Building a Home Within: Meeting the Emotional Needs of Children and Youth in Foster Care - Softcover

Softcover

ISBN 10: 1557668396 ISBN 13: 9781557668394

Publisher: Brookes Publishing, 2005

Synopsis

All children need stable, lasting relationships with caring adults to ensure their healthy emotional, cognitive, and social development. But for children and adolescents in foster care, these essential relationships are often absent. This book presents a proven solution based on over 10 years of groundbreaking work by the Children's Psychotherapy Project (CPP): When young people work with the same therapist for as long as they need to, they'll make better progress toward developing strong, healthy relationships and hope for the future. More than a dozen experts from the CPP give psychologists, social workers, counselors, and program administrators a complete, research–supported introduction to this successful "one child, one therapist, for as long as it takes" model as they share their triumphs and challenges. Through the lessons these therapists learned as they donated their time to weekly psychotherapy sessions, readers will gain new insight on how to build positive relationships with children. They'll learn how to address various aspects of foster care, including

• the neuropsychological effects of foster care on children
  
  
• the specific challenges of preschool children in foster care
  
  
• kinship care
  
  
• reunification with parents
  
  
• foster children and the educational system
  
  
• collaboration between public and private forces
  
  
• the transition out of foster care at age 18

With a combined emphasis on biological, psychological, and social aspects that sets it apart from other books on the subject, this candid and compelling resource will help therapists fully address the emotional needs of children and adolescents in foster care.

P.S. Perfect for professional development! Includes case studies for discussion and extended therapy-in-action scripts that show how children speak and how to respond.

*Royalties from the sale of this book will support the programs of A Home Within, a non-profit organization building lasting relationships for foster youth—one hour at a time.

About this title

About the Author:

Toni Vaughn Heineman, D.M.H., is the founder of the Children's Psychotherapy Project (CPP) and Executive Director of A Home Within, the national nonprofit organization that houses the 12 chapters of CPP across the United States. She received her master's degree in social work from the University of California, Berkeley, and her doctoral degree in mental health from the University of California, San Francisco. Dr. Heineman has taught for the Psychoanalytic Institute of Northern California, the San Francisco Psychoanalytic Institute, and many local and national training programs. She is the author of numerous articles and presentations about clinical work with foster children and of The Abused Child: Psychodynamic Understanding and Treatment (The Guilford Press, 1998). Dr. Heineman has been in private practice in San Francisco since the late 1970s and is Associate Clinical Professor of Pediatrics and Psychiatry at the University of California, San Francisco.

Diane Ehrensaft, Ph.D., is a senior clinician and founding member of the Children's Psychotherapy Project and Vice President of the board of directors of A Home Within. A developmental and clinical psychologist, she received her doctoral degree from the University of Michigan. She has lectured and published nationally and internationally on the subject of parenting and child development. Dr. Ehrensaft has served on the faculty of The Wright Institute in Berkeley, the Psychoanalytic Institute of Northern California, and the University of California, Berkeley, and has been in private clinical practice in the San Francisco Bay Area since the late 1970s. She is the author of Mommies, Daddies, Donors, Surrogates: Answering Tough Questions and Building Strong Families (The Guilford Press, 2005); Spoiling Childhood: How Well-Meaning Parents Are Giving Children Too Much but Not What They Need (The Guilford Press, 1997); and Parenting Together: Men and Women Sharing the Care of Their Children (The Free Press, 1987).

Excerpt. © Reprinted by permission. All rights reserved.:

Excerpted from Section IV of Building a Home Within: Meeting the Emotional Needs of Children and Youth in Foster Care, edited by Toni Vaughn Heineman, D.M.H., & Diane Ehrensaft, Ph.D.

Copyright © 2006 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

This clinical vignette illustrates the challenges encountered by one infant, Lilly, and her family as they navigated the disruptions of separation, foster care, and reunification. Interruptions of attachment are particularly significant during infancy and early childhood, when healthy brain development relies on consistent, contingent caregiving. This narrative describes an infant’s extraordinary attempts to survive the multiple breaking of primary bonds and the efforts of a family to reconnect.

