Maltreated Toddlers in Foster Care: What Can We Do for Them?

A week or so ago I had an email from a CASA (court-appointed special advocate) working in Washington State. She asked a very reasonable question: So, you say not to send young foster children for Attachment Therapy. Well, what are our options? What should we do to help them?

In reply, I sent her a journal article and suggested that she read about the Attachment and Biobehavioral Catch-up  (ABC) program directed by Dr. Mary Dozier of the University of Delaware. Dr. Dozier has spent 22 years developing this program and has reported four randomized controlled trials showing its benefits to children who have experienced serious adversity. ABC is now being implemented in 15 states and is wanted in others, but Dr. Dozier is concerned about maintaining high fidelity to the original program and must thus move more slowly than we might like.

ABC is a 10-session program, done in the home by trained coaches, which targets key child issues resulting from experiences of adversity. The focus is on parenting behavior, not on underlying attitudes or motives, and the parents may be neglecting birth parents, foster parent of toddlers, or parents who have adopted internationally. Randomized controlled trials have supported the effectiveness of ABC as done by certified coaches, with long-term positive effects for children’s development. The coach does not interact with the children, but watches and comments on the parent’s behavior.

ABC teaches and increases three basic parenting behaviors: 1) nurturance, 2) following the child’s lead, and 3) non-frightening behavior. These behaviors are not all carried out at the same time, so a challenge for a parent is deciding which kind of behavior is suitable at a given time.

Nurturance, or comforting or helping when the child needs this, is especially important for children who have experienced early adversity. Their high rate of disorganized attachment behavior shows that they have no consistent strategy for deciding whether to approach or avoid an adult caregiver, so caregivers need to be able to recognize situations and subtle communications showing a need for nurturance. When toddlers are avoidant or resistant to nurturance, caregivers tend to respond “in kind” – to feel rejected and to avoid trying to comfort the child. To increase nurturance, ABC-trained coaches actively comment in the moment by making, once a minute, positive comments on a caregiver’s nurturing behavior, like going to a child who has fallen down or picking up a child who approaches the caregiver.

Increasing parents’ nurturing behavior helps to decrease the non-nurturing behaviors that are too easily resorted to when toddlers are perceived as avoiding caregivers. These behaviors include making fun of the child, acting on unrealistic expectations of the child, deliberately letting a child get into difficulty “so he will learn”, telling the child “you’re okay, you’re not hurt” or “you’re too big to cry”, ignoring the child, or distracting the hurt child by pointing to something interesting. These actions all tell the child that the parent is saying “you don’t need me”, whereas the fact is that the child does need a nurturing caregiver and needs to identify a specific adult as actually being such a person.

Nurturing behavior involves responding to the distressed child’s needs with minimum--  or perhaps, no—signals from the child.  This behavior is different from  following the child’s lead, in which the parent responds to a child’s interest signaled by speech, gaze direction, movement, or toy play. For example, if a toddler is banging two blocks together, a caregiver might follow his lead by banging two other blocks or by putting one block forward to join in the banging, or jut by saying “bang!” each time. A caregiver is not following the child’s lead if he or she takes one of the blocks and asks the child to say what the letter on it is, or takes the blocks and starts to build a tower with them.  These parent activities have their place, but ABC tries to increase the adult’s success in identifying the child’s interest and making use of it for pleasurable communication. 

Parent behavior that does not follow the child’s lead can be “teach-y” under the wrong circumstances, bossy, intrusive, or ignoring. Of course, there are many times when a caregiver appropriately does not follow a child’s lead, especially when limits need to be set or boundaries established. The ABC goal is to increase the caregiver’s ability to follow the child’s lead when doing so is appropriate--  not when the child’s lead will take the child or others into danger.

ABC-trained parents also learn to avoid frightening behavior that makes it more difficult for a young child to stay calm and regulated. This includes intrusive behavior like grabbing or tickling. For a child who has experienced severe adversity, typical “normal” parent-toddler games like “I’m gonna get you”, the threatened tickle with a finger that goes around and around near the child’s belly, or exciting chasing and hiding, may all be inappropriately frightening. The child who still struggles with knowing whether to approach or avoid a caregiver may interpret even play at frightening behavior as a signal that this adult should be avoided if possible.   

The ultimate goal of ABC is to improve the ability of the child to stay calm and regulated in the everyday circumstances of the home. This improved regulation allows the child to learn and communicate more effectively and to have more inhibitory control. One of the ABC outcomes is that children of ABC-coached parents later have more success than controls in a laboratory test where they are shown some fascinating toys and told not to touch them by an adult who then leaves the room.

When Internet sites for foster and adoptive parents tell parents that conventional treatment “just makes a child worse”, or when they advocate highly authoritarian, intrusive, managing methods that are supposed to make maltreated children “attached” and therefore obedient, they are badly mistaken (to put it politely). Evidence-based treatments like ABC and PCIT (Parent-child Interaction Therapy) can make enormous positive differences to the lives of children and families. I hope my CASA correspondent will pass along what I told her to others and help them understand this.