A Developmental Psychopathology Perspective on Foster Care ...

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CHAPTER 12

A Developmental Psychopathology Perspective on Foster Care Research PHILIP A. FISHER, LESLIE D. LEVE, BRIANNA DELKER, LESLIE E. ROOS, and BRYNA COOPER

Foster Care as a Context for Prenatal Substance Exposure 530 Methodological Challenges to Research on Prenatal Substance Exposure 530 Developmental Outcomes of Prenatal Substance Exposure 531 Developmental Outcomes of Prenatal Exposure Among Children With Foster Care Histories 531 The Combined Effects of Prenatal Substance Exposure and Early Adversity 532 Independent Effects of Prenatal Exposure and Early Adversity 532 Early Adversity as a Mediator of the Effects of Prenatal Substance Exposure 533 Postnatal Risk and Protective Factors That Moderate the Effects of Prenatal Substance Exposure 534 RESILIENCE (I.E., TYPICAL DEVELOPMENT IN THE FACE OF ADVERSITY) IS EVIDENT IN ALL SAMPLES OF FOSTER CHILDREN (ALTHOUGH WHAT CONTRIBUTES TO IT IS NOT WELL UNDERSTOOD) 535 FAMILY-BASED CARE (INCLUDING FOSTER CARE) IS, AS A GENERAL RULE, BETTER THAN INSTITUTIONAL CARE 537 Child Care in Institutions 537 A Comparison of Foster and Institutional Care: The Bucharest Early Intervention Project 538 FAMILY-BASED INTERVENTIONS THAT CAN MITIGATE THE EFFECTS OF EARLY ADVERSITY 541 Treatment Foster Care Oregon for Adolescents (TFCO-A) 542 Multidimensional Treatment Foster Care for Preschoolers (TFCO-P) 542 Kids in Transition to School (KITS) 542 Keeping Foster Parents Trained and Supported (KEEP-SAFE) 542 Middle School Success (MSS) 543 Attachment and Biobehavioral Catch-Up (ABC) 543 The Incredible Years 543 Fostering Individualized Assistance Program (FIAP) 543 Fostering Healthy Futures (FHF) 544 Limitations of Existing Foster Care Interventions 544 Summary 544 CONCLUSIONS, TRANSLATIONAL IMPLICATIONS, AND DIRECTIONS FOR FUTURE RESEARCH 545 REFERENCES 546

INTRODUCTION 514 A HISTORY OF FOSTER CARE AND FOSTER CARE RESEARCH 514 Foster Care Research 516 EARLY ADVERSITY INCREASES THE LIKELIHOOD OF ATYPICAL EMOTIONAL, PSYCHOLOGICAL, AND COGNITIVE DEVELOPMENT 517 Mental Health Outcomes 518 Attachment and Social Functioning 519 Cognitive Functioning Deficits and Academic Adjustment 519 Developmental Delays 520 Demographic and Race/Ethnicity Differences 520 Long-Term Effects 520 EARLY ADVERSITY HAS THE POTENTIAL TO ALTER BIOLOGICAL DEVELOPMENT AND TO INCREASE RISK FOR DISEASE 520 Neuroendocrine Effects of Adversity 521 The Effects of Early Adversity on the Structure and Function of Brain Regions 522 Other Physical Effects of Adversity 524 Genetic Research Related to Adversity 525 Summary 525 THE TIMING AND DURATION OF ADVERSITY IS ASSOCIATED WITH DIFFERENTIAL BEHAVIORAL AND NEUROBIOLOGICAL OUTCOMES, WITH A GENERAL TREND OF LONGER LASTING ADVERSITY PRODUCING THE MOST PROFOUND EFFECTS 526 NEGLECT IS A PARTICULAR CAUSE FOR CONCERN BECAUSE OF ITS PERVASIVENESS AND ITS PROPENSITY TO DISRUPT HEALTHY DEVELOPMENT AND EXERT A LASTING IMPACT ON HEALTH AND WELL-BEING 527 TRANSITIONS AMONG PRIMARY CAREGIVERS ARE A SPECIFIC CLASS OF ADVERSE EXPERIENCE WORTHY OF ATTENTION BECAUSE THEY APPEAR TO NEGATIVELY AFFECT THE DEVELOPMENT OF KEY COGNITIVE AND BEHAVIORAL SKILLS NEEDED FOR SOCIAL AND ACADEMIC SUCCESS 529 THE COMBINED EFFECTS OF PRENATAL STRESS (ESPECIALLY PRENATAL SUBSTANCE EXPOSURE) AND EARLY ADVERSITY ON NEUROBEHAVIORAL DEVELOPMENT ARE ADDITIVE AND PRODUCE WORSE OUTCOMES THAN PRENATAL STRESS OR EARLY ADVERSITY ALONE 529 513

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INTRODUCTION Foster care—the practice of temporarily placing children with nonbiological parents as a way to promote their safety and well-being—is a custom that is likely as old as humanity itself. Allusions to children being cared for by foster caregivers can be found as far back as biblical times in the Talmud and the Old Testament. However, the formal public foster care and child welfare systems in the United States that have been created by regulatory statutes and are administered by federal, state, and county governments are a relatively modern invention, originating in the early twentieth century. How it is that current policies and practices designed to protect vulnerable children and families evolved during the centuries following European colonization of the New World is a matter of some historical interest. Tracing this history is a useful exercise, not only for those who wish to know the origins of family-based care in the United States (as an alternative to institutional care or no care at all), but also for students of typical and atypical child development. An analysis of the historical record reveals many approaches for addressing the problem of parentless children that were identified by observers at the time as clearly not facilitative of positive adjustment. From the emergence of beliefs that children are more than property, to the growth of understanding that childhood is a distinct period of development during which a nurturing environment facilitates well-being across the life span, to commentaries about the high mortality rates in orphanages and recognition of the fundamental needs and rights of children to be reared in families, the evolution of our current foster care system parallels the emergence of the science of psychology. In this chapter we consider the study of foster care and foster children from a developmental psychopathology perspective. As described by Cicchetti and Toth (2009), this perspective emphasizes a number of key focal points for scientific investigation. In particular, developmental psychopathology seeks to highlight the recursive relationship between research on typical development and atypical development. It uses multiple levels of analysis, from molecular genetics to neurobiology to the individual, family, and society, to examine relevant phenomena. It views prevention and intervention research not only as Philip A. Fisher, Leslie D. Leve, Brianna Delker, Leslie E. Roos, and Bryna Cooper are at University of Oregon. Support for the writing of this chapter was provided by the following NIH grants: P50DA035763, R01HD075716, and P50MH078105. The authors thank Matthew Rabel for editorial assistance.

a way to improve outcomes, but also as a way to understand developmental processes and their underlying neural mechanisms—and as such, as a means for grounding theoretical models of human development. It incorporates conceptualizations of diversity in both process and outcome. Finally, it emphasizes equally the negative outcomes that occur from adverse experiences and the ability of individuals to exhibit significant resilience in the face of adversity. Our discussion begins with an examination of the roots of the modern foster care system and the origins of research on foster care. We then provide a summary of the extant scientific knowledge base. The chapter concludes with a discussion of future directions for the field.

A HISTORY OF FOSTER CARE AND FOSTER CARE RESEARCH In North America, from the early European settlements in the 1600s through colonial times, there were no systematic efforts for providing for the needs of dependent children. Rather, as McGowan (1983) noted in her history of foster care in the United States, many citizens were primarily concerned with sustaining the resources needed for survival and considered children as property; in contrast, the concepts of childhood and children’s rights that we may take for granted today were unknown, and the children of paupers and orphans fell under the auspices of the English Poor Laws. This led to a number of possible outcomes for dependent children: being housed in almshouses, becoming indentured servants, being farmed out (i.e., auctioned off to citizens who were paid to house them), or staying with their families, who were given minute amounts of subsistence aid. Most commonly, dependent infants and young children were cared for in almshouses until they were old enough to be indentured. The growth of slavery in colonial America reduced the need for indentured servitude. Moreover, the rise of the abolitionist movement in the early nineteenth century further led to opposition to indentured servitude because it amounted to treating white children in ways that many had come to believe were morally wrong for black children and adults. As such, by the 1830s, institutional care in almshouses became the predominant form of care for children of all ages. The economic expansion that came after the end of the Civil War was followed by mass industrialization, urbanization, and immigration. These changes and the strongly held religious values in many communities made

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it a priority and a possibility to devote resources to caring for the poorest and most needy children and families in America’s cities. Newly established private Christian and Jewish philanthropies and public welfare organizations took up the cause of providing support for these individuals. However, care for the needy was still largely provided in orphanages and other institutional settings. In 1854 Charles Loring Brace, founder of the New York Children’s Aid Society, was among a group of social reformers who first identified the propensity for poor outcomes among children in institutional care. Of particular concern to Brace and others was the practice of housing children together with adults, which led to many abuses. Brace and his colleagues promoted an alternative strategy that involved the practice of placing out poor and parentless children from eastern cities. These children were put aboard trains and sent to live with families in rural areas in the upper Midwest and upstate New York. The practice proliferated quickly: By one estimate, 40,000 children had been placed out by 1879 (Bremner, 1970–1974). In addition to the practice of placing out children, the late nineteenth and early twentieth centuries saw the rise of the Children’s Home Society movement in the United States. These statewide agencies provided free-of-charge foster placements; like the practice of placing out children, the growth of this movement was rapid. By 1916, there were Children’s Home Societies in 36 states. As might be expected, the so-called orphan trains and Children’s Home Society family placements produced a wide range of outcomes; these practices led to much better lives for some children, while others experienced ongoing neglect and maltreatment (O’Connor, 2004). The orphan trains and the Children’s Home Society movement marked the beginning of a societal shift toward family-based care as an alternative to institutional rearing in the United States (Herman, 2008). Throughout the twentieth century in the United States, opposition to institutional care grew steadily, at least among professionals. For example, the renowned pediatrician Henry Dwight Chapin (1926) noted that mortality rates for children younger than age 2 years in orphanages was exponentially higher than in the general population: In 1914 the then American Association for Study and Prevention of Infant Mortality attempted a study of this question. In their review the New York State Department of Charities is quoted as presenting the statistics from 1909 to 1913 of eleven institutions in the State in which the death rate for babies under two years, during this period, based on the total number of children cared for, varied in the different institutions from 183 to 576 per 1,000, with an average mortality rate for the eleven

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of 422.5 per 1,000. During these same years the death rate for children under two years, based on the estimated population for the state at that age, was 87.4 per 1,000 or about one-fifth of that in institutions. (P. 486)

By the mid-twentieth century, professionals working with the large number of children orphaned and displaced by World War II had repeatedly documented the numerous negative effects of institutional care on children’s healthy development (Freud & Burlingam, 1974). During this era, Renee Spitz (1945) coined the term hospitalism to refer to children whose growth and functioning had been impaired by long periods of time spent in institutional settings. Psychodynamically oriented research on human attachment by John Bowlby (1953) and animal research examining the effects of maternal separation on rhesus monkeys by Harry Harlow (Harlow & Harlow, 1962) provided further evidence of the importance of a strong bond with a primary caregiver to a child’s development and well-being. Although professionals in the fields of social work, psychology, and pediatric medicine were already strong advocates for foster family care by the mid-twentieth century, institutions remained a very common form of care during this time. Barr (1992) estimated that, in 1910 in the United States, there were more than 100,000 children in institutions and more than 50,000 children in foster care. It was not until 1950 that the number of foster children exceeded the number of institutionalized children. Although the original foster care programs in the United States were run by charitable and religious organizations, efforts to organize a governmental foster care system did enter the social policy landscape early on. Programs at the federal level can be traced to the first White House Conference on Children in 1909, followed by the establishment of the Children’s Bureau in 1912. The Children’s Bureau was charged with protecting the welfare of all children in the United States. The New Deal era brought with it numerous federal and state government programs designed to provide a social safety net for the needy, including Social Security. By the 1960s, the growth of these government social welfare programs had led to a formal foster care system funded at the federal level but administered at the state level through a network of county child welfare offices. During the 1960s, the size of the foster care population in the United States began to grow rapidly, a trend that continued through the end of the twentieth century. Indeed, between 1983 and 2000, the foster care population more than doubled in size, from approximately 250,000 children to estimates of close to 600,000 children (U.S. Department of Health and Human Services, 2000).

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This trend was attributed to a number of factors: changes in regulations and laws regarding child abuse and neglect reporting, including the passage of the Child Abuse Prevention and Treatment Act (PL93–247) in 1974; more children entering than exiting care; and the combination of increases in poverty, urban and rural substance abuse, and other mental health and social problems in the face of decreasing budgets for social services (Barbell, 1997). In the years since 2000, the size of the foster care population in the United States has stabilized and no longer appears to be increasing. However, there is increased concern regarding the large proportion of very young foster children, who many consider to be most vulnerable. For a period of time in the 1990s, the number of young foster children was growing at twice the rate of other foster children (U.S. General Accounting Office, 1994), and children younger than 6 years came to represent one-third of the children in care (U.S. Department of Health and Human Services, 1999). While mining several large foster care databases to document these trends, Wulczyn, Ernst, and Fisher (2011) noted that foster children ages 2 years and younger tended to spend more time in care than did their older peers and showed particularly high vulnerability for delayed development. Notably, in countries outside the United States and especially in developing countries that have historically relied upon institutional care for children in need of out-of-home placements, there has also been some growth in the use of foster care. As we discuss elsewhere in this chapter, this development may be in part a response to widespread documentation—much of it from the scientific literature—that the absence of a primary caregiver that occurs in the case of institutionalized rearing produces the worst outcomes possible. As such, the use of foster care as an alternative to institutional care must be viewed as a positive development. Foster Care Research For almost as long as foster care has been an organized system of care in the United States, it has been the subject of systematic research. The first known empirical study of foster care outcomes (van Senden Theis, 1924) examined outcomes from close to 1,000 children placed in care by the New York State Charities Aid Association during the previous 2.5 decades. The study found what numerous subsequent investigations have continued to replicate (e.g., Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Glisson, 1994, 1996; Halfon, Mendonca, & Berkowitz, 1995; Pilowsky, 1995; Trupin, Tarico,

Benson, Jemelka, & McClellan, 1993; Urquiza, Wirtz, Peterson, & Singer, 1994): Foster children fare far better than children who remain in maltreating families but manifest poorer adjustment and increased problem behavior compared with nonmaltreated children. Despite remarkably consistent evidence that foster children lag behind their peers on most measures of development and well-being, the policies and programs designed to address the needs of foster children have been almost continuously in flux. McGowan (1983) observed that child welfare policies have been akin to a pendulum swinging back and forth along a number of key dimensions. They include the rights of parents to maintain their family with integrity versus the vulnerability of children and their need for protection; the need to provide families with support versus the need to keep children safe; federal responsibility versus state, local, or individual family responsibility for the care of the child; public versus charitable and philanthropic funding for services; services to support children’s development versus services to prevent harm; family preservation versus child-centered services; maintaining clearly defined boundaries among services designed to meet the needs of families (e.g., child welfare, family service, juvenile justice, other services) versus integrating services within systems of care; patient- or client-centered approaches to intervention tailored to the specific needs of the individual versus uniform standards of treatment; and specialized professional services versus paraprofessional, community-based supports. One explanation for the fluctuations in policies has been the lack of penetration of scientific knowledge about child development, and the needs of foster children in particular, into legislative settings. This has begun to change as researchers have endeavored to engage in translational communications designed to be useful in programmatic decision making and resource allocation, and policy makers have embraced evidence-based practice as a standard of care. Whatever the explanation for the historical instability of policies, however, although we tend to think of the latest trends in foster care services as novel and innovative, and although vast resources are regularly put into reengineering public child welfare systems, few trends have not been the focus of prior reform efforts, and no approach or combination of approaches has substantially reduced the disparities found among foster children. Over and above documenting the trends in foster care and the ongoing needs of the children and families involved, and germane to the subject of this chapter, research on foster care provides a window into how extreme variations in typical early rearing experiences

