Intervening with Foster and High-Risk Families:

Attachment and Biobehavioral Catch-up

Mary DozierInfant-Caregiver LabUniversity of Delaware

Many Paths to Enhancing Parent Child Relationships

Orlando, FloridaApril 23, 2014

Infant reliance on parent

Temperature regulationNeuroendocrine regulationProtection from infectionProtection from danger Contact comfortSecurity

Please note that not all slides are included here. This will, though, provide a general outline to follow along if you would like.

Effects of Neglect on Health and Mental Health

Health Growth; immune

system functioning

Mental Health Emotion regulation:

Depression, Anxiety Behavioral

regulation: Conduct disorders, Substance use

Attachment and Biobehavioral Catch-up

10- session intervention

Targets key issues identified as problematic for children who have experienced early adversity

Implemented in home

Attachment and Biobehavioral Catch-up Intervention

Adapted for Foster parents of infants Neglecting birth parents of infants Foster parents of toddlers (2-3 year olds) Parents adopting internationally

Visitation (birth parents and foster parents)

Issue Intervention target

Children push caregiver away

Children need nurturance even though they fail to elicit it

Children dysregulated behaviorally and biologically

Children need responsive care to help them develop regulatory capabilities

Parents behave in frightening ways

Children need parents who are not frightening

Children push parents away

Diary study over 60 days What did child do? What did you do in response?

Infants older than 12 months or so did not show secure behaviors across period studied

Contingency analyses reveal that parents respond “in kind”

(Stovall-McClough & Dozier, 2004)

Please note that this condenses several slides from the talk into one.

First intervention component:Re-interpreting child’s behavioral signals

Your child may not appear to need you But, every child needs his or her parent• Need to re-interpret signals• Need to provide nurturance

Task is tougher for high-risk birth, foster, and adoptive parent than for parents of children who have not experienced early adversity

Intervention strategies

Help parents to change through:Issues raised through manualVideo feedbackIn The Moment feedback

Biological dysregulation

Early adversity leads to biological dysregulation

Non-human and rodent (as well as human) studies have shown effects of early experience on HPA system

HPA system

H - HypothalamusP - PituitaryA – Adrenal

Cortisol an end product

Sensitive to effects of early experience

HPA system: 2 orthogonal functions

Stress reactive function Body’s mounting a stress response

Diurnal function Organism functioning as diurnal (or

nocturnal) creatureWe (and many others) have found more action

with diurnal function

When we measure cortisol

Wak

e-up

30-m

in

mid

-am

mid

-aft

bedtim

e0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

mg/

dl

Early Adversity and Diurnal Cortisol

Bernard, Butzin-Dozier, Rittenhouse, & Dozier, 2010

Wake-up Bedtime

-1.2

-1

-0.8

-0.6

-0.4Low-risk (n = 96)

Foster (n = 184)

Neglected (n = 155)

Log

-tra

nsf

orm

ed

Cort

isol V

alu

e

(in

ug

/dl)

Dysregulation

Biological dysregulation: cortisol Behavioral dysregulation:

Behavior problems Inhibitory control

Second target for intervention: Helping children develop better regulatory capacities

Synchronous interactions predict better regulatory capabilities (Raver, 1996)

Frightening behavior

Many parents behave in frightening ways• way to control behavior • response to distress • unaware (even dissociating)

Reduce frightening behavior

Make clear how parental behaviors can be overwhelming to child (e.g., tickling, teasing), followed by behaviors that are frankly frightening

Help parents notice those behaviors

Help parents see other choices

Problem Target Outcome

Children push caregiver away

Provide nurturance even though children fail to elicit it

Secure, organized attachment

Children dysregulated behaviorally and biologically

Provide responsive care

Enhanced regulatory capabilities

Parents behave in frightening ways

Don’t behave in frightening ways

Assessing effectiveness

Randomly assigned children and parents to ABC or to an alternate intervention (DEF)

120 children, half in ABC, half in DEF

Intervention Effects on Diurnal Cortisol Production

Wake-up Bedtime-1.2

-1.1

-1

-0.9

-0.8

-0.7

-0.6

ABC PostDEF PostABC Follow-upDEF Follow-up

Sample

Lo

g-t

ran

sfo

rme

d C

ort

iso

l (i

n u

g/d

l)

Attachment quality

Assessed in Strange Situation N=120

Breakdown significantly different for ABC and DEF For disorganized vs. organized

attachment For secure vs. insecure attachment

Percentage Disorganized Attachment Among Children in ABC and DEF Interventions

Bernard, Dozier et al., Child Development, 2012

Foster Toddlers

Preliminary data from Preschool Strange Situation

Intervention includes calming in addition to nurturance, synchrony, non-frightening behaviors

Percentage Secure Attachment Among Foster Children in ABC and DEF Interventions (Toddlers/Preschool SS)

ABC DEF0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Secure(84%)

Secure(44%)

Insecure(16%)

Insecure (56%)

Intervention Group

Perc

ent

of

Childre

n w

ith S

ecure

vs.

Insecure

A

ttachm

ent

Cla

ssifi

cati

ons

Assessment of emotion expression

Assess emotion expression/regulation in challenging task (Tool Task)

N=120

Negative Affect Among Children in ABC and DEF Interventions

Anger Anger towards CG

Negative Affect0

1

2

3

4

ABC

DEF

Assessment of executive functions

Assess executive functions in Dimensional Change Card Sort (DCSS) Foster children (sort according to one dimension, then

switch dimensions) Assess number correct pre- and post-

dimensional change

Pre-switch Post-switch0

1

2

3

4

5

6

7Non-fosterFoster controlFoster ABC

Ta

sk

Pe

rfo

rma

nc

e

(Nu

mb

er

Co

rre

ct)

ABC Effects on Mother ERPs

Does mothers’ processing of children’s emotional faces change as the result of ABC?

Compared 3 groups: Low-risk comparison (n = 34) High-risk control DEF intervention (n = 25) High-risk ABC intervention (n = 24)

Kristin Bernard dissertation

Attachment and Biobehavioral Catch-up

10 session intervention In home In the moment comments

Most critical aspect

Why so important?

Supports parent Rewarding, she feels supported, valued

Bring parent’s attention to specific behavior She did x, you did x

Links behavior with intervention targets That’s such a good example of ….

Links behavior with child outcomes That will help her feel….

In the moment commenting

Every opportunity for nurturing or synchronous behavior is trigger for parent coach comment (up to 100+ in hour session)

Components of comments:▪ Describe behavior ▪ Link to target▪ Link to child outcomes

Sessions

1-2: Introduce intervention; Nurturance

3-4: Following the lead 5-6: Avoiding intrusive and

frightening behaviors 7-8: Parents’ own issues 9-10: Consolidate gains

ABC

Evidenced based intervention Effects on attachment, physiology, etc. Uses in the moment commenting as

central

Example of pre-intervention to montage

Acknowledgments

NIMH R01 52135, 84135, 74374 Philadelphia DHS Delaware DFS Edna Bennett Pierce

Infant-Caregiver Lab