Module 3-211

Infants and Toddlers in Foster Care

Mary Dozier, 1 Charles H. Zeanah,

2 and Kristin Bernard

1

1 University of Delaware and

2 Tulane University

ABSTRACT—Young children involved in the child welfare

system are susceptible to behavioral and physiological

dysregulation. These children need nurturing care to

develop organized attachments to caregivers, they need

synchronous care to support their physiological and

behavioral regulation, and they need stable caregivers

who can commit to them, supporting their sense of self

and behavioral regulation. Without intervention at the

level of the parent and the system, most children involved

with the child welfare system are unlikely to have these

needs met. We present two models of intervention

designed to enhance parents’ synchrony and nurturance,

and highlight aspects of the system that can enhance the

stability and commitment of caregivers.

KEYWORDS—foster care; attachment; maltreatment

Every year, many children and families are involved with the

child welfare system. In 2011, more than 650,000 children were

identified as victims of child abuse and neglect, almost half

(47%) of them age 5 or younger (U.S. Department of Health &

Human Services, 2011). Infants and young children involved in

the child welfare system typically have experienced maltreat-

ment as well as disruptions in their relationships with primary

caregivers at a point in development when parents serve a criti-

cal role in helping children regulate their physiology, behavior,

and emotions (Hertsgaard, Gunnar, Erickson, & Nachmias,

1995; Hofer, 1994, 2006). Perturbations in the caregiving sys-

tem are especially challenging for the youngest children. Chil-

dren adapt in a variety of ways to such challenges, some with

problematic long-term consequences. Therefore, intervention

strategies are needed that enhance parents’ capacity for provid-

ing synchronous, nurturing care, and those that promote stable

relationships.

The primary role of the child welfare system is to protect

young children. Following occurrences of neglect or abuse,

young children may be placed with foster or kinship parents.

Although reunification with the biological parent is the goal for

most children, the child welfare system may work toward estab-

lishing a permanent out-of-home placement (i.e., adoption) when

reunification is impossible. For intervention strategies to meet

the unique needs of these vulnerable children, it is critical to

identify key caregiving variables that influence children’s early

development.

KEY CAREGIVING VARIABLES FOR VULNERABLE

CHILDREN

In the first several years of life, children depend especially on

caregivers for help regulating their physiology, attention, behav-

ior, and emotions. Early in development, parents serve as coreg-

ulators, with children gradually taking over these regulatory

functions themselves (Hofer, 2006). This process is facilitated

by the experience of stable, enduring relationships with commit-

ted parents who behave in synchronous and nurturing ways

(Blandon, Calkins, & Keane, 2010; Carlson, 1998; Dennis,

2006; Dozier & Lindhiem, 2006). Four dimensions—synchrony, nurturance, stability of care, and commitment—are key to defin- ing the quality of caregiving.

Synchrony

First, children whose parents behave in more synchronous ways,

that is, parents who follow children’s lead in interactions,

develop stronger self-regulatory capabilities than children whose

parents are less synchronous (e.g., Raver, 1996; Rocissano,

Slade, & Lynch, 1987). In one study, children were more likely

Mary Dozier, Department of Psychology, University of Delaware; Charles H. Zeanah, Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine; Kristin Bernard, Department of Psychology, University of Delaware.

The writing of this paper was supported by National Institutes of Health Grants R01 MH052135, MH074374, and MH084135 to the first author.

Correspondence concerning this article should be addressed to Mary Dozier, Department of Psychology, University of Delaware, Newark, DE 19711; e-mail: [email protected].

© 2013 The Authors

Child Development Perspectives © 2013 The Society for Research in Child Development

DOI: 10.1111/cdep.12033

Volume 7, Number 3, 2013, Pages 166–171

CHILD DEVELOPMENT PERSPECTIVES

to control their behavior when their parents were synchronous in

their interactions than when they were not (Rocissano et al.,

1987). When caregivers are intrusive or neglecting, children

miss the opportunity for interactions that build a sense of control

over the environment and over their own ability to regulate.

Children in the child welfare system are especially unlikely to

have caregivers who behave in synchronous ways. This, com-

bined with other adverse experiences, places these children at

risk for problems regulating physiology and behavior (e.g., Ber-

nard, Butzin-Dozier, Rittenhouse, & Dozier, 2010; Fisher,

Stoolmiller, Gunnar, & Burraston, 2007). Compared to children

from low-risk environments, children of neglecting parents show

a more blunted diurnal pattern of cortisol production (Bernard

et al., 2010; Bruce, Fisher, Pears, & Levine, 2009) and are

more vulnerable to behavioral dysregulation (e.g., Pears &

Fisher, 2005).