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affect development. Although animal models involving rodents and primates have provided extensive information in this area, only a few other contexts in research on human development (e.g., adoption) allow such questions to be investigated empirically. Similar to research on the broader topic of child maltreatment, research on foster care can delineate how variations in specific dimensions of adversity affect the trajectories of children’s lives; in addition, this work can uniquely inform us about how the alterations in the caregiving environment that occur with placement in care and subsequent caregiver transitions, including reunification with birth parents and subsequent foster placements, mitigate or compound the effects of adversity. As such, this work informs our understanding of which behavioral, cognitive, and biological systems are most pliable (and, thus, affected positively or negatively) at specific times during the course of development. In addition, prevention and intervention research in this area is helping to inform our understanding of the best strategies to use to maximize opportunities for recovery from early adversity. Finally, and perhaps most remarkably, research on foster care informs our understanding of typical development under the most adverse conditions and which intrinsic and environmental factors buffer individuals from experiences that would ordinarily disrupt health and well-being. The remainder of this chapter focuses on a developmental psychopathology perspective (Cicchetti & Toth, 2009) on how research on foster care can increase our understanding of typical and atypical development. A great deal of literature pertains to this topic—for example, searching foster care on the PsycNET scientific database results in more than 5,000 empirical publications between 1950 and the present. As such, it can be challenging to synopsize the scientific knowledge base in this area, and we strongly emphasize that this chapter is not intended to be an exhaustive review of the field of foster care research. We acknowledge that the organizational scheme we have used is somewhat arbitrary and some readers will undoubtedly fail to incorporate all important domains. Moreover, with respect to much of the research in this area, it is often not possible to disentangle the effects of maltreatment and other forms of adversity from the effects of placement in foster care, which itself may conflate factors such as separation or loss with the effects of care by nonbiologically related adults. In short, there are clear limitations to the amount of scientific control that can be applied to investigations in this area. Consequently, we fully expect this summarization of a developmental psychopathology perspective on foster care research will be updated, extended, and broadened in future discussions. With these

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qualifications in mind, we assert that foster care research provides evidence that: • Early adversity increases the likelihood of atypical emotional, psychological, and cognitive development. • Early adversity has the potential to alter biological development and to increase risk for disease. • The timing and duration of adversity is associated with differential outcomes, with a general trend of longer lasting adversity producing the most profound effects. • Neglect is a particular cause for concern because of its pervasiveness and its propensity to disrupt healthy development and exert a lasting impact on health and well-being. • Transitions among primary caregivers are a specific class of adverse experience worthy of attention because they appear to negatively affect the development of key cognitive and behavioral skills needed for social and academic success. • The combined effects of prenatal stress, especially prenatal substance exposure, and early adversity on neurobehavioral development are additive and produce worse outcomes than do prenatal stress or early adversity alone. • Resilience (i.e., typical development in the face of adversity) is evident in all samples of foster children, although what contributes to it is not well understood. • Family-based care, including foster care, is as a general rule better than institutional care. • Systematic, well-timed, family-based interventions have the potential to mitigate the effects of early adversity on healthy development. The next section elaborates upon each of these topics. A unifying discussion follows that includes future directions and implications for research in the emerging field of translational neuroscience. EARLY ADVERSITY INCREASES THE LIKELIHOOD OF ATYPICAL EMOTIONAL, PSYCHOLOGICAL, AND COGNITIVE DEVELOPMENT Perhaps the strongest conclusion that can be drawn from foster care research with respect to development is that it provides convergent evidence, along with evidence from many other areas of research, that early adversity alters typical life-course trajectories in a negative manner. This is consistent with a large body of animal research on the effects of adverse rearing conditions (Levine, 2005)

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and research on child maltreatment (Cicchetti, 1996; Toth & Cicchetti, 2013). It is also consistent with research on other forms of human adversity, such as poverty (Duncan, Magnuson, Kalil, & Ziol-Guest, 2012; Duncan, Ziol-Guest, & Kalil, 2010). Put simply, foster children as a group consistently lag behind their peers on measures of development and show poorer psychological adjustment (Pears & Fisher, 2005a, 2005b). In this section, we summarize the research on psychological, developmental, and cognitive problems that have been observed among foster children. Mental Health Outcomes One of the best-investigated domains in this area is foster children’s mental health. The National Survey of Child and Adolescent Well-Being (NSCAW) is a landmark study that provides some of the most compelling evidence of the disparities of foster children in the United States in this area. The NSCAW is a nationally representative sample of more than 6,000 children and families who have been investigated by public child protective services programs in the United States between 1997 and 2014. This study was funded by the U.S. Administration of Children and Families and has produced a multitude of technical reports and peer-reviewed publications to date. Two cohorts of children were recruited into the NSCAW study, and information was gathered from the children, their parents, other caregivers, caseworkers, teachers, and administrative records. Analyses of the NSCAW dataset have revealed that emotional and behavioral problems are present in more than 50% of the children in the sample (Burns et al., 2004). Numerous other publications using the NSCAW data set have documented the prevalence of specific mental health problems in this population (e.g., Casanueva, Cross, Ringeisen, & Christ, 2011; Orton, Riggs, & Libby, 2009; Southerland, Casanueva, & Ringeisen, 2009) High rates of mental health problems in foster children are not specific to the United States. Rates in Norway have been shown to be similar to those observed in the NSCAW study; for example, one in two children out of a sample of 279 foster children have been shown to exhibit some form of mental health disorder (Lehmann, Havik, Havik, & Heiervang, 2013). Similarly, English foster children have been shown to exhibit close to four times higher rates of mental health disorders than children living in economically disadvantaged families (Ford, Vostanis, Meltzer, & Goodman, 2007). Similar patterns of mental health disparities among foster children have been found throughout Europe (Holtan, Ronning, Handegard, & Sourander, 2005), Australia (Sawyer, Carbone, Searle, & Robinson, 2007), and Canada (Legault, Anawati, & Flynn, 2006).

Externalizing disorders appear to be one of the most common forms of psychopathology among foster children. For example, Garland et al. (2001) surveyed children receiving services within a number of public-care institutions (e.g., child welfare, juvenile justice, public school services for youths with serious emotional disturbances) and found that the most prevalent disorders were attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (e.g., oppositional defiant and conduct disorder). The foster care portion of this larger sample comprised 426 children, of whom 38.7% displayed ADHD or a disruptive behavior disorder; overall, externalizing disorders accounted for a much higher percentage than did anxiety or mood disorders, which were present collectively in only 13.8% of the foster children. While externalizing mental health disorders are more prevalent among foster children, rates of internalizing disorders also appear to be higher for foster children than for their community counterparts to a meaningful extent. For example, when 373 older foster children were interviewed for a study, the prevalence rates of major depression were revealed to be greater than those of a sample of working-class 18-year-old community youths. Depending on the early adversity the foster child had experienced prior to entering out-of-home care, the percentage of individuals suffering from major depression changed: 23% for physical abuse, 22% for physical neglect, and 26% for sexual abuse (McMillen et al., 2005). These findings are congruent with those from other studies that have found an elevated risk for lifetime major depression in foster children compared with nonfoster children and an increase in suicidal ideation and attempts related to feelings of unimportance and inferiority within the child (e.g., Pilowsky & Wu, 2006). It should be noted, however, that not all data on internalizing disorders are consistent. Some studies have found no differences between scores of depression of foster children and published norms, relevant to the Children’s Depression Inventory on children between ages 8 and 16 years (Allen, Combs-Orme, McCarter, & Grossman, 2000). Trauma-related anxiety disorders are also common among foster children who had experienced some form of sexual abuse or multiple forms of abuses. A comparison between sexually abused, physically abused, and nonabused foster children revealed that more than 60% of sexually abused children exhibited posttraumatic stress disorder (PTSD) and that physically abused children had a higher prevalence for PTSD than did nonabused children, at a rate of one in five (Dubner & Motta, 1999). When compared with a community comparison sample, foster children who had experienced maltreatment, including

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neglect, had 1.75 times the risk for manifesting PTSD (Widom, 1999). Other problem domains include sexual behavior and eating difficulties (Tarren-Sweeney, 2006). For example, using the Assessment Checklist for Children, Tarren-Sweeney & Hazell (2004) found that approximately 33% of their sample of foster and kinship children ages 4–9 years exhibited age-inappropriate sexual behavior. Two prominent trends exist in terms of food-related difficulties as a result of early adversity: food maintenance syndrome and pica-type eating behavior. Tarren-Sweeney (2006) examined these patterns in a study of 347 preadolescent children and found that 24% displayed clinically significant eating difficulties. The eating difficulties tended to be associated with developmental profiles. For instance, those displaying food maintenance syndrome were comorbid with psychiatric disturbances, specifically, disruptive behaviors and affective problems, and pica-type eating behavior was associated with developmental problems ranging from intellectual disability to speech and reading problems (Tarren-Sweeney, 2006). Attachment and Social Functioning Research on foster care also provides support for the association between early adversity and problems with social functioning, especially in terms of caregiver attachment (Stovall-McClough & Dozier, 2004) and peer relationships (Leve, Fisher, & DeGarmo, 2007). Reactive attachment disorder and disinhibited attachment disorder are common forms of atypical attachment that have been observed when youths are exposed to early adversity. At the time of initial placement for foster children (ages 1–4 years), for example, Zeanah et al. (2004) found that 37% were diagnosed with reactive attachment disorder, 22% were diagnosed with disinhibited attachment disorder, and 17% were diagnosed with both disorders. An additional study showed similar findings. In a comparison between foster children and nonmaltreated, school-age children, higher rates of reactive attachment disorder were found among the foster children (Minnis, Everett, Pelosi, Dunn, & Knapp, 2006). One factor that was found to be associated with increased risk of developing reactive attachment disorder was increased numbers of placements for the foster child (Lehmann et al., 2013). In addition to these general patterns of atypical social functioning, young foster children show a propensity to be indiscriminately friendly toward others, readily approaching unfamiliar individuals and showing little social reserve (Pears, Bruce, Fisher, & Kim, 2010). This pattern has also been observed among children reared in institutional settings (Gleason et al., 2014; Rutter et al., 2010); however,

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it is important to note that studies of both populations have shown that indiscriminate friendliness, while associated with problems in inhibitory control, is not correlated with attachment difficulties (Bruce, Tarullo, & Gunnar, 2009; Pears, Bruce, et al., 2010). Thus, as is discussed later in this chapter, this atypical pattern of behavior may be most accurately characterized as a neurobehavioral difficulty associated with social development than as an attachment problem. A Canadian study examined the psychological adjustment of foster children, specifically, their anxious behavior and physical aggressiveness in the context of caregiver relationships (Legault et al., 2006). More permanent and higher quality caregiver relationships resulted in less frequent physical aggression, increased number of close friends, greater self-esteem, the use of approach coping strategies, and less frequent avoidant coping strategies and attachment behaviors. Cognitive Functioning Deficits and Academic Adjustment Foster children also show deficits in a variety of domains of cognitive functioning. More than half of foster children are estimated to have cognitive difficulties (Landsverk, Davis, Ganger, Newton, & Johnson, 1996). Many of these deficits have been found to be a direct result of early adversity, including early separation from the biological parent, multiple placements, neglect, and abuse. For example, Mueller et al. (2010) found that early adversity experiences were associated with altered cognitive ability when maltreated adopted children were compared with their typical adolescent counterparts on a change task experimental paradigm that tests one’s ability to inhibit responses: The adopted children showed impaired cognitive control after having experienced early adversity. Preschool-age foster children exhibit specific cognitive deficits, including poorer visuospatial processing, poorer memory skills, lower scores on intelligence tests, and less developed language capacities (Pears & Fisher, 2005a). Visuospatial processing was found to be associated with type of abuse and the number of maltreatment types: The ability to process visuospatial information increased with number of maltreatment types and decreased with neglect or emotional abuse. These unexpected patterns offer an early understanding of how the developing mind reacts to maltreatment and abuse. Language is important to success in multiple realms of development because of its use as a tool for expression and communication (Stock & Fisher, 2006). In contrast, language deficits can lead to poor academic adjustment, which has been shown to increase mental health and behavioral problems, including internalizing and externalizing

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problems (Halonen, Aunola, Ahonen, & Nurmi, 2006). Before children have the ability to read, their phonological awareness in kindergarten is one of the most predictive prereading skills. Pears, Heywood, Kim, and Fisher (2011) examined phonological awareness among foster children entering kindergarten: Up to 54% scored below the 23rd percentile, indicating a risk for later reading difficulties and other academic challenges. Poor academic adjustment is also a common problem among foster children. For example, when researchers looked at more than 11,000 second-grade children, they found that compared with community children, those in out-of-home placements showed a higher prevalence of school suspensions and experienced higher rates of poor academic achievement (Fantuzzo & Perlman, 2007; Mitic & Rimer, 2002). Developmental Delays The preceding review of social and cognitive functioning deficits in foster children clearly indicates that developmental delays are also very common among foster children. For example, one study compared prevalence rates of developmental delays between children in the general population and foster children and found a 4% to 10% rate in the general population and rates as high as 60% in foster children (Leslie, Gordon, Peoples, & Gist, 2002). When Klee, Kronstadt, and Zlotnick (1995) examined the psychomotor development of 125 children ages 0–3 years, they found that 50% of the foster children rated below the typical level of psychomotor development for their age group, compared with 13% in the normative sample. Demographic and Race/Ethnicity Differences Some noteworthy differences exist between male and female foster care alumni. Female foster care alumni are at not only heightened risk for multiple pregnancies, but are at higher risk than are their male counterparts for maltreating their children. Educational outcomes differ, as well. When Dworsky and DeCoursey (2009) examined a sample group of 4,590 pregnant or parenting foster care alumni from metropolitan Chicago, they found that only 44% of the females and 27% of the males possessed a high school diploma or graduate equivalent degree when they exited the program. The race/ethnicity of foster families and children has been shown to be less influential in determining mental health outcomes among foster care alumni (Villegas & Pecora, 2012). For Caucasian, Hispanic/Latino, and

African American individuals who had experienced some form of foster care, ethnic background was not a strong predictor of whether mental health services would be needed later in life. However, gender, age of entrance into foster care, number of placements, and maltreatment before and while in foster care were factors associated with the eventual need for mental health services (Villegas & Pecora, 2012). It is noteworthy that there is relatively limited research in this area, however; this is a concern in part because of the overrepresentation of racial and ethnic minorities in foster care. Long-Term Effects Evidence suggests that the impact of early adversity on psychological and emotional well-being among foster children is not transitory and can persist well into adulthood. In a study in England, for instance, researchers found that adults who had spent time in foster care had twice the rates of mental health, drug, or alcohol problems than those with no histories of foster care (Viner & Taylor, 2005). Similarly, among a sample of 19,430 foster children ages 12–17 years, foster children were shown to have much higher rates of alcohol and illicit drug use (Pilowsky & Wu, 2006). The problems observed also extend to antisocial and criminal behavior. For example, among the NSCAW sample, arrests had occurred at more than four times the national rate for individuals ages 18–24 years (Administration for Children and Families, 2008). In addition, compared with their community peers, youths aging out of foster care have been shown to display higher rates of criminal and delinquent behaviors ranging from minor infractions to more serious crimes (Cusick & Courtney, 2007). To summarize, the research suggests that foster children show alterations in development across many domains of mental health and well-being. There are few instances in which, when compared with nonmaltreated community children, foster children haven’t been found to show disparities. This cumulative body of evidence supports the conclusion that early adverse experiences exert pervasive and enduring influences on typical development.

