appropriate signs of affection reduce these hormones. • Establishes eye contact • Seems to enjoy the child Over time, the brain develops • Expresses likes and dislikes • Knows child’s likes and dislikes pathways that allow this soothing Adolescents behavior to kick in during periods of • Knows personal strengths/weaknesses • Encourages self-control stress. Eventually the child is able to • Engages in positive peer interactions • Trusts adolescent with increasing levels • Exhibits signs of conscience of responsibility calm themselves when they are angry • Involved in interests outside the home • Interested in/accepts teen’s friends or disappointed. • Developing goals for the future • Interested in teen’s school performance Trauma and Attachment • Emotionally close to parents • Shows affection Inherent in the trauma of child abuse Sources: Queensland Department of Child Safety, 2007; Fahlberg, 1991 and neglect are experiences of fear, stress, and rejection by the very per- in a position to help support secure Provide concrete supports. Over- son who is supposed to protect and attachment with both biological and whelmed caregivers have difficulty soothe the child. Because these emo- resource parents. Here’s how: focusing on the needs of children and tional experiences are in direct con- Educate. Make sure caregivers are not as effective at reading and flict with the experiences that promote know why secure attachment matters responding to cues. Providing con- attachment, it follows that children and the behaviors that build it. Mes- crete supports and resources that help with a history of maltreatment often sages to send include (Dozier, et al., caregivers manage stress allows them have attachment problems. to focus on their children’s needs. 2008; Wittamer, 2011): Children with trauma histories may In addition, young and inexperi- • Be responsive and warm have a wide range of problems related enced parents may need to build their • Respond to children’s needs to lack of secure attachment; these knowledge of parenting and child • Soothe children in distress include developmental delays, difficulty development. Although parenting with emotional regulation, impaired • Learn to read and respond to programs can help with this, they are social relationships, aggression, low children’s cues not all alike. Look for programs, such self-esteem, and depression (Hildyard • Spend time together (quantity matters) as the Incredible Years, Attachment & Wolfe, 2002; Erickson & Egeland, • Engage in positive physical contact and Biobehavioral Catch-Up, and 2002; Shipman, et al., 2005). (hugging, singing, holding, etc.) Circle of Parents, that have a specific Supporting Secure Attachment • Play with children, specifically in focus on cultivating skills that build As a child welfare worker you are activities that support reciprocity. attachment (Wittamer, 2011). 

2 Identifying Attachment Problems

Understanding the quality of a child’s attachment with his ural. Most children have attachment Attachment isn’t caregivers can help you intervene more effectively to pro- that can be described as secure. something a child mote safety, well-being, and permanence. The benefits and hallmarks of this has or doesn’t Every Child Has Attachment type of attachment are described in have. It develops detail in the preceding article. even in the face Before we go further, it’s important to understand one fun- of maltreatment Yet some children’s attachment damental concept about attachment. The question isn’t or severe whether or not children are attached to their caregivers. can be considered “organized,” punishment. Attachment isn’t something a child has or doesn’t have. even though it is not secure. When caregivers are unable or unwilling to respond to a child’s Attachment develops even in the face of maltreatment and basic need for food, comfort, and nurturing, children fig- severe punishment. It is the quality of the attachment relation- ure out other ways to get their needs met. In the process ship that is compromised in these circumstances, not the pres- they may develop patterns of behavior with their caregiver ence or strength of attachment (Carlson, et al., 2003). that elicits what they need despite the lack of consistent, In other words, no matter how harmful a child’s parents sensitive care. Some of these patterns are considered might seem, the child still has a strong attachment to them “organized” because, in a sense, the child knows what to that needs to be respected. A child removed from an abu- do and does the same things repeatedly. sive or neglectful home will experience just as much pain While to an outsider the behavior looks problematic, it and trauma, and possibly even more, than a child sepa- helps the child survive. It is a coping mechanism that makes rated from a healthy and loving parent. As you probably sense in the context of the child’s primary relationship. know from experience, children are unlikely to be relieved However, when transferred to other people, these behav- or grateful at being “rescued,” regardless of how clear-cut iors create barriers and can make others turn away from the danger may appear to us. In fact, for children who lack giving the child what he most needs: safe, consistent care. a safe and secure attachment figure in their lives, being There are two types of insecure attachment: removed from their home is likely to reinforce their nega- Insecure-Avoidant tive beliefs about themselves and the world around them. • Child explores with minimal interaction or checking in The table below provides detail on the different catego- with the caregiver. ries of attachment and what you might see in each when a • No extra emotion in sharing delight or upset with parent. child is in distress. As the table indicates, there are two main • Child doesn’t seek interaction or closeness to the care- categories of attachment—organized and disorganized. giver after separation or when distressed, and doesn’t Organized Attachment respond when caregiver provides it. When most people hear the words “organized attach- • When distressed, child avoids parent and minimizes ment,” they usually think of secure attachment. This is nat- emotions. continued next page