Nurturance

Second, when parents respond in nurturing ways to their dis-

tressed children, the children develop expectations that they

can depend on them and are thus likely to develop secure, orga-

nized attachments (Ainsworth, Blehar, Waters, & Wall, 1978;

Carlson, 1998). Children whose parents are emotionally unavail-

able when they are distressed, or are frightening (at any time,

regardless of whether children are distressed), often develop dis-

organized attachments to their parents (Lyons-Ruth, Bronfman,

& Parsons, 1999; Schuengel, Bakermans-Kranenburg, & van

IJzendoorn, 1999; van IJzendoorn, Schuengel, & Bakermans-

Kranenburg, 1999). Children in the child welfare system are at

much greater risk for developing disorganized attachments than

children not in the system (Carlson, Cicchetti, Barnett, &

Braunwald, 1989; Cyr, Euser, Bakermans-Kranenburg, & van

IJzendoorn, 2010). Disorganized attachments are associated with

a host of problematic outcomes, most especially an increased

risk for behavioral dysregulation as seen in externalizing prob-

lems (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley,

& Roisman, 2010; Madigan, Moran, Schuengel, Pederson, &

Otten, 2007).

Although nurturing care tends to be driven primarily by care-

givers’ qualities (van IJzendoorn, 1995), children who have

experienced early adversity often behave in ways that fail to

elicit nurturing care from caregivers (Stovall-McClough & Dozier,

2004). Children who experience disruptions in care after about a

year of age are especially likely to turn away from caregivers

rather than seek them when distressed. Children’s behaviors

elicit complementary behaviors from caregivers (e.g., children

who avoid caregivers elicit rejecting behavior by caregivers).

Synchrony and nurturance are considered separate dimen-

sions of parenting that predict key child outcomes in different

ways. Many studies consider these two dimensions together as

sensitivity more broadly, but recent work has separated synchro-

nous behavior that follows a child’s lead (also termed autonomy

support) from nurturance to children’s distress (Whipple, Ber-

nier, & Mageau, 2011). Although synchrony and nurturance are

variable even among low-risk parents, both are important for

children involved in the child welfare system.

Stability of Care

Third, most children live with their birth parents throughout

childhood, with occasional visits to close family members and

friends. Thus, for most children, stability of care can be taken

for granted. However, for many children in the child welfare sys-

tem, relationships with primary caregivers are disrupted, some-

times multiple times (Casanueva et al., 2012). Among other

problems, children who experience more disruptions in care can

show deficits in executive functioning, such as in their ability to

inhibit behavior (Lewis, Dozier, Ackerman, & Sepulveda-Koza-

kowski, 2007).

Commitment

Most children are raised by birth or adoptive parents who are

fully committed to raising them throughout childhood, so solid

caregiver commitment can typically be assumed among biologi-

cally intact parent–child dyads. However, foster parents vary in their commitment to the children in their care. To assess com-

mitment, parents who took part in the This Is My Baby interview

(Bates & Dozier, 1998) were asked basic questions such as

“How much would you like to raise this child?” Commitment

was greater among foster parents who had fostered fewer chil-

dren in the past (Dozier & Lindhiem, 2006). At a behavioral

level, more committed foster parents showed more delight in

their children than less committed foster parents (Bernard &

Dozier, 2011). Commitment matters because humans are an

altricial species (i.e., depend on a parent at birth), and infants

expect to have a committed caregiver. From an evolutionary

perspective, human infants probably would not have survived

without committed caregivers. When children do not have care-

givers who are committed to them, they are at increased risk for

negative self-perceptions and problem behaviors (Ackerman &

Dozier, 2005; Lindhiem & Dozier, 2007). Whereas synchrony

and nurturance are variable even among low-risk parents,

stability and commitment represent constructs that are unique to

high-risk caregiving.

A DEVELOPMENTALLY INFORMED SYSTEM OF CARE

Synchrony, nurturance, stability of care, and commitment have

been identified as factors key to optimal development in the first

years of life. Without intervention at the parent and systems

levels, the caregiving that children in the child welfare system

receive is not likely to be optimal. By organizing prevention pro-

grams with birth parents and foster parents, and making changes

at the systems level, however, we can enhance the likelihood

that children receive nurturing, synchronous care; decrease the

number of disruptions; and increase the commitment of caregiv-

ers. Several attachment-based intervention programs have

Child Development Perspectives, Volume 7, Number 3, 2013, Pages 166–171

Infants and Toddlers in Foster Care 167

targeted high-risk infants and toddlers who have been mal-

treated or received inadequate care (Bakermans-Kranenburg,

Juffer, & van IJzendoorn, 1998; Cicchetti, Rogosch, & Toth,

2006; Hoffman, Marvin, Cooper, & Powell, 2006; Lieberman &

van Horn, 2009). In the following section, we describe and

distinguish two such prevention programs: The first targets par-

ents’ nurturance and synchrony, and the second targets nurtur-

ance and synchrony as well as system-level variables that can

enhance stability and commitment. We then describe consider-

ations for enhancing the child welfare system to provide a devel-

opmentally sensitive approach for vulnerable children.