EARLY ADVERSITY HAS THE POTENTIAL TO ALTER BIOLOGICAL DEVELOPMENT AND TO INCREASE RISK FOR DISEASE The notion discussed in the previous section—that early adversity affects typical mental development—has been a mainstay of the field of psychology dating back to the

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early psychoanalysts. Similarly, there is a long tradition of research on the effects of stress on biological development dating back to the seminal work by Hans Selye (1936). Selye described a general adaptation syndrome in which the body goes through a series of stages in response to chronic stress, including alarm, resistance, and finally exhaustion. This helped explain the prevalence of illness and other negative sequelae in animals (and humans) exposed to chronic adversity. Although Selye’s ideas have received considerable revision and clarification in the ensuing decades, many of the core ideas encompassed in his theory remain. A vast animal literature about this topic shows the impact of stress on cognitive development and on neuroendocrine, immune, and metabolic systems (Levine, 2005). Much of this work has used paradigms that disrupt the early rearing environment of the species under investigation, most commonly through separating the offspring from its parent or by creating stress in the environment of the mother and her offspring. These studies have led to the fairly incontrovertible conclusion that stress experienced early in life has the potential to compromise the physiology of an organism at many levels. Whereas research involving animals has provided an extensive and precise knowledge base regarding the timing, type, and duration of adverse experiences on typical development, the human literature about this topic is, understandably, considerably more limited because of the unfeasibility of exerting the degree of experimental control on specific dimensions of adversity that has been used in animal studies. However, as described in the next sections of this chapter, researchers have extensively documented the atypical physical, brain, and biological development in populations that have experienced early adversity. Neuroendocrine Effects of Adversity The primary neuroendocrine regulation system known to be affected by early adversity is the hypothalamic-pituitaryadrenal (HPA) axis, which is believed to contribute to a number of neurocognitive and physical health outcomes (Chrousos, 2009; Pechtel & Pizzagalli, 2011). In this system, physical or psychological stressors,(including separation from a primary caregiver in infancy or social threat in late childhood, trigger a neuroendocrine cascade. Specifically, with sensory input and input from other areas of the brain indicating a disruption in homeostatic balance, corticotrophin releasing hormone, or CRH, is released in the hypothalamus. CRH is transported to the anterior pituitary, where it stimulates the release of

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adrenocorticophin releasing hormone, or ACTH; ACTH then enters the bloodstream and stimulates the release of glucocorticoids in the adrenal cortex. The release of these glucocorticoids (cortisol in humans, corticosterone in rodents) signals the widespread engagement of additional resources throughout the body to respond to environmental stressors, including increased metabolic rate and immune function (Chrousos, 2009; Hostinar, Sullivan, & Gunnar, 2014; Pechtel & Pizzagalli, 2011). In this way, cortisol released from the HPA axis plays a number of key roles in helping maintain a balance in response to perturbations (Chrousos, 2009). Under normative (nonmaltreating) environmental conditions, activation of the HPA axis in response to acute stressors is considered adaptive; however, environments with excessively high levels or chronic exposure are believed to reach harmful, toxic stress levels (Shonkoff, Garner, et al., 2012). The HPA axis also exhibits a diurnal rhythmicity (Kirschbaum & Hellhammer, 1989). In humans, cortisol levels are very low during the night, begin to rise around the time of awakening, and reach their daily peak approximately 30 minutes after awakening. Levels then drop off fairly precipitously and continuously throughout the morning, and reach their nadir from bedtime through the night. Although this pattern is not established in infancy until children develop regular day/night sleep cycles, it does appear to remain fairly stable once established. One exception is that when individuals undergo periods of chronic stress (e.g., a health crisis, divorce, college exams), cortisol levels may fail to decrease, and instead, remain elevated throughout the day. Research evidence has documented adversity-related alterations in the typical diurnal pattern of HPA-axis activity. Specifically, a blunted pattern is commonly observed in maltreated children, including foster children, that characteristically involves low morning cortisol levels that remain low throughout the day or a smaller decline across the day from morning to evening (Bruce, Fisher, Pears, & Levine, 2009; Trickett, Noll, Susman, Shenk, & Putnam, 2010). Although the specific mechanism for this blunted diurnal pattern, termed hypocortisolism, among foster children is not known, it may represent a down-regulation of the HPA-axis system as a resource-conservation mechanism in response to chronic early adversity (Fisher & Gunnar, 2010; Hostinar et al., 2014). Similarly dysregulated HPA-axis function has been observed in institutionally reared children (Carlson & Earls, 1997; Gunnar, Morison, Chisholm, & Schuder, 2001). Notably, improved environments, including adoption from institutional care or therapeutic foster care interventions, have been found to

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normalize diurnal cortisol patterns in maltreated children or prevent further dysregulation from occurring (Fisher, Stoolmiller, Gunnar, & Burraston, 2007). Substantial evidence from the animal literature suggests there are pathways through which dysregulated cortisol patterns may confer broader risk to the organism. Specifically, the function of brain regions dense with glucocorticoid receptors (e.g., prefrontal cortex, hippocampus, amygdala) are particularly compromised following acute and chronic stress exposure (Hostinar et al., 2014; Pechtel & Pizzagalli, 2011). Some evidence suggests that chronic stress and cortisol dysregulation relate to cellular atrophy in some of these regions (e.g., prefrontal cortex) and the opposite (i.e., increased cellular structure) in other regions, such as the amygdala (related to fear-based learning). These changes are theorized to contribute to a decreased capacity for adaptive homeostasis in the HPA-axis system and resulting stress sensitivity (Hostinar et al., 2014). Although less established in the literature, the neuroendocrine regulation of the oxytocin hormone, which is involved in human bonding and social behavior, may also be altered by early adversity. This hormone is predominantly synthesized in a hormonal cascade similar to that described for the HPA axis. In this case, the cascade begins in the hypothalamus and proceeds through the pituitary and peripheral organs (e.g., uterus, testis, heart; Hostinar et al., 2014). Although there are no studies of oxytocin in foster children, inferential evidence can be obtained about the effects of early adversity on this hormone from related areas of the literature. For example, in comparison with nonadopted children, children who were adopted following early institutionalized care show lower levels of urinary oxytocin when interacting with their mothers (Wismer Fries, Shirtcliff, & Pollak, 2005). In addition, oxytocin levels in the cerebrospinal fluid of adult women with a history of maltreatment have been shown to be lower than those of controls with no such histories (Heim et al., 2008). The Effects of Early Adversity on the Structure and Function of Brain Regions A wide variety of brain regions important to basic and complex cognitive skills (e.g., self-regulation) appear particularly susceptible to environmental experiences because of their protracted course of development and stresssensitive neurochemical properties (Berkman, Graham, & Fisher, 2012; Pechtel & Pizzagalli, 2011). Research evidence about the impacts of early adversity on these brain regions suggests alterations in the structural properties

of the brain and functional correlates in neuroimaging and electrophysiological studies. It is important to note, however (as we present later in this chapter), that with a few noteworthy exceptions (e.g., Bruce et al., 2013), this research base is drawn from populations that are overrepresented in foster care, but in many cases it is not specific to research on samples of foster children. A key developmental marker of healthy brain development is an increase in white-matter density and integrity, reflecting myelination and the insulation of neural pathways. Increased white-matter density and integrity, particularly originating from prefrontal brain regions, is believed to reflect the adaptive refinement of neural networks through heightened connectivity and integration within and between brain regions and circuits (Pechtel & Pizzagalli, 2011; Uddin, Supekar, Ryali, & Menon 2011). However, early adversity in the form of maltreatment has been found to alter white matter, with severe institutional neglect predicting whole-brain white-matter reductions and specific reductions in tracts within prefrontal brain regions and between prefrontal and temporal cortices (Hanson et al., 2013; McCrory, De Brito, & Viding, 2012). Children who have experienced maltreatment and show PTSD symptomatology, in contrast, have been shown to exhibit specific white-matter reductions in prefrontal brain regions but no whole-brain differences in white-matter integrity (De Bellis et al., 2002). The corpus callosum comprises the largest white-matter structure in the brain and has been found in all but one study of maltreated children to have adversity-associated reductions in white-matter integrity (McCrory et al., 2012). This cross-hemispheric brain structure is involved in a number of higher cognitive abilities (e.g., executive function, emotion). Atypical development of the corpus callosum has been theorized to contribute to the cognitive impairments found in maltreated children, although this association has yet to be established (McCrory et al., 2013). Research evidence about the effects of early adversity on gray-matter volume in the cerebral cortex, which reflects neuronal density, is less consistent, with different studies reporting adversity-related increases or decreases in gray-matter volume (De Bellis et al., 2002; McCory et al., 2012). These discrepancies may result from the inverted U-shaped trajectory of gray matter over the course of development—specifically, early increases followed by a decrease in adolescence and relative stability in adulthood (Pechtel & Pizzagalli, 2011). Combined with developmental increases in white-matter density, these cortical thinning processes are believed to reflect the refinement of neural networks and the establishment of more efficient processing

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that facilitates advanced cognitive skills (Padmanabhan, Geier, Ordaz, Teslovich, & Luna, 2011). Because of this nonlinear trajectory of gray-matter development, altered development could be reflected in multiple ways—for example, a lack of experience-related neuronal growth, resulting in reduced gray-matter volume, or insufficient gray-matter pruning, resulting in increased gray-matter volume. Interpreting the existing literature in this area is further hindered by the heterogeneity of maltreatment experiences, the differing sample age groups studied, and the differing timing of adversity across studies (McCrory et al., 2013). The results for gray-matter integrity of noncortical brain regions are somewhat more consistent, with reductions in cerebellum gray-matter volume reported in multiple studies of children and adolescents with a history of maltreatment and adversity (McCrory et al., 2013; Pechtel & Pizzagalli, 2011; Teicher, Tomoda, & Andersen, 2006). Hippocampal-volume reduction is also associated with a history of adversity, although this difference does not appear to emerge until later adolescence or early adulthood. Although this reduction may be exacerbated by adversity-related high-risk behavior, such as alcohol abuse, findings from human and animal studies suggest that it also occurs as a consequence of early adversity itself. In rodent models, this has been posited to arise from alterations in expected prepubertal gray-matter overproduction and subsequent postpubertal pruning processes, resulting in a net deficit in hippocampal cells (Teicher et al., 2006). Findings from research conducted during challenging cognitive tasks also provide evidence for the impacts of early adversity on the function of prefrontal and hippocampal brain regions. Such research uses functional MRI (fMRI) to measure regional blood-flow activity during performance of computer tasks, including protocols that assess the neural bases of inhibitory control (i.e., the ability to stop a planned motor response) and working memory (Bruce et al., 2013; Carrión, Haas, Garrett, Song, & Reiss, 2010; Mueller et al., 2010). In experimental paradigms involving inhibitory control, young maltreated adolescents in foster care were found to have less fMRI activation than did controls in prefrontal brain regions associated with inhibitory control (e.g., anterior cingulate cortex) and in visual processing brain regions (e.g., occipital cortex; Bruce et al., 2013). However, these findings somewhat contrast with the findings from another study of young adolescents with severe institutional neglect: These adolescents were found to have greater activation in prefrontal brain regions (e.g., inferior frontal cortex, anterior cingulate cortex, striatum) for inhibitory control

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versus non–inhibitory control trials (Mueller et al., 2010). Although both studies provide evidence that early adversity affects functionality in the neural substrates of advanced cognitive skills, the conflicting directionality of the findings has yet to be reconciled in the literature. Measures (fMRI) of brain activation during a working-memory task have also been examined in children and adolescents exhibiting PTSD symptomatology following early interpersonal trauma (e.g., physical abuse, sexual abuse, witnessing violence; Carrión et al., 2010). Such findings suggest that the participants who had experienced adversity had significantly less hippocampal activation during memory retrieval compared with participants who had not experienced adversity. This reduced activation was also found to be related to PTSD symptoms, particularly in the avoidance/numbing cluster, further strengthening the potential implications of hippocampus hypoactivation as a potential link to memory abnormalities associated with early adversity (Carrión et al., 2010). Event-related potential (ERP) research has provided additional support for atypical functioning in prefrontal brain regions during challenging cognitive tasks. This research measures average electrophysiological activity at the scalp, which relates to specific task events and associated cognitive processes. Across samples facing early adversity (i.e., foster children and severely neglected institutionalized children), there is converging evidence that children exhibit slower executive attention–related ERP components that involve prefrontal attention processes (e.g., the N200; McDermott, Westerlund, Zeanah, Nelson, & Fox, 2012). This delayed neurocognitive response has been theorized to reflect a slower processing speed and has been associated with longer trial-reaction times. Early adversity has also been associated with reduced ERP responses related to attention and inhibitory control (e.g., the N200 and the P300), which have been theorized to reflect attention-regulation difficulties (Loman et al., 2013; McDermott et al., 2012). Although the aforementioned ERP components likely have multiple neural generators, prefrontal brain regions are critically implicated and theorized to coordinate activity across neural networks (Baumeister et al., 2014; Huster, Westerhausen, Pantev, & Konrad, 2010). The growing body of ERP research findings also suggests that prefrontal brain regions (e.g., anterior cingulate cortex) in children who have experienced early adversity function atypically during tasks that require performance monitoring (Bruce, McDermott, Fisher, & Fox, 2009; McDermott et al., 2012). Performance monitoring refers to increased attention to errors in performance on a given

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task and may include internal monitoring (internal awareness that an error has been made) and external monitoring (processing feedback that indicates the presence of an error). Specifically, during computerized inhibitory control tasks, children in regular foster care were shown to lack the expected ERP response following errors in performance versus correct trials. Notably, the adversity-related reduction in cognitive performance monitoring has been found for both internal and external monitoring processes. However, the children in therapeutic foster care (with additional intervention services) exhibited the expected exaggerated ERP response to errors for internal and external monitoring processes; this suggests that children who have experienced early adversity have the capacity for more normative cognitive processing in the presence of intervention and supports. The neurocognitive processing of emotional stimuli has also been shown to differ among children with histories of adversity. Across a wide range of ages (e.g., 15 months to 9 years), ERP research findings indicate that adversity is associated with exaggerated, later stage attentional processing of angry stimuli, including angry (vs. happy) faces and voices (Curtis & Cicchetti, 2013; Shackman, Shackman, & Pollak, 2007). Research findings using fMRI have also shown an exaggerated right amygdala response to angry faces in maltreated children compared with controls (Dannlowski et al., 2012). Multiple contributing factors have been proposed to understand these findings, including increased exposure to anger in adverse environments and hypervigilance to threat (Curtis & Cicchetti, 2013; Shackman et al., 2007). Research in the early stages of attentional processing has also shown evidence for the increased processing of happy faces in maltreated children, which has been theorized to reflect the heightened processing of emotional stimuli as an adaptation to emotional stress (Curtis & Cicchetti, 2013; McCrory et al., 2013). Other Physical Effects of Adversity Beyond documenting the effects of early adversity on neurobiological regulatory systems, findings from research on foster care also indicate that some of the most basic functions are disrupted by perturbations to the early environment. For example, researchers have found that young foster children show signs of so-called failure to thrive, as indexed by a shorter stature and a smaller head circumference compared with that of typical children (Pears & Fisher, 2005a). As with the aforementioned study findings, these findings match those obtained in investigations of

post–institutionally reared children and highlight the profound alterations that early adversity has on a child’s physical, brain, and biological development. The large-scale, population-based Adverse Childhood Experiences Study (ACES) has illuminated the general gradient between the cumulative number of adversity categories that an individual has suffered and the deleterious effects on many domains of adult health and well-being (Anda et al., 2006). In this study, the measure of adverse experiences included childhood maltreatment and general household dysfunction (e.g., adult in household with mental illness, incarceration, substance use problems, suicide, violence against the mother). The cumulative-risk approach used by the ACES investigators is particularly useful given that childhood adversity categories typically co-occur at rates as high as 80% to 98% (Dong et al., 2004; Pears, Kim, & Fisher, 2008). A range of health problems has been found to be overrepresented in population-based survey data in samples of adults with four or more adversity categories (Felitti et al., 1998). They include heart disease, obesity, high blood pressure, allergies, arthritis, asthma, circulation problems, ulcers, chronic pain, and cancer. However, not all studies have found increased risk for every health problem (Chartier, Walker & Naimark, 2010; Felitti et al., 1998; Springer, Sheridan, Kuo, & Carnes, 2007). A challenge in interpreting the causal links between childhood experiences and poor adult health in populationbased studies is the fact that ACES also includes risk for adulthood-specific, health-threatening behavior (Arnow, 2004; Felitti et al., 1998; Springer et al., 2007). In addition, epidemiological research findings suggest that some of the negative physical-health outcomes associated with abuse (e.g., arthritis, obesity, cardiovascular health) may be associated with developmental exposure to harsh physical punishment, which does not meet severity criteria for maltreatment (Afifi, Mota, MacMillan, & Sareen, 2013). This suggests that some of the effects of early adversity among foster children and others may exist along a continuum of stressors with potential detrimental effects at levels even below maltreatment thresholds. However, recent research findings also suggest multiple biological pathways that are perturbed in adulthood based on childhood maltreatment status. This research includes the effects of child maltreatment and physical health from clinical adult populations that are referred for specific medical problems. It also includes evidence from matched-cohort designs of children with substantiated maltreatment and community controls (Davis, Luecken, & Zautra, 2005; Widom, Czaja, Bentley, & Johnson, 2012).