LILLY’S FAMILY HISTORY

Lilly’s parents, Jill and Mark, had extensive histories of homelessness, drug and alcohol dependence, and drug-related incarcerations. Each of their children from previous relationships experienced removal from the home by child protective services and placement in foster care due to severe neglect. Two of the older children had drug-related problems and had spent time in juvenile hall.

Mark was incarcerated at the time of Lilly’s birth and when released from jail was sent to a residential recovery program for men. At birth, Lilly tested positive for methamphetamines and was removed from Jill’s care at age 2 days. She was returned to her mother 2 weeks later, and Jill was ordered by the court to participate in a substance recovery program. Following relapses in her mother’s recovery, Lilly was removed from her mother’s care. Each time she was returned to Jill from foster care homes. By her first birthday Lilly had experienced five disruptions of primary caregiving and safe havens were few.

When Lilly was 9 months old and in her third foster home, Jill rejoined her drug treatment program as a condition of reunification. Two months later, Lilly was enrolled in a therapeutic child care center staffed by teachers, a psychologist, a psychiatrist, and a special education teacher. The center was designed to provide child care for young children whose parents’ substance abuse and other psychological disorders made them vulnerable to attachment and mental health disorders. The therapeutic program had a preventive focus that included assessment of all developmental domains and treatment when concerns emerged.

Prior to attending the therapeutic center, 11-month old Lilly was visited in her fost–adopt home by me, the psychologist. She seemed to have an emotional connection with her foster mother, Sarah, who had cared for Lilly for 2 months. Lilly seemed curious about me as the visitor, crawled to a nearby table, and cautiously initiated a game of tapping on the table. Sad, weak smiles were Lilly’s responses to reciprocal tapping. It was evident that the infant was capable of attending to her world and interacting purposefully. However, her affect was constricted, and there seemed to be minimal energy and pleasure during exchanges. Throughout the visit, Lilly was silent and she frequently made eye contact with Sarah. Her foster mother gently supported Lilly’s mild curiosity about me and was warm in her responses to the infant’s soundless bids for reassurance.

During daily activities at the child care center, Lilly was found to have difficulty remaining calm and attentive during exchanges with caregivers and peers. When calm, she was able to engage in Peekaboo and other games, to which she responded slowly and with her characteristic sad smile that did not reach her eyes. Exchanges were brief and often lacked vitality. In addition, her appetite was poor and her sleeping patterns included frantic flailing when falling asleep and frequent sleep disruptions.

Prior to walking, Lilly’s activity range was narrow. She was regularly seen sitting and observing her peers and caregivers, and she frequently aborted attempts to initiate interaction. When she became ambulatory, Lilly often toddled aimlessly, making quiet whimpering sounds. She tended to wander from toy to toy without showing interest for more than 15 seconds. When Lilly made bids for attention, she waited for a response and then quickly ran away.

Lilly’s emotional capacities were found to be at age level, but her affect was generally constricted and her ability to be intentional and reciprocal was vulnerable to stress. Her overall development was screened at 2-month intervals using the Ages and Stages Questionnaires® (ASQ; Bricker & Squires, 1999). Lilly was repeatedly found to be at age level in the cognitive, communication, gross motor, fine motor, and personal-social skills domains. Sarah completed the Preventive Ounce Temperament Questionnaires (Cameron & Rice, 1999), and the results suggested that she thought of Lilly as being easily frustrated and slow in adapting to changes and novelty.

FAMILY REUNIFICATION

After 2 weeks at the therapeutic center, Jill began having unsupervised biweekly visits with Lilly. Initially Lilly seemed confused and somewhat fearful as she clung to caregivers and avoided looking at Jill. Throughout the 2 months of gradual reunification, routines and connections were regularly interrupted and Lilly seemed chronically stressed by the changes thrust on her. She needed considerable support to regulate herself to a calm state. Eventually, during visits with Jill, Lilly began toddling in circles and exhibiting clowning behaviors that engaged and enlivened her mother. Jill was frequently distracted and often jokingly criticized her child’s attempts to gain attention. The toddler worked diligently to be the focus of her mother’s attention. Lilly’s behavior with Jill was contradictory, as the infant sometimes avoided her mother and at other times frantically demanded to be held. Jill’s efforts were often intrusive and lacked empathy. She seemed to be uncertain about how to interact with her daughter and perhaps did not understand how to begin to repair the relationship.