ORGANIZED DISORGANIZED Attachment Child knows what to do Child doesn’t know what to do Category to meet emotional needs to meet emotional needs Insecure/ Insecure/ Secure Avoidant Resistant Disorganized Parenting Style Sensitive, loving Insensitive, Inconsistent, unpredictable, “Frightening, frightened, When Child Is (pick up and rejecting (ignore, or self-centered dissociated, sexualized, or Distressed reassure) ridicule, become (overwhelmed or wanting otherwise atypical” (Lyons-Ruth, annoyed) child to meet their needs) et al., 1997)

Child’s Response Seek out and stay Avoid interaction Cry and seek out parent even Inconsistent, contradictory Exhibited only close to parent with parent, before separation, then show responses; freezing; when child is minimize emotion anger and struggle when self-stimulating behavior distressed and comforted; exaggerated (rocking, pacing, head needs caregiver response to get parent’s banging, etc.) support attention

3 Identifying continued from the previous page

Insecure-Resistant • Child seems wary of strangers and shows little interest What About RAD? in normal exploration. Is Reactive a form of disorganized • Child often cries or seeks caregiver even before sepa- attachment? ration. Unable to happily move away. No, RAD is entirely different. As we have seen, disorganized • Having the caregiver return or attempt to provide attachment is a form of insecure attachment caused by comfort doesn’t help or reassure. Child alternates maltreatment and/or other actions of the child’s caregiver. In contrast, RAD is a very rare disorder that results from between actively seeking contact and struggling/ non-attachment. With RAD, it is the child’s lack of a care- crying/stiffness. giver to attach to that causes the problem. According to • Child shows anger and anxiety when caregiver Gleason and colleagues (2011), RAD also likely has a attempts to comfort. genetic component. To learn more about RAD, see page 8. • When distressed, child exaggerates resistance and dis- tress to try to get needed attention from inconsistent or • Child’s behavior believed to result from caregiver unresponsive caregiver. being a source of fear; child is in conflict between (Benoit, 2004; Carlson, et al., 2003; Flaherty & Sadler, 2011) wanting to flee to and flee from the caregiver. Disorganized Attachment (Benoit, 2004; Carlson, et al., 2003; Flaherty & Sadler, 2011) These children exist in a chronic, low-level state of arousal This is the category that describes children with the most and stress: in survival mode. If you have learned that peo- significant attachment problems. It’s likely you work with ple who try to care for you are dangerous or untrustworthy, children who have this type of attachment due to their his- then even a caring and well-meaning foster parent who tories of abuse and severe neglect. In a large analysis that tries to offer comfort could be perceived as a threat. looked at over 80 studies, up to 80% of children with a his- Children with attachment insecurity, especially disorga- tory of parental maltreatment or drug abuse had disorga- nized attachment, are at increased risk for oppositional nized attachment. By contrast, only about 15% of children defiant disorder (ODD) and related behavioral disorders, from low-risk families had disorganized attachment (Van as well as dissociative disorders, and are more likely to Ijzendoorn et al. 1999, cited in Green & Goldwyn 2002). have academic and social deficits (Boris, et al., 2007). Disorganized Attachment If You Suspect Attachment Problems • Caregiver’s behavior is “frightening, frightened, dis- The next article offers suggestions for what to do if you sociated, sexualized, or otherwise atypical” (Lyons- suspect a family you are working with is struggling with Ruth, et al., 1997). insecure or disorganized attachment. • Child shows apparently undirected, inconsistent, and Before you turn the page, it may be helpful to note that sometimes contradictory responses to parent (e.g., an not all children will continue to have severe attachment who kicks, struggles, fails to focus attention on problems throughout their lives. In one of the few long- any one person or activity, without any apparent pat- term studies that has been done, 25% of children who tern or rhyme or reason). were attachment disorganized as infants did not show • Sometimes child shows abnormal behavior (freezing, disorganized attachment at age seven (Lyons-Ruth et al. repetitive self-stimulating behaviors). 1997, cited in Green & Goldwyn, 2002). 