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One prospective study has followed children with a documented adversity history and community controls to adulthood, examining blood, vision, and respiratory biomarkers of health risk and controlling for a number of sociodemographic and lifestyle variables (Widom et al., 2012). This study found increased risk for diabetes (indexed by higher levels of poor glycemic-control blood levels), lung disease (indexed by poor peak airflow), and vision problems (indexed by an acuity test) in adults who experienced early adversity. The race and gender interactions suggested that women were at particular adversity-related risk for poor glycemic control and that White adults were at increased adversity-related risk for heart disease (as indexed by C-reactive protein). Other research on pubertal timing has highlighted the impacts of early adversity on developmental physical processes, with early neglect being associated with slowed pubertal development that later increased in boys; in contrast, sexual abuse was specifically associated with early pubertal timing for girls (Negriff, Blankson, & Trickett, 2014). A specific focus on the biological bases of pain perception has been studied, given the diverse types of pathological presentations that include chronic pain (e.g., chronic pelvic pain, fibromyalgia, migraines) that are found to be overrepresented in samples with histories of adversity (Arnow, 2004; Davis et al., 2005; Tietjen et al., 2010; Walker et al., 1997; Walker et al., 1998). Evidence and theory suggest that a history of adversity may result in increased vulnerability to experiencing pain through stress-related hormonal processes (Arnow, 2004; Fisher, Gunnar, Dozier, Bruce, & Pears, 2006; Nicolson, Davis, Kruszewski, & Zauta, 2010). Research among adult women with fibromyalgia, a chronic pain condition without a known medical explanation, has shown that self-reported childhood maltreatment is associated with higher diurnal cortisol levels compared with women without maltreatment histories. This suggests that, although the dysregulated HPA-axis functioning may not be a contributing factor to fibromyalgia in all women, it may be a contributor or indicator of fibromyalgia risk in women who have experienced maltreatment. Genetic Research Related to Adversity Among the most noteworthy developments in recent years is the discovery of specific genetic vulnerabilities that may be responsible for poorer outcomes among some individuals who have experienced early adversity (Banny, Cicchetti, Rogosch, Oshri, & Crick, 2013; Caspi et al., 2002; Cutuli, Raby, Cicchetti, Englund, & Egeland, 2013).

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In this research, genetic vulnerabilities often interact with early environmental adversity (G×E interactions) to predict negative outcomes more likely to occur in the presence of early adversity. In the first study to document this effect, Caspi et al. (2002) found that among individuals who had experienced early adversity, carriers of a low activity MAOA-1 allele were at particular risk for antisocial behavior. Follow-up research has shown that this polymorphism is associated with an exaggerated neurocognitive response to threat and reduced activity in the brain regions involved in emotion regulation, suggesting a heightened vulnerability to aggressive or reactive behaviors (McCrory et al., 2012). Other notable studies have focused on Gene × Environment interactions of early adversity that predict later life depression based on polymorphisms of the serotonin transporter gene, which influences the availability of the serotonin neurotransmitter at neuronal synapses (Banny et al., 2013; Cutuli et al., 2013). Additional research has shown that genetic variations relevant to neuroendocrine stress response predict dysregulation of stress-related hormones (e.g., cortisol) in maltreated, but not in nonmaltreated, samples (Cicchetti, Rogosch, & Oshri, 2011). Additional recent developments in the genetics literature include findings suggesting that early adversity may also affect the expression of specific genes (epigenetic effects), thereby modifying the blueprint for ontogeny provided by DNA (Essex et al., 2013). In rodent models, developmental exposure to maltreating caregivers can lead to changes in gene expressions related to neural growth, which is particularly important for prefrontal cortex development (Roth, Lubin, Funk, & Sweatt, 2009). The only study on early adversity to date in humans has shown support for epigenetic effects in adolescents related to maternal stress during the adolescent’s infancy and paternal stress when the adolescent was preschool age. The implications of these effects have yet to be established, with some changes occurring in genes with plausible links to family stress (e.g., genes coding for cellular differentiation in the nervous system) and others in genes with no identified links (Essex et al., 2013). Increased cellular aging, as indexed by reduced telomere length, has also been reported among adults with a history of early adversity; however, the mechanisms contributing to increased cellular aging have yet to be established (Tyrka et al., 2010). Summary This large body of evidence across research among high-risk populations that include foster and maltreated

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children suggests that early adversity contributes to profound changes in healthy biological, brain, and physical development. Recent genetic research findings suggest that certain phenotypes increase a child’s vulnerability to the effects of adversity on outcomes such as depression and antisocial behavior. At the neuroendocrine level, early adversity is well documented to contribute to dysregulation of the HPA axis and atypical patterns of cortisol in the body. The effects of dysregulated cortisol production are strongly supported by animal models to contribute to a range of neurocognitive and physical health consequences, which are commonly overrepresented in samples with histories of early adversity. Evidence of atypical cognitive processing from fMRI and ERP methods also supports the findings from the animal literature of increased adversity-related deficits in brain regions with higher densities of glucocorticoid receptors. Given the widespread effects of early adversity on developing bodily systems, it is particularly promising that early intervention has been shown to ameliorate atypical development of neuroendocrine and cognitive-response monitoring processes. Ongoing research in the area is seeking a more in-depth description of the underlying mechanisms, which could advance the ability of interventions to improve outcomes for individuals with histories of early adversity.

THE TIMING AND DURATION OF ADVERSITY IS ASSOCIATED WITH DIFFERENTIAL BEHAVIORAL AND NEUROBIOLOGICAL OUTCOMES, WITH A GENERAL TREND OF LONGER LASTING ADVERSITY PRODUCING THE MOST PROFOUND EFFECTS Although the animal literature contains extensive information about the timing and duration of effects of adversity on typical development, research with humans is much less suited for characterizing how such dimensions of adversity lead to alterations in key domains of functioning. However, research on foster care provides some information in this area. Consistent with findings from the institutional-rearing and international-adoption literatures, research findings about foster children indicate that increased time spent in adversity increases the likelihood for compromised outcomes. For example, children in the previously described NSCAW sample who lived in maltreating families longer (placed in foster care at older ages) showed more behavior problems than did those placed in care at younger ages (Burns et al., 2004). Perhaps what is most noteworthy about these results is that the effects

of prolonged exposure to adversity appear to outweigh the effects of out-of-home placement. Other research on symptoms of serious psychopathology, such as borderline personality disorder, also suggests that the chronicity of adversity is particularly predictive of negative outcomes (Hecht, Cicchetti, Rogosch, & Crick, 2014). Moreover, research with a large cohort of public-school children has shown that earlier onset adversity is linked to increased academic problems (Fantuzzo, Pearlman, & Dobbins, 2011). Although evidence across studies shows that the chronicity and earlier onset of adversity are related to more severe behavioral problems, research findings also suggest that the timing of certain types of maltreatment predicts distinct behavior problem trajectories (Keiley, Howe, Dodge, Bates, & Pettit, 2001; Manly, Kim, Rogosch, & Cicchetti, 2001). In particular, the severity of physical neglect in infancy has been related to later developing externalizing behavioral problems, whereas the severity of physical neglect in the preschool years has been related to later developing internalizing problems. In this same study, emotional abuse in infancy and physical abuse in the preschool years were related to externalizing problems. It is important to note that maltreatment in the school years contributed significant variance to behavioral problems after controlling for earlier maltreatment, suggesting that although earlier onset maltreatment might be the most harmful, later maltreatment also contributes to significant behavioral problems (Keiley et al., 2001). In growth models of behavioral problems, children who experienced later onset maltreatment have been shown to exhibit a more rapid increase in externalizing behavior despite having fewer behavioral problems at kindergarten entry. Supportive evidence about the importance of the timing and duration of adversity can be derived from international studies such as The English and Romanian Adoptee (ERA) Project. The ERA Project investigated the development of Romanian children adopted into the United Kingdom in the early 1990s. The vast majority of the adoptees had experienced extreme early global deprivation up to age 42 months as a consequence of their early placement in Romanian institutions (Rutter et al., 2010). However, there was greater catch-up among children who were adopted prior to age 6 months (Rutter et al., 2010). Overall, the research in this area corroborates evidence from the animal literature and highlights the vulnerability of children to early and prolonged adversity. In addition to the behavioral consequences associated with a longer duration of adversity, exaggerated adversity-related effects on brain development have been documented. Specifically, in a study of children with

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maltreatment and PTSD, researchers found that smaller brain volume was associated with a longer duration of maltreatment and an earlier onset of PTSD-related trauma (De Bellis et al., 2002). Relatively little research has been conducted about the effects of the timing of adversity on brain development, but findings from neuroimaging studies suggest that timing may be important given the differential development of specific brain regions across childhood (Pechtel & Pizzagalli, 2011). For example, in young adult females who experienced childhood sexual abuse, the abuse has been shown to predict different impacts on regional brain volume associated with timing of exposure (Andersen et al., 2008). Sexual abuse in very young children (ages 3–5 years) and early adolescence (ages 11–13 years) was shown to be associated with smaller hippocampal volume, whereas abuse in other age groups was shown to be associated with reduced volume in the corpus callosum (ages 9–10 years) and the prefrontal cortex (ages 11–13 years). Such changes are theorized to reflect the fact that brain regions may be differentially developing at distinct time points and, accordingly, may be differentially vulnerable based on the timing of maltreatment. However, as noted by Pechtel and Pizzagalli (2011), the specific mechanisms underlying such time-sensitive structural abnormalities have been minimally described despite extant theory related to the role of neurogenesis, myelination, and synaptic pruning. The importance of timing has also been highlighted in a study investigating maltreatment-related declines in brain volume of the amygdala, thalamus, and caudate (Pechtel, Lyons-Ruth, Anderson, & Teicher, 2014). In early adulthood, participants (maltreated and control) were asked to recall specific maltreatment periods in their childhood to understand the importance of timing and severity on brain volume. Although the thalamus and caudate volumes were not different in the maltreated group, right amygdala volume was significantly larger in individuals who experienced childhood maltreatment, with larger volume associated with increased severity of maltreatment. Furthermore, a sensitive preadolescent period (ages 10–11 years) with even moderate maltreatment exposure contributed to increased right amygdala volume. The authors noted that the right (vs. left) amygdala exhibits a prolonged developmental trajectory and has been shown to be particularly sensitive to maternal prenatal stress (Pechtel et al., 2014). Furthermore, multiple fMRI studies have demonstrated maltreatment associated hyperreactivity of the amygdala to emotional stimuli (Dannlowski et al., 2012; van Harmelen et al., 2013). Based on animal studies, researchers have highlighted the potential significance

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of the preadolescent/prepuberty period for its increased neural pruning, but the mechanisms contributing to such a sensitive period are unknown (Pechtel et al., 2014). Taken together, these results strongly suggest that the duration and severity of maltreatment are associated with increased aberrations from typical development. Theory suggests the potential importance of timing on different outcomes associated with the changing developmental processes of the body and brain (Pechtel & Pizzaglli, 2011). However, the evidence for such impacts in humans is just emerging. Multiple methodological challenges must be overcome to examine and understand the impacts of timing, including recruitment of sufficient sample sizes of at-risk children and the potential for regionally specific effects, which require the development of specific hypotheses to detect potential differences (Teicher & Samson, 2013).

NEGLECT IS A PARTICULAR CAUSE FOR CONCERN BECAUSE OF ITS PERVASIVENESS AND ITS PROPENSITY TO DISRUPT HEALTHY DEVELOPMENT AND EXERT A LASTING IMPACT ON HEALTH AND WELL-BEING One of the lesser known characteristics of the foster care population, but one that has been the focus of research and public policy in recent years, is that many children are placed in out-of-home care because of neglect (e.g., failure to provide age-appropriate care, food, shelter, healthcare, supervision, or safety precautions) rather than physical and sexual abuse. Neglect is nearly ubiquitous among foster children—for example, more than 78% of foster children are estimated to be in care because of neglect alone, and nearly all those in care because of abuse have experienced neglect (U.S. Department of Health and Human Services, 2012). Moreover, neglect—even in the absence of other maltreatment—appears to represent a serious threat to the health and well-being of young children. Neglect is an interesting phenomenon from a developmental perspective because it represents an omission of expected caregiving input rather than a commission of an act of physical or sexual violence toward the child. Because neglect is not an overt form of abuse and leaves no physical marks, the damage resulting from prolonged neglect may be more difficult to detect. However, as reviewed later, there is increasing evidence that neglect represents a threat to mental and physical development, which may become apparent in later years as the child experiences delays and is unable to keep pace with peers on key tasks of cognitive,

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physical, or socioemotional development. The difficulty detecting neglect, especially among infants and toddlers who lack the language to describe their experiences, is one of neglect’s most concerning qualities. It is important to qualify any discussion of neglect by noting that neglect does not occur when a parent is unresponsive intermittently but otherwise consistent in providing care and promoting a loving environment. Intermittent inattentiveness is not cause for concern; rather, it may have the potential to promote independence in the child and increase the child’s ability to self-soothe and problem solve. Similarly, variability in the attention given to the child by the parent has been shown to benefit the child. Such variability in an otherwise nurturing environment represents positive stress that has been shown to be beneficial to children as young as age 6 months (Tronick & Gianino, 1986). One way to understand why neglect is so impactful is to consider the importance of adult–child interaction in development. Development in childhood is hierarchical in nature. Early skills develop out of consistent and nurturing interactions with caregivers, and these skills lead to later success and aptitude in academics, physical achievement, and control of the surrounding social environment (Shonkoff, Garner, et al., 2012). Neglect essentially represents the absence of evolutionarily expected environmental input. Much of the research on the effects of neglect has not been specific to foster care; however, when compared with the general population, neglected children are clearly overrepresented in foster care. Moreover, neglect samples often contain many children currently in care or with a history of child welfare involvement. Research on samples of neglected children has consistently found that neglect is associated with numerous effects on development, health, and well-being (Horwitz, Widom, McLaughlin, & White, 2001). For example, the longitudinal Minnesota Mother–Child Project examined 267 children born to mothers who, for various reasons, were at risk for neglectful or psychologically reserved parenting, that is, psychologically unavailable mothers and neglectful mothers who failed to provide physical care and protection to their child. When these two groups of mothers were compared with other maltreatment groups, the neglected children performed the worst on the Bayley Scales of Infant Development from 9 to 24 months of age (Egeland & Sroufe, 1981; Hildyard & Wolfe, 2002). The neglected children also possessed more behavioral problems, including frustration and anger in problem solving. At age 48 months, the neglected children showed poor impulse control on an obstacle task and showed less creativity in problem solving.

Neglected children’s academic and cognitive abilities suffered as well (Gowen, Christy, & Sparling, 1993). De Bellis et al. (2009) investigated the academic performance of neglected children and that of their nonneglected peers. The neglected children performed significantly lower on measures of intelligence. In addition, neglected children lacked aptitude in tasks that measure memory for faces, names, and narratives. Egeland and Sroufe (1981) examined the attachment behavior of 31 maltreated children and 33 nonmaltreated children, based on attachment theory. During feeding and play, all the children of mothers who lacked the basic skills in caring for their child were anxiously attached and in the avoidant attachment group at age 12 months. The authors further noted that following DHS intervention to remove the child from the home for some period of time, the mother was totally psychologically unavailable. Rutter et al. (2010) noted the co-occurrence of many symptoms of neglect and identified a specific behavioral phenotype among children who had experienced institutional deprivation (a severe form of neglect neglect) that included symptoms of quasi-autism, disinhibited attachment, cognitive impairment, and inattention/overactivity. In institutional settings, neglect can be especially extreme (a condition referred to as privation). According to UNICEF, an estimated 1.5 million children in Central and Eastern Europe live in public care institutions, where it is typical for children to outnumber caregivers 15 to 1. In many contexts, caregivers work 8-hour shifts, meaning that the limited contact the child receives is provided by a changing “cast of characters.” Research on children reared in institutional settings provides evidence that neglect affects neurobiological development. For example, Tottenham et al. (2010) examined the whole brain and limbic structures (amygdala and hippocampus) of children adopted following early institutional care versus a healthy comparison group. Measures used included indicators of emotion regulation, anxiety, and internalizing behavior. Results indicated that the later a child was adopted, the more psychiatric disturbances were associated with larger amygdala volumes, poorer emotion regulation, and increased anxiety. The ability to recover from neglect varies depending on the specific experiences of the child and on genetic factors. The environment that the child enters after being exposed to neglectful conditions can benefit or hinder such recovery. The more stimulating the home and the more supportive the caregivers are, the better the child’s chance to catch up with peers (Bradley & Caldwell, 1984). Foster care, when paired with supportive parenting programs,

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The Combined Effects of Prenatal Stress

offers a first step for promoting learning and development in neglected children.