Jill tended to speak in a sad, pressured voice and focused on her own challenges with housing and economics and her wish to reunite with Mark. She was more appropriate in her interactions with Lilly’s peers and was more of a spectator than a participant with her daughter. Jill frequently spoke about having failed Lilly and her fears of making mistakes again.

As Jill’s visits with Lilly commenced, weekly visitation with Mark was initiated. Lilly and her mother were transported to Mark’s residential treatment facility, and Jill reported that the encounters were successful. Within a month, Mark returned to live with Jill and began to participate in a local day treatment program.

During visits with his daughter at the therapeutic center, Mark’s calm demeanor and his capacity to follow Lilly’s lead seemed to engage and soothe the toddler. Mark was able to pause and allow Lilly to respond to his overtures. His visits included time with Lilly outside in the yard, where the toddler was often observed leading Mark around the path and looking over her shoulder at her father with smiles and quiet giggles. Father and daughter seemed to enjoy their outdoor ritual of shuffling back and forth along the pathways. Lilly began to brighten during the visits with Mark, and there was noticeable joy growing between them as they shared attention and experience.

Jill seemed overwhelmed by her own emotions and unable to soothe her daughter. Lilly appeared to be burdened by the dramas of her mother and her fost–adopt family, and the adults seemed paralyzed by their own disorganized states. Jill expressed fear that Mark would relapse, and she talked about her difficulty managing her feelings of guilt regarding Lilly and the older children. An older son had recently been incarcerated in juvenile hall, and Jill blamed a variety of agencies that she believed were impeding the family’s progress. The blaming was often preceded by expressions of guilt. In addition to coping with her relationships with her children, Jill frequently spoke of the challenges of managing withdrawal, relapses, and attempts to incorporate new behaviors.

Sarah’s family coped with the grief of losing Lilly. The family of five had hoped that Lilly would join them permanently. Although Sarah was appropriate in her support of Lilly’s reunification, her affect revealed the sadness that was present. Following reunification, Sarah and her children continued to visit Lilly until Jill reported that Lilly was confused by the visits. One month following reunification, Jill suggested that it was in Lilly’s best interest to terminate the visits with Sarah’s family.

DIAGNOSTIC IMPRESSIONS

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0–3; ZERO TO THREE Diagnostic Classification Task Force, 1994) guided the consideration of a diagnosis for Lilly. I found that she met the criteria for a prolonged bereavement reaction. She exhibited emotional withdrawal that included lethargy, a predominantly sad facial expression, and low interest in ageappropriate activities. In addition, Lilly’s sleeping was frequently disturbed.

DC: 0–3 Axis II addresses the characteristics of the parent–infant relationship. Behavioral interaction, affective tone, and psychological involvement are considered when making a diagnosis. In addition, the assignment of a DC: 0–3 Parent–Infant Relationship Global Assessment Scale (PIRGAS) score of less than 40 is compatible with an Axis II diagnosis. Jill was found to be insensitive to Lilly’s cues and often misinterpreted Lilly’s intentions. Affective tone within the dyad was sad and constricted. These elements are features of an uninvolved relationship. The findings for Lilly were as follows:

• Axis I: Primary Diagnosis
  Mood Disorder: Prolonged Bereavement/Grief Reaction
  
  
• Axis II: Relationship Disorder Classification
  Underinvolved Relationship Disorder (mother)
  
  
• Axis III: Medical and Developmental Disorders and Conditions
  Methamphetamine and Hepatitis C exposure in utero
  
  
• Axis IV: Psychosocial Stressors
  Moderately severe effects of enduring stress
  
  
• Axis V: Functional Emotional Developmental Level
  Interactive intentionality and reciprocity (needs some structure or sensorimotor support to evidence capacity — otherwise manifests capacity intermittently or inconsistently; earlier levels of mutual attention and mutual engagement are not at age-expected forms of capacity)
  