NC Revamps Key Course to Increase Focus on Attachment and Trauma This spring the NC Division of Social Services retired one course on attachment and launched another. Recently the Jordan Institute for Families at UNC-Chapel Hill undertook a major revision of the well-known course Effects of Separation and Loss on Attachment (ESL). In the end the revi- sion—which introduced new research on trauma and attachment to the course—was so extensive that ESL was renamed “Assessing and Strengthening Attachment.“ This new two-day classroom training teaches about the attachment process, how secure and insecure attachment affect , and how to assess and build secure attachments between children and their caregivers. Participants leave this course with new skills and ideas to use in their work with families. To learn more or sign up to take Assessing and Strengthening Attachment, log in to www.ncswLearn.org.

4 Child Welfare Practice When Children Have Attachment Issues What can child welfare professionals tion about attachment-informed men- do to help children who have insecure tal health treatments, which are often Trauma Exposure or disorganized attachment? The pri- a critical part of effective intervention. Screening Tool for Adults mary goal is to give the child a chance Supporting Caregivers For a simple, free trauma exposure to create a secure attachment with a screening tool you can use with Help caregivers address their own safe, consistent, sensitive primary yourself or other adults, go to attachment and trauma histories. caregiver. Once you identify a birth http://bit.ly/1nLhMWp or foster parent who could provide People who are wounded or over- the loving, reciprocal relationship the whelmed by their own histories may child needs, there are two challenges not have developed the capacity to that often need addressing (Dozier, et read and respond to their children’s As a child welfare professional, it’s al., 2009; Speltz, 2002): cues (Dozier, et al., 2009; Speltz, important to ask caregivers about their • Caregivers’ own attachment and 2002). A parent’s history of trauma history of trauma and to get a sense loss issues can make it hard for has many implications for their ability of what their primary attachments them to focus on the child’s needs. to regulate their emotions, maintain were like as a child. The box above • Children with attachment issues their physical and emotional health, provides a link to a short, simple, free tend to send confusing signals. parent effectively, and maintain family trauma screening tool for adults. Even well-attuned, empathic par- stability (NCTSN, 2011). Parents with Many caregivers never have the ents sometimes struggle to figure unaddressed trauma histories are chance to think about their own par- out what the child needs and how likely to treat their own children the enting and the way they were raised to comfort or calm the child. way they were treated, and often have (Dozier, et al., 2009). Asking open- Here are suggestions for overcoming difficulty forming healthy attachments ended questions and exploring their these challenges, along with informa- with their children (Chadwick, 2013). own and their parents’ discipline continued next page