TRANSITIONS AMONG PRIMARY CAREGIVERS ARE A SPECIFIC CLASS OF ADVERSE EXPERIENCE WORTHY OF ATTENTION BECAUSE THEY APPEAR TO NEGATIVELY AFFECT THE DEVELOPMENT OF KEY COGNITIVE AND BEHAVIORAL SKILLS NEEDED FOR SOCIAL AND ACADEMIC SUCCESS Although the child–caregiver attachment system has been investigated extensively in the literature, it is most often assessed within the context of the child’s relationship with permanent primary caregivers (e.g., biological or adoptive parents). In contrast, foster care research uniquely allows us to examine the pliability of the attachment system in children across multiple caregiver relationships. Indeed, within the context of foster care, transitions between caregivers are common: One to two thirds of foster placements disrupt within 12–24 months of placement, for various reasons (Wulczyn, Hislop, & Chen, 2007). In addition to uncontrollable child problem behavior, other variables appear to cause placement failures. In a study about this topic, Oosterman, Schuengel, Slot, Bullens, and Doreleijers (2007) conducted a meta-analysis of research involving more than 20,000 foster children. In addition to child problem behavior, the strongest predictors of placement failure were older age at placement, history of residential treatment, and number of prior placements. Similarly, Fisher, Burraston, and Pears (2005) found that placement instability essentially begets further instability. Placement transitions in foster care also result from administrative decisions (e.g., siblings subsequently being removed from the birth parents and placed into care). Moreover, even positive changes, such as reunification with birth parents or adoption, represent caregiver transitions. Regardless of the cause, caregiver transitions appear to have the potential to compromise typical development. Rubin, O’Reilly, Luan, and Localio (2007) examined placement instability among NSCAW children and categorized the children according to whether or not they achieved a stable placement within 18 months in out-of-home care. They found that more than one quarter of the sample failed to achieve a stable placement and that placement instability predicted problem behavior, as assessed using the Child Behavior Checklist. Specifically, placement instability resulted in a 63% increase in problem behavior. In a second study, Chamberlain et al. (2006) found that the

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number of behavior problems was directly related to the number of placement disruptions. Placement disruptions have also been shown to contribute to foster child inhibitory-control difficulties. Pears, Bruce, Fisher, and Kim (2010) reported that among a sample of foster preschoolers, the number of unique placements a child had experienced was significantly correlated with inhibitory control problems. These inhibitory control problems were noted as being part of a more general set of difficulties with self-regulation that included indiscriminate friendliness. Similarly, Lewis, Dozier, Ackerman, and Sepulveda-Kozakowski (2007) examined inhibitory control in a sample of foster children who were adopted following care, including children with and without a history of placement instability. They found that the children with a history of placement instability (vs. that of the comparison group) performed more poorly on a measure of inhibitory control derived from a day/night Stroop task and were rated as more oppositional (although inhibitory control did not mediate the association between placement instability and oppositional behavior). To summarize, research on foster children provides evidence that experiencing caregiver transitions has the potential to disrupt healthy child development. In particular, the literature suggests that such transitions are associated with an increased likelihood for disruptive behavior and inhibitory-control difficulties. These findings provide evidence that this particular form of adversity may interfere with the development of regions of the prefrontal cortex involved in executive functioning, suggesting that policy and programming designed to mitigate risks for foster children (and others) should seek to prevent or reduce the number of caregiver transitions that children experience.

THE COMBINED EFFECTS OF PRENATAL STRESS (ESPECIALLY PRENATAL SUBSTANCE EXPOSURE) AND EARLY ADVERSITY ON NEUROBEHAVIORAL DEVELOPMENT ARE ADDITIVE AND PRODUCE WORSE OUTCOMES THAN PRENATAL STRESS OR EARLY ADVERSITY ALONE Although research on foster children and other samples experiencing early neglect/deprivation provides a strong case for the cumulative effects of adversity on typical development, one noteworthy aspect of this evidence base is that it focuses almost exclusively on experiences that occur after the birth of the child. In reality, for many

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foster children, adversity begins at conception, continues throughout pregnancy, and is ongoing antenatally. An extensive literature involving animal models and humans documents the effects of prenatal adversity (particularly substance use) on biobehavioral development (Thompson, Levitt, & Stanwood, 2009). However, to be consistent with the natural ecology of foster children (and many other high-risk populations), modeling the combined effects of prenatal and early adversity is a necessary addition to examining separately the effects of either developmental period. Interestingly, relatively limited research has been conducted in this area.

in care within 1 month of birth. Similarly, in a study of high-risk mother–infant dyads recruited at birth, Eiden, Foote, and Schuetze (2007) found that 19.1% of the infants prenatally exposed to cocaine entered foster care within 1–2 months of birth. Prenatally exposed infants are also likely to be exposed to postnatal parental substance use and its attendant risk for neglect (Dunn et al., 2002) and primary caregiver transitions (Bauer et al., 2011). They also have a high propensity to be placed in foster care, where they often experience further placement transitions (Smith, Johnson, Pears, Fisher, & DeGarmo, 2007).

Foster Care as a Context for Prenatal Substance Exposure

Methodological Challenges to Research on Prenatal Substance Exposure

Foster care provides an excellent context for examining the combined effects of prenatal substance exposure and early adversity: Estimates are that between 43% and 79% of the parents of foster children meet criteria for a substance use disorder (Besinger, Garland, Litrownik, & Landsverk, 1999; Young, Boles, & Otero, 2007). Also, 80% to 90% of cases of neglect reported to child welfare involve parental substance use disorder (Dunn et al., 2002). Thus, it is likely that for many foster children, parental substance use occurred at least intermittently if not throughout pregnancy. Indeed, evidence for this exists in the literature. For example, in a study of 204 infants placed in family foster care at ages 0–15 months, prenatal substance exposure was verified for 61.7% and suspected for 16.7% of the infants (McNichol, 1999). Similarly, in a foster care population in Washington state, the rate of fetal alcohol syndrome was 10–15 times greater than in the general population (Astley, Stachowiak, Clarren, & Clausen, 2002). In response to the recognized prevalence rates of prenatal substance exposure and the risks associated with such exposure, 19 states and the District of Columbia have implemented mandatory reporting procedures at birth for prenatally exposed infants, and 12 states and the District of Columbia define prenatal exposure as child abuse or neglect (Child Welfare Information Gateway, 2011). Perhaps owing to the vigilant use of these indicators of prenatal exposure at the birth of a child, these infants are some of the youngest foster children. For example, McNichol (1999) found that infants with verified prenatal substance exposure (verified by maternal self-report or toxicology tests at birth) were placed in foster care at a significantly earlier mean age (3.8 months) than were infants with suspected prenatal exposure (5.6 months) and infants with no suspected exposure (5.9 months). Further, nearly half of the prenatally exposed infants were placed

Before considering the combined influences of prenatal and early adversity on foster children, we briefly review prenatal substance exposure and its major short- and long-term effects. The majority of research on prenatal exposure has considered the effects of alcohol, tobacco, cocaine, methamphetamine, marijuana, and opiates on the developing fetus. Epidemiological evidence suggests that alcohol (10%) and tobacco (16.7%) are the most common substances consumed by pregnant women (Substance Abuse and Mental Health Services Administration, 2009). There are a number of challenges to definitively predicting the impact of prenatal exposure on infant outcomes. First, the quantity, frequency, and timing of prenatal substance use vary across women, and drug effects on fetal development vary by stage of gestation, with more significant teratogenic effects being observed during the embryonic stage (particularly in the case of alcohol) and more subtle effects being observed during the fetal period (Behnke, Smith, Committee on Substance Abuse, & Committee on Fetus and Newborn, 2013). Moreover, some pregnant women eliminate substance use when they learn of their pregnancy, (although this may not occur until well into the pregnancy, whereas others never desist from substance use [Massey et al., 2011]). Rates of prenatal substance use also vary by age group, with past-month alcohol and illicit drug use levels being higher for pregnant teenagers ages 15–17 years, compared with adults ages 18–25 years (Substance Abuse and Mental Health Services Administration, n.d.). Efforts to disentangle the effects of prenatal substance exposure on biobehavioral development are complicated by a number of issues. First, the reality is that most prenatal substance exposure involves multiple substances (Lester, Andreozzi, & Appiah, 2004). In spite of the fact that the literature reports many studies that are designed to investigate the effects of a specific substance (e.g., alcohol,

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cocaine) on the fetus, a great many of the individuals in the samples that have been gathered are polysubstance exposed. There are advantages and disadvantages of this methodological strategy. On the positive side, polysubstance exposure appears to be something of a reality for many women who use alcohol, tobacco, and illicit drugs during pregnancy. Moreover, some studies have attempted to control for the effects of substances that are not the focus of the investigation by using statistical covariation. Nevertheless, it is not clear that the extant knowledge base involving humans provides a clear picture of the effects of specific substances on development. Although it is difficult to find nationally representative statistics for polysubstance exposure, several studies highlight this phenomenon as it manifests in high-risk and child welfare–involved families. In the Infant Development, Environment, and Lifestyle (IDEAL) longitudinal study of prenatal methamphetamine exposure, women who used methamphetamine (vs. those who did not) consumed significantly more tobacco (71% vs. 25%), alcohol (49% vs. 16%), and cannabis (43% vs. 8%) during pregnancy (Derauf et al., 2007). Among women referred to a perinatal addiction outpatient clinic in the United Kingdom, 49% were polysubstance users of at least two of the following drugs: heroin, cocaine, alcohol, cannabis, and methamphetamine (Mayet, Groshkova, Morgan, MacCormack, & Strang, 2008). In a study of a 3-year home visitation intervention for mothers with alcohol or other drug problems during pregnancy (N = 458), the women used tobacco (90%), alcohol (73%), cocaine (63%), cannabis (63%), and methamphetamine (42%; Grant et al., 2011). Despite the prevalence of prenatal polysubstance exposure, the mechanisms by which multiple substances interact to influence fetal development are not yet understood (Lester et al., 2004). A related issue that complicates research in this area is that prenatal substance exposure is likely to co-occur with many other known stressors. For example, prenatal nutrition may be inadequate for many of these infants. Poverty, domestic violence or other relationship stress, and other environmental stressors may also be present. These variables may represent confounds in the assessment of prenatal exposure.

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to alterations in the development of the fetal brain and autonomic nervous system. This is a logical supposition, inasmuch as substances used by the mother cross the placenta, where they may exert specific or individual effects (Behnke et al., 2013; Lester et al. 2004). In their model of the developmental effects of prenatal substance exposure, Lester and colleagues (2004) proposed that immediate drug effects emerge in early infancy (before the postnatal environment becomes influential) and may be transient or long lasting. For instance, tobacco use has twice the impact on infant birth weight compared with illicit drug use (Bailey, McCook, Hodge, & McGrady, 2012). However, by age 24 months, few studies find effects of fetal tobacco exposure on physical growth (Behnke et al., 2013). As an example of a longer lasting immediate drug effect among prenatally exposed (cocaine) children, high neonatal arousal and stress (an immediate drug effect on neonatal neurobehavior) have been indirectly associated with increased problem behavior at ages 3 and 7 years via difficult temperament at age 4 months (Lester et al., 2009). Lester and colleagues (2004) argued that in addition to immediate drug effects, latent drug effects can be observed later in development in the context of brain and behavior effects specific to older children. For instance a recent meta-analysis revealed a significant association between any binge alcohol exposure (≥4 or ≥ 5 drinks per occasion) during pregnancy and negative child cognition outcomes between ages 6 months and 14 years (Flak et al., 2014). These researchers also observed a significant, detrimental association between moderate prenatal alcohol exposure (“up to 6 drinks per week, including some individuals who consumed at least 3 drinks per week,” p. 215) and child behavior between ages 9 months and 5 years. During the transition to adolescence, prenatally exposed youths demonstrate an especially pronounced vulnerability to substance use. For example, in a prospective longitudinal study, Cornelius, Goldschmidt, and Day (2012) found that prenatal exposure to cigarette smoking at all three trimesters predicted earlier child smoking experimentation at age 10, heavier smoking at age 14, and higher rates of smoking and addiction to nicotine at age 22, all while accounting for prenatal exposure to other drugs. Parallel outcomes have been observed among adolescents prenatally exposed to alcohol (Behnke et al., 2013).

Developmental Outcomes of Prenatal Substance Exposure In spite of the limitations in the research methodology, research on prenatal exposure has yielded a considerable amount of important information. In general, the adverse effects of prenatal substance use are attributed

Developmental Outcomes of Prenatal Exposure Among Children With Foster Care Histories Prenatally exposed foster children tend to demonstrate more latent drug effects than do their prenatally exposed

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peers in stable living arrangements, suggesting that prenatal effects are compounded by subsequent experiences. For example, in a prospective longitudinal study from birth, prenatally exposed 6-year-olds (n = 169) self-reported more symptoms of oppositional defiant disorder and ADHD than did nonexposed children (n = 153; Linares et al., 2006). Further, prenatally exposed children in adoptive or foster care (n = 36) self-reported significantly more externalizing symptoms than did nonexposed children (n = 153) and prenatally exposed children living in maternal or relative care (n = 133; Linares et al., 2006). Notably, the sample in the studies by Linares and colleagues was specifically selected for prenatal cocaine exposure. Several prospective longitudinal studies from birth have followed prenatally exposed children with a foster care history into adolescence. In one study of prenatally exposed versus nonexposed adopted children (some adopted from foster care and others from private agencies or other means), the prenatally exposed adolescents exhibited significantly more externalizing problem behavior, according to parent reports 14 years postadoption (Crea, Barth, Guo, & Brooks, 2008). In another prospective longitudinal study, pregnant women considered to be at risk for prenatal substance use were recruited at the child’s birth (Min, Minnes, Yoon, Short, & Singer, 2014). Behavioral adjustment at ages 12 and 15 years was compared between subsamples of prenatally exposed (cocaine) and nonexposed youths. Controlling for covariates, including prenatal exposure to alcohol, tobacco, and cannabis, prenatal exposure was associated with more externalizing behavior problems at ages 12 and 15 years and with more attention problems at age 15 years. Consistent with findings from Linares et al. (2006), the prenatally exposed adolescents in nonkinship foster or adoptive care (23% of the prenatally exposed adolescents) reported significantly more externalizing and attention problems than did nonexposed adolescents in nonkinship foster or adoptive care (4.5% of the nonexposed adolescents) at ages 12 and 15 years (Min et al., 2014). Behavioral maladjustment in prenatally exposed (cocaine) adolescents in nonkinship foster or adoptive care occurred despite these caregivers having higher educational attainment and less substance use than biological/relative caregivers of prenatally exposed youths had (Min et al., 2014). There are several possible explanations for this finding. In keeping with the developmental model proposed by Lester and colleagues (2004), the heightened behavioral maladjustment of prenatally exposed (cocaine) adolescents in foster or adoptive care could reflect latent effects of prenatal cocaine exposure on fetal nervous-system

development. In addition, prenatally exposed youth may have endured more severe or persistent early adversity than did their nonexposed peers. This heightened early adversity, in turn, may have contributed to their entry into foster care and to their long-term biobehavioral development. Taken together, the findings from these studies of children with foster care histories illustrate the importance of understanding the effects of prenatal substance exposure in the context of the child’s early caregiving environment. The Combined Effects of Prenatal Substance Exposure and Early Adversity Beyond understanding the immediate and latent effects of specific drugs, it is important to identify risk and protective factors in the postnatal caregiving environment that moderate prenatally exposed children’s developmental outcomes (Lester et al., 2004). Research on the combined effects of prenatal and early adversity is in its early stages. Commonly, studies that account for the postnatal environment in their analyses have conceptualized the environment as a variable that must be controlled to isolate the independent effects of prenatal exposure to a specific substance. These studies are frequently motivated by behavioral-teratology questions. However, a few studies have considered the independent, mediated, and moderated effects of prenatal exposure and early adversity on developmental outcomes from infancy into adolescence. Research findings about aspects of the postnatal environment that mitigate prenatal-exposure effects on child outcomes suggest important directions for future research and prevention in this area. In the remainder of this section, we provide a representative summary of existing evidence about the combined effects of prenatal exposure and early adversity in samples of children recruited on the basis of prenatal exposure—some that included children with histories of foster care and some that focus exclusively on foster children. Independent Effects of Prenatal Exposure and Early Adversity Lambert et al. (2013) examined the effects of prenatal exposure and other demographic and environmental risk factors on risk-taking behavior among 963 adolescents in the Maternal Lifestyle Study, a multisite, longitudinal cohort study that examined prenatal exposure effects in a sample that included 433 prenatally exposed (cocaine) infants and 530 nonexposed infants. Children in this landmark study, many of whom had contact with the child

