Infants & Toddlers in Court Systems: A Survey of Indiana Professionals

Angela M. Tomlin, Ph.D. & Steven M. Koch, Ph.D. Riley Child Development Center - LEND, Indiana University School of Medicine

ABSTRACT
This poster presents results from a survey of Indianas professionals / volunteers who work with infants and toddlers in the court systems. The survey included 4 vignettes representing common experiences of this vulnerable population of young children with questions related to the professionals knowledge of infant mental health concepts and decisions they make related to further assessment, visitation, treatment and intervention. Recommendations for next steps were also shared.

SAMPLE VIGNETTE & QUESTION

Vignette 2: Bobby
Bobby is 20 months old. His mother Samantha is currently serving a 10-year sentence for drug offenses. Bobby was born shortly after his mother was incarcerated, and was immediately placed with Bobbys father, Robert. Robert has a history of bi-polar disorder and received special education help for learning problems. Robert receives disability income and has some help from his family Upon returning from work at 6am one morning, Roberts neighbor found Bobby wandering the street wearing only his diaper. Bobby did not appear upset, and allowed the neighbor to pick him up. The neighbor knocked on Roberts door, but there was no answer. Not knowing what else to do, the neighbor called the police. A CPS assessment found sufficient evidence to substantiate neglect, noting also that Robert had insufficient food, clothing and diapers in the home. The home was in disarray and full of trash, including a large number of empty alcohol bottles and unwashed baby bottles. While there were no toys in the home, Bobbys bedroom had a television turned to the Disney Channel, which Robert stated kept Bobby from crying. He added that he hoped watching TV would help Bobby learn to talk. Robert was referred to CPS in the past, has a history of drinking problems, and previously participated in an alcohol treatment program. He was passed out the morning Bobby was found in the street, but reported he had since called his sponsor and was sure that he was back on the right track. Bobby was placed into kinship care with his great aunt, one of the family members who often helped Robert in the past. Unfortunately, about 3 weeks after this placement, Bobbys great aunt was hospitalized with severe complications from her uncontrolled diabetes and heart problems. Bobby was placed into a temporary foster home on an emergent basis. In this home, Bobby cried incessantly and could not be soothed. The foster parents had a vacation scheduled, so Bobby was soon placed into another foster home, about 10 days later. In his second foster home, Bobby again cried, but within a couple days he became quiet, withdrawn, and had what his foster mother described as empty eyes. Each out-ofhome placement sent Bobby geographically further from his fathers home. Robert was unfortunately unable to attend supervised visits because of transportation problems and his required alcohol treatment appointments. 2. What is likely the best explanation of Bobbys reaction in the second foster home? Grief response or depression from being away from his father Traumatic response to removal from his great aunts home Broken bond with his first foster parents Being removed from a caregiver who makes him feel safe Reactive attachment disorder

RESULTS
VIGNETTE 1: PHYSICAL ABUSE Most likely observed behavior (pick 3) Self-soothing 66.7% Irritable mood 65.3% Sleep difficulties 51.4% Behavior regression 50.7% Aggression 40.3% Language regression 15.3% Walking regression 7.6% Picky eater 1.2% Overeating 0.0% Most likely outcome without treatment Will impact future relationships 86.2% Resolve within 2 weeks 11.0% Return to normal within 1 week 2.8% Relive abuse indefinitely 0.0% Attachment demonstrated with Foster mother 81.0% Case worker 15.5% Biological mother 3.5% Most effective recommendation to build mother-child relationship Perform caregiving tasks 77.6% Treat reactive attachment disorder 9.8% Bring objects from home 8.4% No foster parent during visits 4.2% VIGNETTE 2: NEGLECT/MULTIPLE PLACEMENTS Additional assessments indicated Developmental evaluation Reactive attachment/bonding Social/emotional well-being Evaluate for earlier phys. abuse Substance abuse of infant No assessments indicated

SUMMARY
Physical abuse Respondents emphasized increased arousal behaviors exhibited in infants, which is appropriate for this age. However, they rarely selected delays or regression in developmental skills. Witnessing domestic violence Respondents endorsed both hyper-arousal and numbing responses in the infants. However, research suggests that hyper-arousal is more likely with infants (Scheeringa & Zeanah, 1995) Neglect One in 5 respondents (81.3%) indicated a developmental evaluation would be appropriate. However, all children with substantiated neglect / abuse should be referred for a developmental evaluation (Cohen, Cole, & Szrom, 2012). Frequent moves / changes in caregiver Respondents often characterized the infants behavior as reactive attachment disorder, rather than a trauma response. Visitation & attachment Uncertainty about attachment to the foster parent was noted in vignette 1, with 1 in 5 respondents (19.0%) indicating that an attachment was evidenced with either the mother or caseworker. Infants can demonstrate an attachment with a foster parent within two months (Stovall-McClough & Dozier, 2004). Respondents recognized that frequent, short visits are preferable to weekly visits.