Rebuilding Ourselves by Nicole Goodwin I learned early on that black women are supposed to be For about four months, the battles con- “strong” and endure pain in silence. The three years I spent in tinued. Then the social worker at Shylah’s After Iraq—and the military and the five-and-a-half months I spent stationed in school introduced me to the Child Welfare removal—I had Iraq taught me the same lessons: Be strong. Be silent. Organizing Project (CWOP), a parent-led to heal myself A month after my daughter, Shylah, was born, I kissed her advocacy organization in New York. and my good-bye and flew off to Iraq. When I came home, I brought At CWOP I joined a reunification daughter. painful memories with me in the form of Post-Traumatic Stress group where we read Rise magazine sto- Disorder (PTSD). I was riddled with anger, self-hatred, and ries by parents who had reunified. Those stories helped me loneliness. see that believing in your family’s recovery is the most impor- A Joyful Reunion. The one bright spot was my daughter. tant thing. Seeing her eyes light up when it dawned on her that I was her The Mom I Want to Be. I also took a class called the Par- mom gave me great hope that I could make things right. enting Journey. There I wrote a letter to my mother express- But over the years, my PTSD grew worse. I had nightmares ing the feelings of abandonment that were at the core of my so bad I would wet the bed. Eventually I had trouble getting sadness. Writing that letter helped me focus my energies on up in the mornings. the mother I wanted to be—a mother that listens, is nurturing Then one day in January 2010, when I was having a par- and forgiving, and takes responsibility. ticularly hard time, I slapped Shylah, who was 6. She told her With Shylah, I went to family therapy. Over time, I learned therapist and the therapist called Child Protective Services. that Shylah had cried for me every night, and that she felt My daughter was in care for six months. Most of that time, blamed for what was happening. One of the hardest things I was lucky to see her almost every day. for me to hear was that Shylah felt abandoned by me. Even I also spent six weeks in a veterans’ hospital for women though it hurt to hear how I had hurt my daughter, I realized who had been raped while serving their country. There I got to all my hard work was paying off when she wanted to hold my talk about other problems that I’d never dealt with, like being hand again, or be held, or, here and there, gave me a kiss. molested in childhood and the rift it put between my mother For a long time I thought my traumas made me strange and me. When I left, I thought I was ready for Shylah. and unlovable. At some points, I thought I didn’t deserve to An Angry Reunion. But when Shylah came home, she would have my daughter. My daughter hugs me now for no reason, go from zero to sixty having complete meltdowns. When I told and it feels glorious. Little by little we’re rebuilding ourselves. her she needed a time out, she would kick, punch, and bang Reprinted, with permission, from Rise, © 2013 by risemagazine.org. Rise is a her head. When we argued, she would say the most hurtful magazine written by and for birth parents involved in the child welfare system. things, like, “You don’t love me,” or “You never wanted me.”

5 Practice continued from the previous page methods, communication styles, and and can build trust, they may be more lating their fear response. As a result, relationships can help caregivers willing to develop a different sense of the child may behave in confusing and gain valuable insights. Once parents themselves and their children. contradictory ways that leave care- acknowledge their histories, they may Help caregivers respond sensitively, givers uncertain and frustrated. For be ready to explore how their past even if children seem to reject them. example, a child may react with anger affects their current functioning and Even well-attuned, empathic caregiv- or recoil when a foster parent tries to parenting. ers can struggle to understand and hug them. The foster parent may then Being involved with the child wel- respond sensitively to children who feel angry and rejected, straining the fare system can be re-traumatizing for have attachment issues. When chil- relationship and continuing the cycle parents. For example, parents’ anger dren have experienced trauma, their of insecure attachment and rejection or avoidance may be a reaction to fear remains even when the risk of (Dozier, et al., 2005). their own traumatic experiences, not physical harm is gone. A certain Helping Break the Cycle to their child welfare worker. Involve- sensation or situation can trigger a Here are some things child welfare ment with CPS may inadvertently memory or flashback of their original professionals can do to help break return parents to a position of vulner- trauma. These trauma triggers cause this cycle: ability and fear (CWIG, 2013). children to have a physical and emo- Help caregivers see the world from If they are not viewed through this tional fear response. Sometimes the the child’s point of view. Some care- “trauma lens,” parents’ behaviors can child may not even be fully aware of givers need to learn to be aware of be easily misunderstood. The more the response or why it’s happening their child’s physical and mental state. you can be attuned to the fear beneath (Klain & White, 2013). You want the caregiver to begin ask- the parent’s response, the more you When caregivers see a child’s dis- ing herself, “Why is my child doing will help them do the same for their tress and try to provide comfort, this this?” To encourage this, notice out children. Once parents feel accepted can feel threatening to the child, esca- loud what the child is doing and why continued next page