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welfare system or a history of placement in foster care, have been followed from birth through the transition to adulthood, with multiple waves of data collection. The assessment includes developmental and behavioral indicators of adjustment and measures of neurobiological functioning. Analyses of this data set have revealed that prenatal cocaine exposure, caregiver socioeconomic status (SES), and male child gender predicted increased odds of being arrested by age 15 years. In contrast, prenatal exposure to cocaine, alcohol, tobacco, or cannabis did not predict increased odds of adolescent alcohol, tobacco, or marijuana use. Rather, other demographic or environmental variables, such as having friends who used each drug, predicted adolescent substance use behaviors. For instance, caregiver abuse, number of caregiver changes, and having friends who used alcohol predicted increased odds of alcohol use at age 15 years. In the case of sexual risk-taking behavior at age 15 years, only prenatal exposure to cocaine or cannabis was predictive. Taken together, community violence, low parental involvement, male child gender, and other postnatal demographic and environmental factors contributed more to the prediction of sexual risk-taking behavior than did prenatal exposure (Lambert et al., 2013). Using data from the same study, Conradt et al. (2014) found that prenatal polysubstance exposure and early adversity did not relate to physiological correlates of behavioral and emotional problems in early childhood or adolescence. However, prenatal polysubstance exposure and early adversity related (differently for males and females) to neurobehavioral outcomes at age 13 years that were associated with risk-taking behavior at age 16 years. Additional information about the combined effects of prenatal substance exposure and early adversity— specifically among foster children—can be derived from a Norwegian study. This prospective, longitudinal investigation of children prenatally exposed to opiates and other substances examined the effects of prenatal exposure on cognitive development at age 4.5 years (Moe, 2002). The sample for this study was considerably smaller than that of the aforementioned study by Lester and colleagues (2009). It consisted of 64 children who were prenatally exposed and 58 in the comparison group. Of the prenatally exposed group, 79.7% were diagnosed with a neonatal abstinence syndrome (i.e., withdrawal) and 84.6% were placed in foster care during infancy. The foster caregivers were recruited specially to provide care for at-risk infants, enabling the researchers to examine the effects of prenatal exposure under conditions of minimal postnatal risk. There was a significant interaction between male child gender

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and prenatal substance exposure such that boys in the prenatal-exposure group demonstrated the lowest general cognitive ability and the lowest perceptual, memory, and motor scores on the McCarthy Scales of General Ability. For the whole sample, prenatal exposure, foster-caregiver SES, gestational age, and mental development at age 1 year were independently associated with lower perceptual performance at age 4.5 years. However, prenatal exposure was not associated with general cognitive ability when these postnatal predictors were added to the model. Rather, only parental SES and mental development at age 1 year predicted general cognitive ability scores. It appears that, especially for girls, specialized foster care may have been protective of the effects of prenatal exposure on general cognitive ability. However, more research on larger samples is necessary to adequately understand the gender effects that were observed. Early Adversity as a Mediator of the Effects of Prenatal Substance Exposure In addition to the previously described work that has examined the separate effects of prenatal exposure and early adversity, several studies have examined early adversity as a mediator of the association between prenatal exposure and neurobehavioral disinhibition in childhood and adolescence. Mediation assumes that the developmental consequences of prenatal exposure are partly explained by the adverse postnatal conditions typically associated with maternal substance use during pregnancy. In two studies on this subject (Abar et al., 2012; Fisher et al., 2011), early adversity was assessed as a summative risk index that measures the presence of postnatal parental substance use, chronic poverty, primary caregiver changes, community violence, sexual/physical abuse, and other risk factors. Using data from the Maternal Lifestyle Study, Fisher et al. (2011) examined the emergence and growth of a phenotype termed neurobehavioral disinhibition across the transition to adolescence among prenatally polysubstance-exposed youths who experienced early adversity. The neurobehavioral disinhibition construct included a composite measure of behavioral dysregulation and a composite measure of executive-function difficulties. They found that behavioral dysregulation at age 8/9 years predicted growth in executive function difficulties from age 8/9 years to age 13/14 years. Prenatal polysubstance exposure predicted the onset and growth of neurobehavioral disinhibition across adolescence. In the case of behavioral dysregulation, prenatal exposure directly predicted growth of neurobehavioral disinhibition across

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adolescence. In the case of executive function difficulties, prenatal exposure was indirectly related to growth in these difficulties through early adversity. Specifically, prenatal polysubstance exposure was related to early adversity, early adversity was related to behavioral dysregulation at age 8/9 years, and behavioral dysregulation at age 8/9 years was related to growth in executive function difficulties across the transition to adolescence. Fisher et al. noted that prenatally exposed youths who enter adolescence with behavior problems may be particularly likely to experience executive function difficulties. Abar et al. (2012) obtained similar findings among younger prenatally exposed children in the Infant Development, Environment, and Lifestyle study of prenatal methamphetamine exposure. In this study, prenatal methamphetamine exposure was indirectly associated with behavioral/emotional control problems at age 5 years and executive function deficits at age 6.5 years through early adversity experienced from birth to age 3 years. That is, children prenatally exposed to methamphetamine were likely to be exposed to early adversity, which was then associated with increases in behavioral/emotional control problems and executive function deficits. Prenatal exposure was not related to these neurobehavioral outcomes when early adversity was included in the model. Postnatal Risk and Protective Factors That Moderate the Effects of Prenatal Substance Exposure Among samples recruited on the basis of prenatal exposure, converging evidence suggests that postnatal family and community adversity can exacerbate the association between prenatal exposure and child outcomes. For example, a study by Lester et al. (2010) found that, at age 11 years, adolescents prenatally exposed to cocaine demonstrated lower elevations in cortisol in response to a laboratory stressor, controlling for prenatal and postnatal drug exposures. Exposure to parental domestic violence between ages 1 month and 11 years also predicted blunted cortisol reactivity to stress. In addition, domestic violence exposure acted as a moderator: Children prenatally exposed to cocaine who also witnessed parental domestic violence were more likely to exhibit blunted cortisol reactivity than were nonexposed children who witnessed domestic violence. This finding was replicated in a study by Fisher, Kim, Bruce, and Pears (2012): Among foster children with prenatal substance exposure, those who had experienced more maltreatment showed significantly lower cortisol elevations in response to a laboratory stressor. Together,

these findings suggest that the vulnerability of the HPA axis to environmental adversity may begin during the fetal period and extend through early childhood. In addition to neuroendocrine effects, there is evidence that combined prenatal and early adversity affect behavioral adjustment. For example, Bada et al. (2012) examined growth in behavior problems from ages 5 to 15 years among prenatally exposed (cocaine or opiate) youths in the Maternal Lifestyle Study. They also evaluated child, family, and community risk and protective factors that could moderate the effects of prenatal exposure on growth in child problem behavior across childhood and into adolescence. The risk factors included caregiver psychopathology, child abuse, male child gender, and postnatal exposure; the protective factors included caregiver involvement, family resources, and child resilience. The number of risk factors (total = 13) and protective factors (total = 9) were summed to create risk and protective indices, respectively. In addition to assessing the impact of risk and protective factors scored in this cumulative way, Bada et al. examined the combination of levels (high vs. low) of risk and protective indices. At child age 5 years, prenatal exposure (vs. nonexposure) was associated with increased externalizing problem behavior. Important to note, a high-risk index combined with a low-protective index contributed to the already-significant effects of prenatal exposure on behavior problems. In addition, among the prenatally exposed children, who had significantly higher total behavior problems at age 5 years, high or low risk in the presence of a high-protective versus low-protective index contributed to greater declines in total behavior problems throughout the study period. Similarly, in a small sample of 38 children younger than age 16 years who were placed in foster care because of prenatal alcohol exposure, Koponen, Kalland, and Autti-Rämö (2009) examined the role of the caregiving environment in child behavioral outcomes. In this investigation, 82% of children were prenatally exposed to alcohol only; the other children were exposed to other drugs as well. The majority of the children in the sample met diagnostic criteria for fetal alcohol syndrome (58%) or fetal alcohol effects (24%). Compared with children exposed to fewer traumatic experiences as reported by social workers and foster caregivers, the children exposed to three or more traumatic experiences demonstrated more attentional and emotional problems. Conversely, entry into foster care before age 3 years appeared to be a protective factor in that fewer of these children demonstrated attentional and emotional problems than did the children placed at later ages. Age at entry into foster care and number of traumatic experiences were strongly correlated (r = 0.67), suggesting

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that early entry into foster care protects children from experiencing further traumatic events in the family of origin. The protective effect of conventional foster care is particularly noteworthy, given that the foster caregivers in this sample reported problems of their own during the child’s placement (e.g., economic problems = 37%, family violence = 11%). Although it is not possible from this study to determine the extent to which aspects of foster care were protective of prenatal exposure effects, per se, it is clear from these findings that the postnatal environment is an important contributor to behavioral outcomes among children with a history of foster care resulting from prenatal exposure. Additional, albeit preliminary, evidence that a positive early environment can offset the adverse effects of prenatal exposure can be found in a nonexperimental study of 22 prenatally exposed infants in a specialized early foster care program (D’Angiulli & Sullivan, 2010). The Safe Babies Program was designed to provide foster caregivers with education and support in caring for prenatally exposed infants. The program recruited “experienced and highly qualified foster parents,” including “people with relevant professional qualifications in social work, pediatric medicine, and nursing in addition to their experience as foster parents” (p. 461). Infants for whom parental substance use during pregnancy was the main factor for court-ordered foster care were placed in care before age 24 months. The authors compared the developmental outcomes, including basal salivary cortisol, between full-term and preterm infants enrolled in the program. Compared with full-term infants, preterm infants were in the norm on all developmental domains (assessed with the Battelle Developmental Inventory) except fine motor skills. The preterm and full-term foster infants scored within two standard deviations of the mean on all developmental domains, suggesting no developmental delays. The infants’ circadian cortisol rhythms were consistent with typical infant patterns and did not differ between preterm and full-term infants when number of months in foster care was included as a covariate in the analysis. It is important to acknowledge the limitations in this study from a methodological perspective. Confidence in the interpretation of these findings will be increased with the inclusion of a comparison group that does not receive the specialized foster care intervention. Although the knowledge base in this area is still emerging, the body of research presented here suggests important opportunities for prevention and intervention scientists working with foster families. Although postnatal interventions would not necessarily protect prenatally

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exposed infants from the immediate neurobehavioral effects of prenatal exposure at birth, such interventions could help mitigate the long-term, or latent, effects of prenatal exposure. Interventions that support and enhance the caregiving capacity of foster caregivers will be particularly relevant in this regard (Healey, Fisher, van Scoyoc, & Relling, 2013). Many important questions remain, the answers to which will help refine existing intervention strategies. For example, it is not clear which dimensions of early adversity are the most detrimental and the most protective of child outcomes among prenatally exposed children. It is also uncertain how the timing of exposure to prenatal and postnatal adversity contributes to child outcomes. Finally, although the general rule is that earlier is better for intervention to offset the effects of postnatal adversity, more research is needed to determine how early in the child’s development postnatal protective influences are needed to positively affect outcomes. In sum, research on foster children and other prenatally exposed populations provides evidence that prenatal adversity represents an independent set of influences over and above the risks conferred by early postnatal adversity, and specifically that it negatively affects behavioral and biological development. Moreover, research suggests that the combined effects of prenatal and early postnatal adversity are worse than that of either alone. This is particularly germane to research on foster children because of the epidemiological evidence that the two may co-occur frequently among children in out-of-home care. Finally, a small but important evidence base suggests that just as a poor postnatal environment may exacerbate the effects of prenatal exposure, a good environment—one that may occur in the context of both conventional foster care and therapeutic foster care—has the potential to mitigate or offset prenatal exposure effects. However, because of the paucity of research in this area, more investigations are needed to replicate and extend the results obtained thus far.

RESILIENCE (I.E., TYPICAL DEVELOPMENT IN THE FACE OF ADVERSITY) IS EVIDENT IN ALL SAMPLES OF FOSTER CHILDREN (ALTHOUGH WHAT CONTRIBUTES TO IT IS NOT WELL UNDERSTOOD) To this point in our discussion of research on foster care, we have focused largely on conclusions that can be drawn about the associations between early adversity and atypical development. However, it is equally important to consider two corollaries of this research: first, that some atypical

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outcomes may be adaptive to the environmental circumstances of early adversity and foster care and second, that although atypical development is in general associated with adversity, it is far from ubiquitous; rather, typical development can and does occur even under conditions of significant adversity. That these issues are sometimes underemphasized or obscured in studies of foster children is not surprising. Although our culture does tend to celebrate the extraordinary instances in which individuals achieve great success amidst traumatic and neglectful childhoods, the prevalence and magnitude of problems observed among foster children may be more salient to researchers and other observers than the less frequent positive outcomes. Moreover, there may be concern that emphasizing positive outcomes could lead to less support from policy makers and the general public for programs that support this population. Nevertheless, there is remarkably consistent empirical evidence that not all foster children fare poorly. Clearly, as we discuss later, some foster children manage to circumvent some or most of the expected negative outcomes. This line of investigation falls into the domain of resilience research, which has been a topic of considerable scientific interest in recent years (Rutter, 2006). The question of what might lead some individuals to emerge from early adversity relatively unscathed or even strengthened while others experience lasting effect has been a matter of considerable speculation (DuMont, Widom, & Czaja, 2007). Cultural models are often invoked with respect to the idea that some individuals’ innate strength of character enables them to be successful even in the most difficult times (Masten, 2001). However, the science of resilience is considerably more developed and nuanced than that. In the scientific study of resilience in the general population, emphasis has been placed upon defining the individual/environmental variables most associated with positive outcomes, including personality characteristics (Flores, Cicchetti, & Rogosch, 2005), genetic polymorphisms (Rutter, 2003), strong caregiver relationships (Flores et al., 2005), and supportive parenting (Forgatch & DeGarmo, 1999). There are several sources of evidence that resilient outcomes in the face of adversity are possible among foster children (Samuels & Pryce, 2008). Ironically, one source of evidence comes from the same sources of data that have been used to document the disparities of foster children. For example, in two earlier sections of this chapter, we highlighted the prevalence of poor psychological, developmental, and cognitive functioning and alterations in key domains of neurobiological development among

foster children. However, these problems are by no means universal. One concrete example of the prevalence of resilient outcomes can be drawn from research on altered cortisol levels in foster children. This research has found that dysregulated diurnal cortisol-level patterns occur approximately three times as often in foster children than in the general population—a finding that may lead to the conclusion that this pattern is exhibited by most foster children. However, examination of the prevalence rates of foster children’s diurnal HPA dysregulation reveals a different perspective: In two different samples, the low morning cortisol “blunted” pattern has been observed in only about 30% of the foster children (Bruce, Fisher, et al., 2009; Dozier et al., 2006). In other words, about 70% of foster children show typical patterns of diurnal cortisol production. Moreover, although we tend to characterize low morning cortisol and blunted diurnal patterns as dysregulated, the fact that this pattern is associated with neglect in foster care and institutionalized samples (Carlson & Earls, 1997) suggests that it may be an adaptive response designed to conserve metabolic and other biological activity in the context of a nonresponsive rearing environment. Put another way, what we perceive from the perspective of typical development as dysregulated may be a strategy designed by nature to increase the likelihood of survival under adverse circumstances. In that sense, although we still may consider low morning cortisol to be atypical in the general population, it may be less appropriate to view it as pathological. Corroborating evidence of resilience following early adversity can be found in the numerous studies of the catch-up that occurs among adopted children. Much of this work is focused not on foster care samples but on children who have experienced institutional rearing (Rutter, 1998). Notably, some of these children also experience foster care or multiple family placements before adoption, although the separate and additive effects of institutional and foster care have not been investigated. In a remarkable meta-analysis that included a synopsis of more than 270 studies with a total of more than 230,000 adopted and nonadopted children and their parents, van IJzendoorn and Juffer (2006) found strong evidence for developmental catch-up in physical and emotional/psychological domains, especially for children adopted early. Although catch-up was often incomplete relative to nonadopted peers, the adopted children consistently fared far better than children who stayed in institutions. Interestingly, Croft, O’Connor, Keaveney, Groothues, and Rutter (2001) found that

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catch-up in postinstitutionalized adoptees was associated with longitudinal improvements in the quality of the parent–child relationship. The literature about specific predictors of resilience in foster children is surprisingly sparse. Healey and Fisher (2011) found that favorable outcomes, such as emotion regulation and academic adjustment in middle childhood, were more likely in foster children who during the preschool years had typical developmental status, particularly with respect to attention and executive functioning and who lacked environmental stress in early-childhood foster care. Several studies have examined the nature of foster children’s experiences while in care that may be associated with resilient outcomes. For example, a longitudinal investigation involving more than 3,000 children younger than age 12 years found factors that may improve placement stability, which is associated with positive outcomes, among foster children (Koh, Rolock, Cross, & Eblen-Manning, 2014). The factors contributing to foster care stability included the caregiver’s dedication to the child’s legal permanence, placement with a relative caregiver, and the absence of child mental health problems. Kinship care also seems to be a protective factor for foster children (Farineau & McWey, 2011; Leathers, Spielfogel, Gleeson, & Nancy, 2012). For example, in a NSCAW subsample, long-term foster adolescents placed in kinship care were shown to have the lowest delinquency scores compared with other long-term foster adolescents (Farineau & McWey, 2011). Kinship care may also help reduce the potential for the child to develop psychosocial problems. Landsverk et al. (1996) found psychosocial problems to be significantly higher for foster children in nonrelative (vs. kinship) placements, with foster children experiencing emotional and behavioral problems more frequently than kinship children (59.9% vs. 31.6%, respectively). This trend was also true for developmental and learning problems (24.2% vs. 15.8%, respectively). Finally, the foster children were also at higher risk for developing multiple types of problems and delays (28.0% vs. 14.5%, respectively). Clearly, more research on the predictors of foster child resilience is needed. It is plausible that much of the research on resilience in the general population might apply to foster children as well. Given the availability of existing datasets in which to explore such issues by means of secondary analyses (e.g., NSCAW), this is an area in which progress may be readily achievable. In sum, it is clear that although foster and adoptive children may face increased risk for numerous negative outcomes, many display very high rates

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of resilience, especially when removed from circumstances of ongoing adversity and placed in stable, supportive, family-based care.