BACKGROUND
Nationally, infants & toddlers are over-represented in the child welfare system. They are also more likely to sustain significant and long-lasting effects when involved in the system. Exposure to trauma is particularly concerning and can lead to life-long physical and behavioral health consequences (Anda et al., 2006). In Indiana, a great proportion of the substantiated child maltreatment occurs in children younger than 6 years of age. For example, during 2009 there were 20,346 substantiated cases of neglect in Indiana. Of these cases, over half (11,449, or 56.3%) were with infants and children under age 6 (Indiana Department of Child Services, 2010). Exposure to maltreatment, which includes abuse, neglect and witnessing violence against others, leads to poor regulation in infants and toddlers, which can lead to developmental delays and difficult behavior. Although these changes in development and behavior can be traced to changes in brain structure and function, recovery is possible (Lieberman & Van Horn, 2008; Schore, 2010). Maltreated and traumatized infants & toddlers require stability and safety to allow for a return to normal development, including physical and emotional wellbeing and the ability to engage in positive relationship building. On June 30, 2009, a total of 14,931 Indiana youth were identified as a Child in Need of Services (CHINS: Indiana Department of Child Services, 2010). Of these youth under court supervision, approximately 3 in 10 (29.8%) remained living in their home, while the rest were placed into alternative care (e.g., relative placement, foster care, etc.). Decision making by professionals and volunteers serving court systems must be informed by science and best-practice guidelines so that maximal positive effects occur (Cohen, Cole & Szrom, 2012). Ongoing experience and research has identified steps legal systems can take to address the effects of adverse experiences. These steps include reducing the number of placements a young child undergoes and ensuring that developmental and behavioral interventions and therapies are provided to the children, parents and other caregivers. In many states, court team approaches allow judges, lawyers, mental health workers and other professionals to coordinate care, resulting in infants and toddlers being provided targeted, effective and integrated services (Katz, Lederman & Osofsky, 2011). Although there are some excellent local partnerships intended to address the developmental and behavioral needs of the youngest children in care and their families in Indiana, there is currently no statewide approach.

81.3% 81.3% 78.7% 29.7% 11.6% 1.3%

Best explanation of reaction in second foster home Removed from caregiver/safety 33.6% Reactive attachment disorder 30.7% Removal from aunt response 17.5% Grief response / depression 13.3% Broken bond from first foster home 4.4%

Best treatment approach Train foster parents / stay in home 85.4% Return to father immediately 13.1% New home with experienced parents 1.5%

NEXT STEPS / RECOMMENDATIONS

Under federal guidelines, children under the age of three years in out-of-home placement as a result of substantiated abuse or neglect should received developmental screening and referrals to Indiana First Steps. Providers who participate in these evaluations should have experience with trauma responses of young children.

PARTICIPANTS
N = 151 Gender Female Male Race Caucasian Black Other Hispanic Experience with Infants 0-2 years 9.2% 3-5 years 11.8% 6-8 years 8.5% More than 8 years 70.6% Experience with Toddlers 0-2 years 6.5% 3-5 years 8.4% 6-8 years 9.1% More than 8 years 76.0% Experience with Court System 0-2 years 19.0% 3-5 years 11.8% 6-8 years 11.1% More than 8 years 58.2% Years at Current Job Less than 1 year 1-5 years 6-10 years More than 10 years

RESULTS
VIGNETTE 3: WITNESS DOMESTIC VIOLENCE Most likely observed behavior (pick 3) Easily startled 66.7% Quiet/withdrawn 50.8% Self-soothing 43.2% Aggression 36.4% Irritable mood 34.1% Sleep difficulties 31.8% Behavior regression 22.7% Fear of police 6.8% Language regression 4.5% Overeating 3.0% Walking regression 0.0% Picky eater 0.0% Assuming reunification, what is best initial visitation schedule Frequent, short visits 92.4% Postpone: improve parent communication 6.8% Regular weekly overnights 0.8% All-day visits weekly 0.0%