Attachment and Biobehavioral Catch-up (ABC)

The ABC intervention was developed specifically to enhance

caregivers’ synchrony and nurturance, and to reduce caregiv-

ers’ frightening, intrusive, or threatening behavior (Bernard

et al., 2012). Carried out in families’ homes over 10 sessions,

the program has been adapted for use with both foster and

birth parents. Notably, the ABC intervention includes charac-

teristics that have distinguished effective interventions in

meta-analyses: It is relatively brief, guided by a manual, and

focuses on changing parents’ behaviors rather than changing

the way parents think about their own attachment experiences

(Bakermans-Kranenburg, van Ijzendoorn, & Juffer, 2003,

2005).

The intervention targets parents’ synchrony in several ways.

With support and encouragement from a coach, parents practice

following their child’s lead during specific activities (e.g., build-

ing with blocks). Through video feedback, parents review clips

in which they effectively followed their children’s lead. Coaches

also present research on the importance of following the child’s

lead in terms that are familiar to parents. The most important

aspect of the training is the in-the-moment comments about par-

ents’ synchronous behaviors as they occur during the session.

Coaches make as many as 100 in-the-moment comments in a

60-min session. For example, if a child held up a toy and said,

“ba ba” and the parent responded with “ba ba,” the parent

coach might say, “He said ‘ba ba’ and you said ‘ba ba’ right

back. That’s such a good example of following his lead. That lets

him know he has an effect on the world.” The frequency of in-

the-moment comments was associated with parents’ synchrony

in subsequent sessions and in postintervention assessments (Me-

ade & Dozier, 2012).

Nurturance is targeted in analogous ways. Parents are taught

that some children, especially those who have experienced early

adversity, behave in ways that fail to elicit nurturing care (Stov-

all-McClough & Dozier, 2004). To highlight this, parents view

videos of unfamiliar children—some of whom show their distress directly and some of whom do not—to learn that children need their parents whether or not they signal this need clearly. As

with synchrony, the most powerful part of the intervention is the

in-the-moment comments that support parents in providing nur-

turing care. For example, when a child bumped his head on the

coffee table and cried, and the parent said, “Are you ok?” the

parent coach said, “That’s such a great example of your being

there for him when he needed you. He hit his head and you

looked concerned and asked if he was ok. You didn’t say, ‘Don’t

cry, that didn’t hurt,’ or any of those other things. That’s so

important for him being able to come to you.”

In randomized clinical trials with both foster and birth parents

referred by the child welfare system, the ABC intervention

enhanced parents’ synchronous behaviors (Bick & Dozier,

2013), and child attachment, cortisol production, and executive

functioning (Bernard et al., 2012; Dozier et al., 2006). Children

living with their birth parents who were randomly assigned to

the ABC intervention showed lower rates of disorganized attach-

ment than children assigned to a control intervention, 32%

versus 57%, respectively, a medium effect size, d = .52 (Ber- nard et al., 2012). Children whose birth parents participated in

the ABC intervention also had more normative cortisol produc-

tion than those whose parents took part in the control interven-

tion (Bernard, Dozier, Bick, & Gordon, 2013). Similar effects of

normalized cortisol production were seen among infants in foster

care (Dozier et al., 2006). Foster children in the ABC group also

showed more advanced executive functioning on the Dimen-

sional Change Card Sort than children in the treatment control

group (Lewis-Morrarty, Dozier, Bernard, Terraciano, & Moore,

2012)—when asked to sort cards according to a particular dimension, all children performed well; after being asked to

change the dimensions by which they were sorting, children

from the ABC intervention group outperformed children in the

control group. Being able to switch dimensions is associated

with other executive functions, such as planning and inhibitory

control.

These effects are exciting in providing support for this rela-

tively brief intervention with both foster and birth parents.

Through ongoing research, we are examining how changes in

targeted parenting behaviors (e.g., synchrony, nurturance) differ-

entially predict changes in outcomes, as well as which aspects

of the intervention process (e.g., in-the-moment commenting)

lead to observed changes.