FAMILY-BASED CARE (INCLUDING FOSTER CARE) IS, AS A GENERAL RULE, BETTER THAN INSTITUTIONAL CARE It is important to note that the foster care system is often maligned, in part because of the proliferation of research documenting atypical development and poor adjustment among foster children and to negative public perceptions about the foster care system. However, as was originally noted by Chapin (1926) and other early researchers and social activists, in spite of all its limitations, foster care allows children to be reared in a family setting. This appears to have significant advantages over institutional care and provides evidence of the central importance of family-based care to health development. Evidence about the advantages of foster care over institutional care can be derived from studies that have compared groups of children living in these different conditions by using the same measures of health and well-being. In this section, we review research on family-based care as an alternative to institutional care. Child Care in Institutions First-hand observations of institutional care for infants and young children describe conditions of profound deprivation. At a postwar United States institution, for example, infants ages 4 days to 24 months spent most of their time in cribs and rarely ventured outside the institution (Provence & Lipton, 1962). The younger group of infants ages 4 days to 8 months experienced the following: [They] shared the time and attention of the attendant with seven to nine other infants in the same age range for the eight-hour period of the day when she was present. For the remaining sixteen hours of the day there was no person in the nursery except at feeding time when an attendant who also had similar duties in other nurseries heated formulas, propped bottles, and changed diapers. Her presence could lead to no more than the briefest of contacts because she had twenty-five to thirty other babies for whom she must do the same before it was time to start over again. During an eight-hour day, five days a week . . . [the infant’s] contact with [the attendant] was mainly in being taken from his crib to the work area once daily for bathing and dressing, and subsequently three or four times for a diaper change. (P. 27)

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As is illustrated in this excerpt, the caregivers interacted with the children to fulfill only the most basic instrumental needs, such as feeding, diapering, and bathing. These interactions offered few opportunities for social engagement: Infants younger than age 8 months were fed by a “propped bottle” rested against padding in their crib, and older infants were spoon-fed for 6–8 minutes each while caregivers talked amongst themselves (Provence & Lipton, 1962). The caregiving staff “seemed to like the babies” and “gave as much of themselves as they could” in overworked conditions (p. 29), but shifting staff schedules and turnover meant that many infants were not regularly assigned to the same caregivers. Strict routines for feeding, diapering, and bathing, along with a paucity of adult supervision, meant that each infant “had very few experiences in having the adult respond to his needs (e.g., the discomfort of hunger) at the time he expresses them.” (p. 19). Perhaps not surprisingly, Provence and Lipton noted “an almost startling quietness” in the nursery (p. 89), an indication that the infants learned to not seek adult attention under either playful or distressed conditions. Based on this brief depiction, it is clear why Nelson, Fox, and Zeanah (2014) argued that institutionalization “represents a form of neglect, albeit a very extreme form” (p. 306) and that children in contemporary institutional care “lack supervision and structure, necessary social interaction and emotion regulation, cognitive and language stimulation, access to adequate nutrition, and so on” (p. 306–307). Echoing the postwar findings of Provence and Lipton (1962), observations of a Romanian institution in the 1990s found that children had limited opportunities to interact socially with caregivers (Nelson et al., 2014). They had long stretches of unstructured playtime, in which the caregivers mostly chatted amongst themselves, ignoring the large number of children wandering aimlessly. Over the course of a day, a child would likely have contact with multiple adults, which precluded consistency or the opportunity for sustained interaction. In a given week, a child could have come in contact with 17 different caregivers, three housekeepers, four nurses, two educators, one physician, one psychologist, and one physical therapist (Nelson et al., 2014; pp. 34–35). Although the conditions of institutional care vary widely within and across countries, the institutions studied by Nelson et al. in Bucharest shared a routinized daily schedule, a high child:caregiver ratio, and staff with little formal training in child development. By contrast, foster caregiving typically involves one or two primary caregivers—extended family members, if possible—who have, under ideal circumstances, made

an investment to provide personalized care for the child. Natural variability in caregiving quality across foster caregivers notwithstanding, children living in foster care can reasonably expect that their primary caregivers will respond to their basic needs. A major question is the extent to which typical development can occur in the absence of a relationship with a primary caregiver. A Comparison of Foster and Institutional Care: The Bucharest Early Intervention Project Although research in the twentieth century has demonstrated that children raised in institutions show impairments across a variety of developmental domains, the inferences that can be drawn from these studies are necessarily limited by a lack of an experimental control (Zeanah et al., 2003). Without random assignment, it remains possible that infants who are abandoned to institutions began life with more severe disadvantages than noninstitutionalized children or that the more-advantaged infants get adopted from institutions, leaving behind their most disadvantaged peers. As a result, sample bias (vs. institutionalization itself) could explain the detrimental outcomes found among this population. In 2000, a landmark, randomized controlled longitudinal study was launched that investigated foster care as an alternative to institutional care: the Bucharest Early Intervention Project (BEIP; Nelson et al., 2014). The BEIP is remarkable because the circumstances in Romania at the time when the study began allowed the researchers to randomly assign children to ongoing institutional care (n = 67) or to family-based foster care (n = 69; Zeanah et al., 2003). Although the foster families received some training (Smyke, Zeanah, Fox, & Nelson, 2009), the conditions did not allow for foster care to be enhanced in terms of ongoing support and treatment for the children. Thus, this study represents a scientifically rigorous comparison of institutional versus family-based rearing development. The BEIP results provide remarkably consistent evidence that institutionally raised children fare worse than foster children across numerous domains in which foster children show atypical development, including emotional, psychological, physical, and neurobiological development. The BEIP assessed children at baseline (before age 31 months) and at ages 30 months, 42 months, 54 months, and 8 years. Some children were as young as age 6 months when the intervention began. At the first assessment, some of the children had as many as 24 months of the intervention, while the older children had a few months or less. In addition to the two randomly assigned groups, a third group of

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72 noninstitutionalized, matched community comparison children who lived with their biological parents was also assessed at each study wave. This permitted researchers to evaluate developmental catch-up among the foster children (Zeanah et al., 2003). Over the course of the study, some of the institutionalized children were adopted or entered foster care. Analyses were conducted on an intent-to-treat basis, such that (for example) a proportion of children in the institutionalized group at age 8 years were living in family-based care (Nelson et al., 2014). Thus, the findings that are reviewed in the next sections represent conservative estimates of the effects of institutionalization on child outcomes. Cognition and Language The children who remained in institutional care until age 8 years demonstrated significant declines and delays in all domains of cognition, including intellectual function, executive function, memory, and language (Nelson et al., 2014). On measures of intellectual function, the children placed in foster care demonstrated higher mean IQ scores on the Bayley Scales (at 42 months) and on the Wechsler Preschool and Primary Scale of Intelligence (at 54 months) than did their institutionalized peers (Nelson et al., 2007). The lesser time the children spend on institutional care, the better their IQ performance. Specifically, children needed to have been assigned to foster care before age 24 months to outperform their institutionalized peers on the intelligence measures. The intervention effects on IQ were not as strong at age 8 months as at ages 42 and 52 months, an indication (perhaps) of the modest gains in IQ among institutionalized children who were placed in newly designated government foster homes between the 54-month and 8-year assessments (Fox, Almas, Degnan, Nelson, & Zeanah, 2011). In some cognitive domains, foster children’s capacities were superior to institutionalized children’s but below those of their community peers. Despite their advantages in IQ over institutionalized children, foster children’s IQ scores were lower than the community control children’s on all Wechsler Intelligence Scale for Children subscales at age 8 years (Fox et al., 2011). Similarly, on assessment of inhibitory control at age 54 months, the foster children scored higher than the institutionalized children did but lower than the community comparison group did (Nelson et al., 2014). In the case of other executive-function skills measured with the Cambridge Automated Neuropsychological Test and Battery at age 8 years, the institutionalized children performed worse than the community comparison children

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on visual memory and executive functioning tasks (Bos, Fox, Zeanah, & Nelson, 2009). The foster children and institutionalized children assigned to ongoing institutional care performed equivalently on all memory and executive-functioning domains except spatial working memory. After controlling for birth weight, head circumference, and duration of time spent in the institution during infancy, spatial working memory performance favored the foster group. In the BEIP, language assessments across time indicated that the foster care intervention remediated the severe language deficits associated with ongoing institutional care, if placement occurred early enough. Compared with the institutionalized children, the foster children demonstrated better expressive and receptive language skills at ages 30 and 42 months (Windsor et al., 2011). The language-development benefits continued for foster children through the 8-year assessment (Windsor, Moraru, Nelson, Fox, & Zeanah, 2013). Socioemotional Development Given the profound absence of emotionally salient, consistent, and contingent social interaction with caregivers in the institutions, the BEIP investigators anticipated that the institutionalized children would show detriments in attachment to caregivers and in the experience and expression of emotion in social contexts. Indeed, foster children (vs. institutionalized children) expressed more joy during Laboratory Temperament Assessment Battery (Goldsmith & Rothbart, 1999) tasks at ages 30 and 42 months and exhibited more improvements in positive emotion during this period (Ghera et al., 2009). Notably, foster children showed even more positive emotion and attention to tasks at age 42 months (Ghera et al., 2009). Institutionalized children demonstrated low levels of attention to the positive emotion-eliciting tasks at ages 30 and 42 months (Ghera et al., 2009). The lower levels of attention and positive emotion expression among the institutionalized children care may relate to disruptions in the neural circuitry involved in emotion processing (Parker & Nelson, 2005). By contrast, the recovery observed among foster children provides evidence for the relative plasticity of neural circuits that support positive affect (Ghera et al., 2009). The disruption of attachment in institutionalized children was severe. At the baseline assessment, investigators assessed attachment behaviors in the community comparison sample and a subset of 95 institutionalized children ages 12–31 months who had spent an average of 90% of their lives in institutional care (Zeanah,

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Smyke, Koga, Carlson, & Bucharest Early Intervention Project Core Group, 2005). The Strange Situation Procedure (Ainsworth, Blehar, Waters, & Wall, 1978) was administered with these institutionalized infants and their preferred caregiver (if none could be identified, it was the caregiver who worked with the child most regularly). In addition to deriving a categorical attachment classification from the Strange Situation Procedure, a continuous, 5-point rating of attachment behavior was assigned by two experts (Zeanah et al., 2005). Compared with the community children, who were classified as 74% secure and 22% disorganized, the institutionalized children were classified as 18% secure, 65% disorganized, and 12.6% unclassified, a rare designation meaning that there were too few attachment behaviors to assign a child to any group (Zeanah et al., 2005). Using the continuous rating scale, investigators confirmed that 65% of institutionalized children exhibited “anomalous behaviors only minimally related to attachment” (Nelson et al., 2014, p. 244). In addition, 9.5% of the institutionalized children “had no discernible attachment behaviors whatsoever” (Nelson et al., 2014, p. 244). At 42 months of age, BEIP intervention effects on attachment and social behaviors among foster children were substantial. Secure attachment at age 42 months was exhibited by 18% of institutionalized children, 65% of community children, and 49% of foster children (Nelson et al., 2014). Foster children also showed significantly fewer signs of an emotionally withdrawn and inhibited type of reactive attachment disorder than did institutionalized children; levels of this subtype were comparable between foster and community children after age 30 months (Smyke et al., 2012). Regarding timing effects, secure attachment at age 42 months was more prevalent among children assigned to foster care at or before age 24 months than among those placed later (Smyke, Zeanah, Fox, Nelson, & Guthrie, 2010). Similarly, children assigned to foster care at or before age 20 months were rated by teachers as significantly more socially skilled with peers at age 8 years than were those placed later (Almas et al., 2012). Psychopathology The impact of severe psychosocial deprivation on the development of psychopathology in institutionalized children was predictably detrimental. At age 54 months, 53.2% and 27.0% of institutionalized children were diagnosed with psychiatric and behavioral disorders, respectively, compared with 22.0% and 6.8% of community children (Nelson et al., 2014). In the case of ADHD, institutionalized

children in the BEIP study demonstrated more symptoms of inattention and impulsivity at age 8 years than did community children (McLaughlin et al., 2014). This effect of early psychosocial deprivation on ADHD symptoms was mediated by reductions in cortical thickness in several regions of the prefrontal, parietal, and temporal cortices (McLaughlin et al., 2014). Foster care tended to improve mental health outcomes when compared with institutional care, but with several qualifications. First, at age 54 months, foster children had fewer internalizing, but not externalizing, disorders than did institutionalized children (Zeanah et al., 2009). Second, this was true only for foster girls (Zeanah et al., 2009). The effect of foster care on internalizing disorders in girls was mediated by secure attachment at age 42 months (Nelson et al., 2014). Nelson et al. identify a number of other psychobiological moderators of BEIP intervention effects. A particularly important finding to note is that the timing of assignment to foster care did not moderate the effect of intervention on psychopathology. Even children who entered foster care relatively late were protected from the effects of early deprivation on anxiety and depression (Zeanah et al., 2009). The Caregiving Conditions Necessary for Typical Development Findings from the BEIP and related longitudinal research on internationally adopted children (Rutter, Kumsta, Schlotz, & Sonuga-Barke, 2012) point to specific developmental domains that have more or less plasticity in response to early deprivation. These studies provide many insights: We highlight only a few here, along with their implications for intervention with children exposed to early adversity. First, it appears that children can form attachments with primary caregivers even after accumulated early experiences with institutional caregivers who, because of their context, were by definition not able to provide sufficiently responsive or emotionally salient interaction. Clearly, this is an area in which earlier intervention is better. In the BEIP, catch-up in attachment security was significantly more common among foster children placed before age 24 months than among children placed later. A meta-analysis of research on adopted children found an even more stringent age cut-off of 12 months, by which children must be adopted to catch up to the attachment security of their nonadopted peers (van IJzendoorn & Juffer, 2006). In turn, secure attachment was associated with a range of short- and long-term psychosocial benefits for foster and adopted children. These findings suggest that the earlier a

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child with unstable living arrangements can be placed with a primary caregiver, the better. Second, in terms of other domains of development, the timing of placement into foster care was important for some but not for others. For instance, attachment security, IQ, language skills, electroencephalogram measures, stereotypies, and other domains were sensitive to the timing at which children began to live in family-based care, with earlier placement generally being more beneficial (Bos, Zeanah, Smyke, Fox, & Nelson, 2010; Zeanah, Gunnar, McCall, Kreppner, & Fox, 2011). Interestingly, family-based care was protective of anxiety and depression no matter what age children were assigned to foster care (Zeanah et al., 2009), though this finding must be interpreted with caution: No child was older than age 3 years when placed into family-based care. It is possible that adoption at a later age may not be protective in terms of internalizing disorders. Nevertheless, this finding highlights the influence of the family caregiving environment on difficulties that are often attributed to inherited biological predispositions. Third, family-based care was beneficial for BEIP children’s cognitive development (Nelson et al., 2007) but did not protect them from difficulties with executive functioning, inattention, and hyperactivity (Bos et al., 2009; McLaughlin et al., 2014). In their longitudinal study of adopted children, the ERA team also found that inattention/hyperactivity was part of a constellation of difficulties, persistent into adolescence, labeled as deprivation-specific psychological patterns (Kreppner et al., 2010; Kumsta et al., 2010). Institutionalized children may have experienced more adverse prenatal experiences that detrimentally influenced neurodevelopment prior to children’s entrance into the orphanages. Regardless, these findings suggest important targets for intervention. To mitigate the executive function deficits associated with early deprivation, ordinary caregiving provided by foster and adoptive families may have to be enhanced or supplemented with specific interventions designed to improve the functioning of children’s neural systems and attendant behaviors (Fisher & Gunnar, 2010; Gunnar, 2010). Nevertheless, the results of the BEIP are critically important because they indicate that typical development seems to require, as a basic condition, the presence of a primary caregiver. Although the most optimal arrangement may be a permanent biological or adoptive parent, it is not always possible to quickly resolve issues of permanency. Within this context, the evidence base is strong that foster care appears to enhance current and future health and well-being more than does institutional care.