Visitation schedules for young children should be individualized with attention to many issues including the childs developmental and chronological age, overall caregiving context, and the degree of conflict between parents. Often, infants & toddlers do better with shorter and more frequent visits. As attachment grows over time with repeated experiences of safety & security, parents should be encouraged to demonstrate they can provide safety & security through caregiving activities (e.g., feeding, play, limit setting) during visits. Those working with the child welfare system should be encouraged to recognize & address ways that infants and toddlers show distress and symptoms of trauma, including agecongruent symptoms of re-experiencing a traumatic event, hyper-arousal, evidence of numbing of responsiveness, developmental delays and possible regression in skills. Providers need clarification about caregiving and attachment relationships across ages, including how attachment behaviors are affected by trauma, loss of access to caregivers, and to foster care. Provide recognition & support to foster parents as they play an important role in a young childs adjustment to being apart from their primary caregiver / parents. Consider ways to provide dyadic supports and interventions that assist parents (foster, biological, adoptive) to reconnect and establish positive relationships with young children who need to repair the effects of prior trauma and to enhance development and behavior.

90.1% 9.9%

MATERIALS & METHODS

This project was designed to survey professionals working in and with the court systems in Indiana to gain information about their understanding of the effects of trauma and maltreatment specifically with infants and toddlers, including the professionals decisions related to assessment, intervention, and placement for very young children. This projects intention was to provide a beginning point for discussion about the experiences of very young children in care and to identify potential gaps in knowledge of these key professionals and volunteers who make decisions that impact the lives and development of these children. Four vignettes were developed to represent common experiences of young children who have court involvement. Topics addressed at least one time across the four vignettes included: substantiated physical abuse, neglect, witnessing domestic violence, divorce, removal from home, foster care and kinship care, multiple placements, visitation, and decisions made by professionals related to assessment, intervention, and visitation for children between 12 and 20 months of age. Each vignette included questions to tap the respondents knowledge of expected behaviors or responses when the child is in the situation and appropriate next steps and decisions. Experts with experience in child welfare, including mental health workers, attorneys, and child welfare workers reviewed the vignettes and questions to provide input regarding their accuracy and representativeness of the kind of situations that are encountered. Email requests were sent to representatives of state agencies, including First Steps (Indianas Part C program), Head Start, Bureau of Child Development, Department of Child Services, Division of Mental Health and Addiction, and other partners (e.g., foster care agencies, CASA and guardian ad litem representatives, individual mental health professionals, etc.). The request invited participants to complete an online survey and to share the link with others working with infants and children in the court system.

87.7% 9.0% 3.3% 2.0%

Education Level Associate 1.3% Bachelor 52.6% Advanced 44.8% Other 1.3% Primary Affiliation DCS 71.1% Mental Health 7.9% First Steps 3.9% Private agency 2.6% Head Start 2.6% Court 0.7% Other 11.2%

REFERENCE
Anda, R.F., Felitti, V.J., Walker, J., Whitfield, C.L., Bremner, J.D., Perry, B.D., Giles, W.H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 56(3), 174186. Cohen, J., Cole, P. & Szrom, J. (2012). A call to action on behalf of maltreated infants and toddlers. Retrieved May 31, 2012, from http://www.zerotothree.org/public-policy/federal-policy/childwelfareweb.pdf. Katz, L.F., Lederman, C.L. & Osofsky, J.D. (2011). Child-centered practices for the courtroom and community. Baltimore: Brookes. Lieberman, A.F., & Van Horn. P. (2008). Psychotherapy with infants and young children. New York: Guilford. Indiana Department of Child Services. (2010, April). Department of Child Services Demographic and Trending Report: State Fiscal Year 2009. Indianapolis, IN: Author. Scheeringa, M. & Zeanah, C. (1995). Symptom expression and trauma variables in children under 48 months of age. Infant Mental Health Journal, 16, 259-270. Schore, A. (2010). Relational trauma and the developing right brain: The neurobiology of broken attachment bonds. In T. Baradon (Ed.). Relationship trauma in infancy (pp. 19-47). New York: Routledge. Stovall-McClough, K.C., & Dozier, M. (2004). Forming attachments in foster care: Infant attachment behaviors during the first 2 months of placement. Development and Psychopathology, 16, 253-271.

VIGNETTE 4: PARENT DIVORCE/SEPARATION

13.0% 32.5% 21.4% 33.1%

Should weekly visits with father occur? Yes, bonding with both parents 91.5% No, maintain primary bond 8.5% Overnight visit considerations Age of child is important Level of parent conflict is important Overnights not recommended None of the above

53.5% 42.6% 3.2% 15.5%

Supported in part by project H25MC00263-04-00 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.