  
• PIR-GAS 30: Disturbed
  Maladaptive interactions and distress in both members of dyad

THERAPEUTIC INTERVENTIONS

Lilly’s mood symptoms and her chronically changing living situation required the attention of staff and family. The therapeutic team identified interventions designed to treat Lilly’s grief, foster her capacity for attachment, and prevent the development of rigid maladaptive patterns. In addition, the parent–child relationship needed therapeutic intervention. Jill and Mark, who had chronic mental health issues that interfered with recovery and the capacity to parent, were referred for individual psychotherapy.

Lilly’s depressed mood and associated symptoms were a primary focus of therapeutic intervention during my daily time with Lilly. In the infant classroom, I used an interactive therapeutic model that focused on Lilly’s symptoms and addressed the vulnerabilities of her emotional development. A major component of treatment involved the teachers who were supported to be consistent and patient as they helped Lilly calmly attend to her world and gradually participate in back-and-forth exchanges. Predictable routines and reliable caregiving were provided by the trained staff. In addition, the staff anticipated Lilly’s distress and offered soothing care. They helped her to soothe herself with her blanket when she was distressed and challenged by daily events. The familiar object had been with Lilly since birth, and Jill brought her daughter to child care wrapped in her blanket. Lilly frequently carried it around with her when tired or upset.

The therapeutic team considered areas of Lilly’s emotional development that had been impeded by the multiple disruptions in her primary care. Goals for Lilly included strengthening both her ability to attend to her world and her capacity to participate in a broad repertoire of emotional exchanges with predictable caregivers. In addition, the team wanted to support her emerging efforts to initiate interactions.

The parent–child relationship was another focus of treatment and was approached utilizing an infant–parent psychotherapy model. I met with Lilly and Jill twice weekly. Initially Jill had difficulty focusing on her infant and seemed overwhelmed and unavailable for interaction. Gradually and with modeling and encouragement, she gained confidence and began to follow her daughter’s lead and be reciprocal. Jill also learned to wait for Lilly to initiate and respond.

Mark was incarcerated again on drug-related charges, so he did not participate in the regular child– parent interventions. When released from jail, he visited Lilly daily and the two resumed their play rituals. He met weekly with the psychologist and began to participate in child– parent therapy.

Lilly’s parents had repeatedly failed Lilly but were willing to join in therapeutic work with their daughter and to participate in their own psychotherapy. Although Jill and Mark are vulnerable to relapse, they have continued to participate in therapeutic interventions. Mother and child are beginning to experience some joyful exchanges, and both parents struggle to maintain sobriety.

Lilly’s range of affect is less constricted, but the characteristic sad smile remains a common feature that conveys the enduring effects of the relationship disturbances that have marked her short life. Although Lilly suffered multiple losses during her infancy and lacked sensitive, consistent care, she gradually absorbed what was offered by caregivers who understood her vulnerability and uniqueness and were willing to wait for her gradual responses. Her energy level and interest in her world have increased, and her capacity for mutual attention and engagement has matured. Lilly also has developed strong representational capacities.

Lilly is now with a group of toddlers at the therapeutic center and spends much of her time in domestic play. She plays with peers in the play kitchen pretending to eat from toy plates, and she has been observed using a block as a phone. However, most of her attention is focused on tending to her baby dolls. She is sensitive to perceived baby doll cues, spends much of her time arranging a blanket around the dolls, and regularly puts her finger to her lips and says, “Ssh. Baby night night.†She seems to enjoy being with peers, and when they are in distress she responds. Once when a peer cried, she left her lunch table to go and give him a kiss. Lilly thrives on routines and rituals at the center....

About this edition

• Publisher: Brookes Publishing
• Publication date: 2005
• ISBN 10: 1557668396
• ISBN 13: 9781557668394
• Binding: Paperback
• Edition number: 1
• Number of pages: 272
• Editor: Heineman D.M.H. Toni, Ehrensaft Ph.D. Diane