Supporting Child Welfare Worker Resiliency Finding Asking parents about their attachment and trauma histories can be Effective stressful for child welfare professionals. They are likely to hear difficult things, and they may experience vicarious trauma. If agencies are going Treatment to take trauma and attachment seriously, it’s important to have a plan for Parents in place for supporting workers’ resiliency and responding sensitively to Parents involved with child welfare may vicarious trauma. Below are strategies for doing just that. need treatment to address their trauma • Review recruitment and hiring practices with a focus on building resil- and attachment histories. According to the ience, professional training, and preparedness National Child Traumatic Stress Network • Provide routine training, education and support to all staff about secondary traumatic stress and how to recognize and manage their (2011), “interventions that do not take into reactions account parent’s underlying trauma issues— • Acknowledge that secondary trauma is an occupational hazard; pro- such as parenting classes, anger manage- mote open discussion of secondary traumatic stress among staff ment classes, counseling, or substance abuse • Use self-assessment measures to evaluate the impact of secondary groups—may not be effective.” trauma exposure on child welfare workers SAMSHA’s National Registry of Effective • Consider agency policies that may exacerbate secondary trauma Programs and Practices states that the follow- (e.g., agency response to high-stress events) and how policies can be ing models integrate issues of trauma, men- amended to enhance staff resilience tal health problems, and substance abuse for • Ensure peer and professional counseling resources are available to more effective comprehensive treatment: staff at all times (not only after a crisis) • Seeking Safety • Provide good mental health coverage and an Employee Assistance • The Trauma Recovery Empowerment Program Model (TREM) • Cultivate a workplace culture that normalizes (and does not stigma- • Trauma Affect Regulation: Guide for tize) getting help for work-related stress Education and Therapy (TARGET) • Implement a comprehensive program to address secondary trauma, • Helping Women Recover/Beyond such as the Resilience Alliance (http://bit.ly/1nXi9gz). Trauma/Helping Men Recover Source: National Child Traumatic Stress Network (January 2013). Child To learn more, visit the Registry at http:// Welfare Trauma Training Toolkit: Comprehensive Guide-3rd Edition. www.nrepp.samhsa.gov/

6 Practice continued from the previous page he or she is doing it. acts of caretaking, engaging, and send the message, “You are part of I see that Johnny looks really sad right playing. Point out what you see that our family. You are loved no matter now. He went into the other room, has shows the child responding positively. what you do.” his head down on the table, and looks Wow, Johnny just loves showing you Ensure caregivers have support like he is going to cry. I wonder why? what he’s made! Look how proud he is! and respite. Children with insecure If the caregiver has a negative Help the caregiver understand all attachment can show extremely frus- interpretation of the child’s behavior, children need nurturing, even if they trating behavior. Caregivers need point it out. don’t show it. Children may turn away help, understanding, and time away It must be frustrating when Johnny or seem angry when parents try to to keep themselves healthy and ener- ignores you. I see why you would think gized (Berliner, 2002). it’s because he doesn’t respect you and provide comfort or reassurance. This wants to be the boss. I wonder why is because the child is used to peo- Conclusion else he might be doing that? ple not responding to or taking care Working with children and families Help the caregiver read cues to of them. Encourage caregivers to be struggling with attachment prob- identify the child’s states and moods. patient, go slow, and see the need lems can be tough, but it can also be Help her feel more confident and and fear underneath the behavior. incredibly rewarding. By teaming with competent as a parent. Children need a strong, secure caregivers, mental health providers, How did you know that Sally was attachment. If they’re not confident and others, over time you can help hungry? What does she do to let you they will be cared for and accepted, bring about deep changes in children know? What about when she’s tired? the risk of getting hurt again will be that will allow them to form positive Encourage the caregiver to talk to too great and behaviors won’t change relationships and lead healthy, suc- and bond with the child with simple (Berliner, 2002). Teach caregivers to cessful lives. 