New Orleans Intervention

Whereas the ABC program targets synchrony and nurturance,

the New Orleans Intervention is a comprehensive program

targeting synchrony, nurturance, stability, and commitment

within a large systems framework. The New Orleans Interven-

tion (Zeanah et al., 2001) is an ongoing community-based pro-

gram designed to provide integrated mental health services to

young children in foster care. A distinctive feature of the pro-

gram is the careful integration of all intervention efforts into a

coordinated approach to care, enhancing the quality of infor-

mation provided to the courts and to child protective services.

A team of mental health professionals works collaboratively

with child protective services, advocating for child-centered

decision making. Because all caregiving relationships matter

Child Development Perspectives, Volume 7, Number 3, 2013, Pages 166–171

168 Mary Dozier, Charles H. Zeanah, and Kristin Bernard

for young children, this program intervenes with biological

parents, foster parents, and child care providers as needed, as

well as in court and with representatives from child protective

services.

Families who participated in the New Orleans Intervention

had significantly less subsequent foster care placement (Zeanah

et al., 2001). Relative risk reduction for the intervention group

ranged from 68% (all mothers) to 53% (only mothers who were

reunited with their children) with regard to the same child

returning to foster care in a subsequent incident of maltreat-

ment. Relative risk reduction for the intervention group ranged

from 63% (all mothers) to 75% (only mothers whose rights were

terminated on the index child) with regard to another child sub-

sequently being maltreated and placed in care. In a follow-up

evaluation when the children were 7, rates of problem behaviors

for children who had taken part in the intervention were similar

to those of children who had not been maltreated (Robinson

et al., 2012).

Enhancing the Foster Care System

In addition to targeted intervention programs that aim to

enhance key parenting variables, the child welfare system can

provide a developmentally sensitive approach to caring for chil-

dren when they are placed in out-of-home care. Foster care for

children younger than about 5 should be considered as an inter-

vention that is fundamentally different from that for older chil-

dren (Zeanah, Dozier, & Shauffer, 2011). When dealing with

foster families of young children, critical issues involve inten-

tionally helping foster parents develop parenting behaviors that

support how children form organized attachments and develop

adequate regulatory capabilities, recruiting foster parents who

can commit to the care of young children and their birth fami-

lies, and making placement decisions in which children’s devel-

opmental needs are primary. Because the child welfare system

typically aims to reunite children with their birth parents, work-

ing to enhance the skills of birth parents is also critical.

Given this goal, the most desirable foster parents to recruit

may be those who can commit to the child yet remain supportive

of the child’s relationship with birth parents. Indeed, foster par-

ents who value the birth parent’s attempts to reunite with the

child and encourage visitation with the child will be best able to

provide needed support to the child. We acknowledge the inher-

ent contradiction in this, both for the foster parent and for the

child: Foster caregivers need to commit to the child as if he or

she were their own child, yet support efforts that would result in

the child leaving their home. Very young children experience

whoever cares for them as a parent and are ill equipped to deal

with changes in caregivers.

Foster parents who can be physically present to support the

child when visiting birth parents will make the child more com-

fortable and more willing to explore and re-engage with the birth

parent, according to anecdotal reports. This approach requires

much preparation and buy-in from adults, some of whom are

reluctant. Foster parents can also help young children move

back into the full-time care of their parents. Abrupt transitions

can be traumatic for young children (Blakey et al., 2012) and

are impossible for very young children to understand or place in

perspective. Carefully planned and gradual transitions back to

biological parents after fostering were shown to diminish distress

in the now-classic study by James and Joyce Robertson in the

mid-20th century (Robertson & Bowlby, 1952; Robertson &

Robertson, 1971). If foster parents believe they can remain

involved with their foster children (e.g., as a foster aunt, god-

mother, etc.), they will probably be willing to commit more and

thus provide important support over time to the birth mother

and the child (Lewis et al., 2007).

LOOKING AHEAD

Synchrony, nurturance, stability of care, and commitment are

key to positive outcomes for infants and toddlers in the child

welfare system. Targeted approaches to intervention can

enhance caregivers’ behaviors and children’s outcomes. Chil-

dren in the ABC intervention had less disorganized attachment

and normalized biological and behavioral regulation, among

other outcomes; children in the New Orleans model of foster

care experienced reduced recidivism. These interventions are

remarkable in showing that they can protect children at a criti-

cal time during development. Research should examine what

factors support or interfere with the success of interventions to

refine and tailor them to meet the needs of the most vulnerable

children. Such studies offer exciting opportunities to advance

developmental science by informing our basic understanding of

pathways toward risk and resilience following early adversity.

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