Be Sure to Advocate for Effective Treatment

Attachment-Focused Models Many children with attachment difficulties need mental health treatment Trauma-Focused Models by clinicians trained to address attachment and trauma. Because attach- In addition, a number of evidence-based treat- ment is all about relationships, a caregiver should be actively involved in ments for child trauma include components the treatment, too. related to insecure attachment, such as help- The interventions below include a focus on attachment and are offered ing clients safely acknowledge and understand in our state. Each has enough evidence of effectiveness to have been their history and learn how to manage emo- rated by the California Evidence-Based Clearinghouse for Child Welfare. tions (self-regulation) and improve psychologi- Well-Supported by Research (highest possible evidence rating) cal safety. These include: Nurse-Family Partnership. For children ages 0-5 and their caregivers. Well-Supported by Research Provides home visits by registered nurses to first-time, low-income moth- Trauma Focused Cognitive-Behavioral Therapy ers, beginning during pregnancy and continuing through the child’s sec- (TF-CBT). For children ages 3-18. For a list of ond birthday. Available in many NC counties. www.nursefamilypartner- clinicians in your county certified in TF-CBT, ship.org/locations/North-Carolina visit the NC Child Treatment Program at http:// Parent-Child Interaction Therapy (PCIT). For children ages 2.5 to 7.5 and ncctp.med.unc.edu or call 919/419-3474 ext. their caregivers. Provides a behavioral intervention focused on decreas- 300. ing the child’s behavior problems (e.g., defiance, aggression), increasing Eye Movement Desensitization and Reprocess- the child’s social skills and cooperation, and improving the parent-child ing for Children and Adolescents (EMDR). For attachment relationship. NC clinicians are being trained in PCIT through children ages 2-17. According to the EMDR PCIT of the Carolinas. www.ccfhnc.org website, certified clinicians are available across Promising Research Evidence NC. www.emdr.com/find-a-clinician.html Attachment and Biobehavioral Catch-Up (ABC). For foster parents of Supported by Research Evidence children ages 0-5. Provides home visits designed to enhance caregiv- ers’ ability to respond sensitively to children who have experienced early Child-Parent Psychotherapy (CPP). For children trauma or maltreatment. NC clinicians are being trained in ABC through age 0-5 and their caregivers. Clinicians are be- the Center for Child and Family Health. www.ccfhnc.org ing trained in NC by the Center for Child and Family Health. www.ccfhnc.org Parents as Teachers. For parents of children ages 0-5. Provides early childhood parent education, family support, and school readiness For more details on these programs, visit through home visiting by trained parent educators. Available in many http://www.cebc4cw.org NC counties. www.parentsasteachers.org/location

7 Reactive Attachment Disorder Reactive attachment disorder (RAD) is a disruptive disorder believed to be RAD Training Resource caused by chronic and severe neglect Understanding Child Mental Health Issues is an instructor- in early childhood. RAD was first led online course that explores the childhood mental health problems most often seen in child welfare settings: pediatric added to the Diagnostic and Statisti- depression, juvenile bipolar disorder, ADD, RAD, oppositional- cal Manual of Mental Disorders (DSM) defiant and conduct disorder, and post-traumatic stress disorder. For each diagnosis in the 1980s. Researchers and practi- participants will learn the causes, symptoms, prognosis, risk factors, and treatments. tioners have been wrestling to clearly To learn more or take the course, log in to www.ncswLearn.org. identify and treat it ever since. RAD Has Been Redefi ned Diagnosing RAD can also be diffi- thorough psychosocial history of the Until recently there were two types of cult because it shares traits with disor- child should be gathered to help with RAD: emotionally withdrawn/inhibited ders such as spectrum disor- the differential diagnosis. Addition- and indiscriminately social/disinhib- der, intellectual disability, oppositional ally, because serious, chronic, social ited. Now the DSM-V, which appeared defiance disorder, conduct disorder, neglect is inherent in a RAD diagnosis, child welfare workers should assess in 2013, classifies these disorders social phobia, and PTSD. Diagnosis the child’s living situation carefully to as separate diagnoses: RAD, which is further complicated by the fact that ensure the child is receiving attentive involves emotionally withdrawn and compared to other children, children and appropriate care (Hornor, 2007). inhibited behaviors, and disinhibited with RAD experience higher rates of social engagement disorder (DSED) general behavior problems, social Treatment which involves indiscriminately social problems, somatic complaints, anxi- At present we do not have effective and disinhibited behaviors. ety/depression, thought and attention interventions specifically for RAD. RAD’s new narrower, more targeted problems, delinquent or aggressive Efforts are being made to develop definition is now characterized by a behavior, and/or a lack of empathy them, however. For example, the lat- child who is inhibited and withdrawn (Buckner, et al., 2008). est NIMH grant for Attachment and from adult caregivers, rarely seeks or It should also be noted note that Biobehavioral Catch-Up (ABC) is for responds to comfort when they are fetal alcohol exposure is quite com- treatment of RAD. The Bucharest Early upset, and has persistent social and mon among children in Intervention Project, which began in emotional disturbances, such as mini- (Ospina & Dennett, 2013). Caregivers fall 2000, is also designed specifically mal responsiveness to others, minimal who see their child as having a Fetal for the treatment of RAD. positive emotions, and irritability, sad- Alcohol Spectrum Disorder (FASD) In the meantime, other treatments ness, or fear during non-threatening may be much more understanding aimed at attachment disorders in general have led to improvement for social interactions. of the child’s behavior, since this is a children with RAD. Programs such One of the reasons the DSM-V sep- neurological problem, not psychiatric. as Parent-Child Interaction Therapy, arates RAD and DSED are their differ- A more positive attitude by caregiv- Behavior Management Training, and ent progressions. After children have ers, in turn, may enhance attachment the Incredible Years may provide a been placed in a stable environment, security and promote healthy devel- place to start therapy. In time these research shows that signs of RAD disap- opment for the child (Potter, 2014). programs may build the evidence pear over time and become quite rare. RAD Is Rare base for effective RAD treatment Symptoms of DSED take much longer The DSM-V estimates that RAD is very (Buckner, et al., 2008). to resolve (Zeanah, et al., 2004). uncommon, occurring in less than Treatment for RAD should involve 10% of severely neglected children. A Diagnosis Can Be Diffi cult work with caregivers as well as the study in the United Kingdom looked at RAD is generally diagnosed in children child, assuming caregivers are psy- all children aged 6-8 in a low-income between the ages of 9 months and 5 chologically healthy enough to par- area and found RAD’s prevalence years. Assessments of RAD past school ticipate (Boris, et al., 2005). It may rate to be 1.4% (Minnis, et al., 2013). age can be quite difficult; by this age also be beneficial for the caregiver— early attachment experiences are just If You Think RAD’s a Possibility whether foster, adoptive, or biologi- one of many factors that determine Child welfare professionals who see cal—to engage in their own therapy. emotion and behavior (Mercer, 2006). troubling behavior or are concerned Children with RAD often respond to The American Academy of Child and about RAD due to the child’s history caregivers in difficult ways. Therapy Adolescent Psychiatry (Boris, et al., should ensure the child is assessed can help caregivers process their own 2005) does not recommend diagnos- by a skilled practitioner familiar with reactions and learn to respond in a ing RAD in children over age 5. diagnosing and treating RAD. A therapeutic manner (Lyons, 2007).  8 “Fostering Health NC” Builds Medical Homes for Children in Foster Care

The North Carolina Pediatric Society to local primary care pro- This effort will Carolina’s foster care system (NCPeds), the state’s chapter of the viders, county Departments help children for years, and we are pleased American Academy of Pediatrics, has of Social Services and each in foster about the possibilities that Fos- introduced Fostering Health NC, a of the 14 Community Care care receive tering Health NC provides to multi-faceted approach to develop- of NC (CCNC) Networks. better care continue that work,” stated Dr. for improved ing and strengthening medical homes Marian Earls, the lead pedia- This will be supported by a health for infants, children, adolescents and state team that will oversee outcomes . trician for CCNC Pediatrics. young adults in foster care. the work and develop policy Fostering Health NC is A Unique Approach solutions that facilitate the develop- supported by a federal grant from The key to Fostering Health NC’s ment of medical homes for children the Children’s Health Insurance Pro- unique approach is integrated com- in foster care. The team will be com- gram – Reauthorization Act (CHIPRA) munication that ties health profes- prised of professionals in child health, administered by the North Carolina sionals together to provide better care mental health and social services. Foundation for Advanced Health Pro- for each child. “Fostering Health NC Through monthly meetings, the team grams, Inc. in cooperation with Com- features a unique multi-disciplinary will identify and develop policy and munity Care of North Carolina. approach to ensure that each child’s practical solutions that promote the Want to Learn More? medical care is overseen by a team of implementation of medical homes for For more information or to request health professionals. Medical profes- children in foster care. technical assistance, contact Leigh sionals, local Departments of Social “Through various initiatives, CCNC Poole ([email protected]) or if you Services and Community Care of regional networks and the NC Pedi- have policy questions or recom- NC Networks form the ‘three-legged atric Society have been working to mendations, contact Adam Svolto stool’ or the foundation on which to improve medical access in North ([email protected]).  build a medical home to meet the needs of each child,” said Leslie Star- Medical Homes Make a Difference soneck, Manager for Fostering Health When they’re enrolled in Community Care of North Carolina, children are assured NC. of having a medical home. With CCNC’s medical homes: The medical home model is a • Families may have a care manager who can help them manage the child’s comprehensive approach to primary health care, show them how to keep the child healthy, and access specialists care to ensure all of the child’s medi- and other service providers, such as Early Intervention. • Families can choose a medical home for the child or continue to use the cal and non-medical needs are met child’s existing medical home. If an enrolled child does not already have a through a unique partnership involv- medical home, one will need to be chosen. Many pediatricians and family doc- ing the pediatric care team, the child tors are already medical home providers with CCNC. Contact the Medicaid and the child’s family. The medical program in your agency for a complete list of CCNC medical home providers. • Families can call the medical home for advice 24/7. For daytime and after- home is a particularly good fit for hours phone numbers, check the child’s Medicaid ID card. children in foster care, whose fami- • The child will receive regular sick care and well care at the medical home. lies include foster and birth families, Care by specialists is coordinated by the medical home. because of its emphasis on coordina- Children in Foster Care tion and comprehensive care. Chil- Some children in foster care in North Carolina today do not have a medical home dren in foster care suffer a higher inci- through CCNC. As a child welfare professional, you can do something about this. If you are a foster care (placement) worker, confirm that every child you work dence of problems with physical, oral, with already has a medical home. If so, try to ensure the child continues to see that and mental health than any other provider. If that’s not possible, try to keep the child in the same CCNC network group of children. so information from the previous medical home can be shared with the new one. “Fostering Health NC is designed If a child in foster care does not have a medical home, partner with the Medic- aid staff in your agency to enroll the child in Community Care of NC. to help the 9,600 children in foster care statewide receive better care for Changing Medical Providers Is Easy A common misconception about CCNC is that it can be hard to change providers. improved health outcomes. An added Actually, it’s easy. When a child or family wants to change primary care providers, bonus is that the focus on abundant they submit a change request to the Medicaid program within their county DSS. coordination for these highly mobile The new primary care provider’s number is entered, a new Medicaid card is auto- children saves health care costs matically generated, and voilà, the change is made. almost immediately,” said Starsoneck. Find CCNC Providers Near You Fostering Health NC will bring Simply contact the Medicaid program in your agency for a complete list of medical home providers participating in CCNC. technical assistance and consultation

9 References for this Issue (Children’s Services Practice Notes, v. 19, n. 3 • www.practicenotes.org)

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