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FAMILY-BASED INTERVENTIONS THAT CAN MITIGATE THE EFFECTS OF EARLY ADVERSITY If a general conclusion of foster care research is that temporary placement in family-based care falls somewhere in the continuum between conditions that promote optimal development care and institutional care, then a related question is how to shift the location on the continuum represented by foster care in a positive direction through interventions. This is a key question from a public policy standpoint and from a scientific perspective inasmuch as it relates to questions about the malleability or plasticity of the biobehavioral systems negatively affected by early adversity. There is a fairly extensive literature in this area, although much of this work has not used randomized experimental designs. A recent systematic review using the Cochrane Collaboration’s criteria (Turner & Macdonald, 2011) noted that only five studies met the criteria for an evidence-based program for foster families. Further, a study by the Office of Victims of Crimes suggested that only 1 of 24 mental health interventions for children who had been abused is effective (Saunders, Berliner, & Hanson, 2004). Foster care families have unique needs that determine which interventions are likely to remediate the effects of early adversity on healthy development. First, because foster children have been exposed to neglectful or abusive parenting prior to their entry into care, in any foster care intervention the caregiver receiving the intervention services does not have a shared history with the child. Further, the foster caregiver may already have a set of parenting skills that are generally effective. Second, because of their maltreatment histories, foster children are more likely to exhibit constellations of behavioral, neurobiological, and relationship vulnerabilities that pose unique challenges to caregivers. Thus, standard parenting intervention programs might not be sufficient or appropriate for improving child outcomes. Third, children enter foster care at varying ages and have likely experienced multiple prior caregiving situations. This may lead foster children to enter care with their own set of expectations and demands based on their histories. Leve et al. (2012) conducted a systematic review of intervention programs that have been tested with foster families and shown to improve child outcomes. The interventions included in the review met the following criteria: evaluated using a randomized, controlled trial; produced at least one positive outcome; randomized at the level of the individual; and included at least 15 children per group. Eight interventions met these criteria. We describe seven of those interventions (the eighth—BEIP—was described

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in an earlier section of this chapter), along with two others (meeting these criteria) that were published after the Leve et al. review. Five of these interventions emanated from the same research group at the Oregon Social Learning Center (OSLC) and are reviewed together, followed in developmental order by four evidence-based programs from other research groups. (Please note that the lead author of this chapter is one of the developers of several of the OSLC interventions.) Treatment Foster Care Oregon for Adolescents (TFCO-A) TFCO-A, the first intervention developed by the Oregon group, consists of a multicomponent program that involves individual placement with a specialized foster family for adolescents being removed from their homes (Chamberlain, 2003). Typically, TFCO-A adolescents have maltreatment histories and serious, chronic problems with delinquency. In TFCO-A, adolescents are placed in community homes where the foster caregivers are intensively trained, supervised, and supported to provide positive adult support and mentoring, close supervision, and consistent limit setting. TFCO-A placements typically last 6–9 months and involve coordinated interventions at home, with peers, in educational settings, and with the adolescent’s long-term placement resource. The results from TFCO-A trials in the United States indicate its effectiveness in reducing arrest rates and deviant peer affiliations for boys and girls; placement disruptions and parenting for boys; and pregnancy rates, depressive symptoms, psychotic symptoms, and school engagement for girls (Chamberlain & Reid, 1998; Harold et al., 2013; Kerr, Leve, & Chamberlain, 2009; Leve, Fisher, & Chamberlain, 2009; Poulton et al., 2014). For example, between baseline and a 12-month follow-up, the TFCO-A adolescents had spent 53 (boys) and 22 (girls) days in lockup (e.g., a detention facility) versus 129 and 56 days, respectively, for the control adolescents. In addition, long-term effects have been found on drug use at 7 years postintervention (Rhoades, Leve, Harold, Kim, & Chamberlain, 2014). Several international replications of TFCO-A have shown positive results. For example, a trial in Sweden indicated significant reductions in youth-reported externalizing and internalizing behavior (Westermark, Hansson, & Olsson, 2010).

management approach and trains, supervises, and supports foster caregivers to provide positive adult support and consistent limit setting. This support and training occurs through weekly parenting groups, individual therapy, family therapy, and 24/7 on-call support and typically lasts 6–9 months. Similar to TFCO-A, it also coordinates with the child’s biological parents, with the assumption that the end goal is reunification. The randomized trial of TFCO-P showed that the intervention improved child attachment behavior: TFCO-P children demonstrated increased secure behavior and decreased avoidant behavior relative to children in regular foster care (Fisher & Kim, 2007). TFCO-P also improved stress–response systems, preventing blunted diurnal cortisol patterns among the intervention children (Fisher et al., 2007) and reducing caregiver stress (Fisher & Stoolmiller, 2008). Further, TFCO-P improved placement stability outcomes across a 2-year period and mitigated the risk of influence of multiple prior foster placements on subsequent placement failures (Fisher et al., 2005). Compared with the TFCO-P children, the control children (in regular foster care) were 3.6 times more likely to experience a permanent placement failure. Kids in Transition to School (KITS) KITS evolved from the TFCO-P intervention as a short-term, readily scalable intervention focused on school readiness and improved school functioning for foster children (Pears, Fisher, & Bronz, 2007; Pears, Fisher, Heywood, & Bronz, 2007). The KITS intervention occurs in two phases: a school readiness phase (2 months before kindergarten entry) focused on preparing children and caregivers for school and a transition/maintenance phase (first 2 months of kindergarten) focused on supporting a positive transition to school. The intervention includes a group-based program for the children (24 sessions) focused on promoting early literacy and socioemotional skills and a parent-based program (8 sessions) focused on promoting caregiver involvement in early literacy and school. Compared with regular foster care services, KITS has been shown to increase foster children’s early literacy and self-regulatory skills (Pears et al., 2013) and to reduce child oppositional and aggressive behavior in the classroom (Pears, Kim, & Fisher, 2012).

Multidimensional Treatment Foster Care for Preschoolers (TFCO-P)

Keeping Foster Parents Trained and Supported (KEEP-SAFE)

TFCO-P is a downward extension of TFCO-A for preschool-age foster children. It uses a behavior-

KEEP-SAFE shares the foster–caregiver component of the TFCO programs described earlier but, like KITS,

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Family-Based Interventions That Can Mitigate the Effects of Early Adversity

was designed to be a less intensive intervention for foster families with school-age children. In the randomized trial of KEEP-SAFE, foster caregivers receiving a new placement were randomly assigned to regular foster care services or to the KEEP-SAFE parenting intervention (Chamberlain et al., 2008). The KEEP-SAFE intervention lasts 16 weeks and includes foster caregiver meetings with 8–10 foster caregivers that are focused on training, supervision, and support for applying behavior management strategies. KEEP-SAFE has been shown to effectively reduce child problem behavior. These child behavior problem reductions were associated with intervention-driven improvements in parenting (Chamberlain, Price, Reid, & Landsverk, 2008). Similar to TFCO-P, KEEP-SAFE also improved placement stability: KEEP-SAFE mitigated the risk-enhancing effects of prior multiple placements (Price et al., 2008), and the KEEP-SAFE children were more likely to be reunified with their biologic parents or permanently placed with relatives or an adoptive family (17% of the KEEP-SAFE children vs. 9% of the control children). Middle School Success (MSS) The final intervention originating from the OSLC team is MSS, a derivative of KEEP-SAFE that targets youths exiting primary school (Chamberlain, Leve, & Smith, 2006). MSS includes foster–caregiver and youth components in the summer prior to middle-school entry (six sessions) and through the first year of middle school (weekly). The parenting sessions were group based and behavior-management oriented; the youth sessions were group based (summer) and individually based (school year) and were oriented toward skill building. Relative to the children in regular foster care, the MSS children exhibited decreased externalizing and internalizing problems at the 6-, 12-, and 24-month follow-ups (Kim & Leve, 2011; Smith, Leve, & Chamberlain, 2011). MSS also resulted in increased prosocial behavior and fewer placement changes at the 12-month follow-up, reduced substance use and health-risking sexual behavior at the 36-month follow-up (Kim & Leve, 2011), and improved decision making at the 5-year follow-up (Weller, Leve, Kim, Bhimji, & Fisher, 2015). Attachment and Biobehavioral Catch-Up (ABC) ABC is one of three interventions shown to be effective during early childhood (BEIP and TFCO-P being the other two). It is a 10-session intervention designed to

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help caregivers facilitate healthy regulation of foster child behavior and stress responses by teaching foster caregivers to be highly responsive to child emotions and to increase their provision of nurturing care and promotion of attachment security during early childhood (Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008). The results of a randomized trial of ABC indicated that the intervention children were more often secure and less often disorganized in their attachments to caregivers than were the control children: 52% (vs. 33%) exhibited secure attachment and 32% (vs. 57%) exhibited disorganized attachment approximately 1 month after the intervention (Bernard et al., 2012). ABC has also shown success in normalizing foster child stress responses (i.e., cortisol reactivity) relative to the control children, which indicates the plasticity of their neurobiological systems and the capacity for recovery. Overall, the ABC findings parallel the TFCO-P effects on attachment and stress responsivity but extend downward developmentally to the infant and toddler period. The Incredible Years The Incredible Years is an effective intervention for at-risk children and children with conduct problems that was modified for foster families with school-age children (Reid, Webster-Stratton, & Hammond, 2003; Webster-Stratton, Reid, & Hammond, 2001). The modified Incredible Years intervention incorporates a coparenting component between foster and biological caregivers to expand their knowledge of each other and their child, practice open communication, and negotiate interparental conflict regarding topics such as family visitation, family routines, and discipline (Linares, Montalto, Li, & Oza, 2006): The results suggest that Incredible Years improves foster caregivers’ positive discipline and coparenting skills. Fostering Individualized Assistance Program (FIAP) The FIAP is focused on wrapping services around the child according to their individual and family needs, with the goal of improving placement stability and reducing behavioral and emotional problems (Clark et al., 1994). The FIAP has four components, including a strengths-based assessment, life-domain planning, clinical case management, and follow-along supports and services. The FIAP children were shown to exhibit fewer attention, withdrawal, and total problems at an 18-month follow-up (assessed via caregiver report; Clark et al., 1994). In addition, the FIAP children had fewer runaways and spent less time incarcerated. Increased placement stability has been found for older FIAP children only (Clark et al., 1998).

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Fostering Healthy Futures (FHF) FHF was designed for maltreated foster children ages 9–11 years (Taussig, Culhane, & Hettleman, 2007). The program promotes child well-being by identifying and addressing mental health issues, preventing adolescent risk behaviors, and promoting competence. The intervention consists of 90-minute therapeutic skills groups for the children over 30 weeks during the school year, combined with one-on-one mentoring (2–4 hours/week) with a graduate student. FHF has been shown to reduce child mental health problems and reduce symptoms of dissociation 6 months postintervention (Taussig & Culhane, 2010). In addition, the FHF children reported better quality of life immediately following the intervention, and fewer FHF youths had received recent mental health therapy 6 months postintervention (Taussig & Culhane, 2010). Finally, the FHF youths were 71% less likely to be placed in residential treatment 1 year postintervention (Taussig, Culhane, Garrido, & Knudtson, 2012). Limitations of Existing Foster Care Interventions Although the nine interventions reviewed in the preceding sections offer promise for improving outcomes for foster children, there are limitations in the work to date. First, there is a lack of long-term follow-up data: five studies do not have published follow-up data beyond a 12-month follow-up period (ABC, Incredible Years, KEEP, KITS, and FPF), and only three have published effects beyond 24 months (TFCO-A, BEIP, and MSS), making it difficult to know whether the observed effects sustain across development. In at least one of these interventions (Incredible Years), the effects dissipated quickly: 3 months after the intervention ended, only the positive discipline effect remained. Further, the length of time between intervention completion and the outcome assessment was often unclear from the published work. For example, the ABC samples had a wide child age range; therefore, the outcome assessment was delayed if the child was younger at the start of the study. In addition, some children in all of the studies experienced one or more placement changes prior to the outcome assessment. Together, these limitations cast doubt about whether the foster children who benefited from intervention will exhibit healthy adjustment later in development. Long-term follow-up studies are needed to better evaluate whether initial effects of such interventions are maintained over time. Second, the effects found across studies did not consistently generalize to other measures. For example, the FIAP effects on child mental health were present for

caregiver reports but not for youth reports, and delinquency outcomes in TFCO-A were present for girls using days-in-locked-settings data but not using self-reported delinquency data. The effects were also sometimes specific to subpopulations (e.g., one gender, older children; FIAP and TFCO-A) or to one set of hypothesized outcome constructs but not to another set (MSS and FIAP). Given these inconsistent findings and the generally small effect sizes (and the failure to report effect sizes in many published reports), there is room for refinement. Efforts to identify patterns of behavior among nonresponders might yield useful insights into how effective interventions could be modified or adapted to further remediate the negative effects of early adversity. Summary In summary, at least nine interventions for foster families have been tested using randomized trial designs at the individual level and have been shown to be effective in improving one or more outcomes for foster children. The results from most of these studies have shown small to moderate effect sizes that decrease over time. TFCO-A is an exception to this pattern, as is BEIP, reviewed in an earlier section of this review. Although these interventions vary in content and target age, they converged around several domains, including being developmentally specific, aiming to reduce known risk factors and promote resilience, and emphasizing the mediating role of parenting in linking early adversity with child outcomes. Of note, the positive effects of the interventions varied based on the developmental period of the children receiving the services. For example, two of the interventions reviewed here (TFCO-P, ABC) and BEIP reviewed in an earlier section showed positive effects on parent–child attachment relations and child neurobiological development in early childhood. Conversely, nearly all the middle-childhood and adolescent interventions showed positive effects on behavior problems (TFCO-A, KEEP, MSS, and FIAP), but only MSS had documented effects on an aspect of neurobiological functioning (decision making; Weller et al., 2015). Whether this is a function of the respective assessment measures in each study or a function of reduced neural plasticity across development is a question for future research. Taken together, however, the results of the interventions reviewed here provide strong evidence that the domains of functioning affected by early adversity in foster children appear to remain, at least to some degree, pliable throughout development.

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Conclusions, Translational Implications, and Directions for Future Research

CONCLUSIONS, TRANSLATIONAL IMPLICATIONS, AND DIRECTIONS FOR FUTURE RESEARCH In any comprehensive, complex review of the literature, it can be challenging to synopsize points into a manageable set of conclusions. However, if such an effort is to prove useful—not only for summarizing the current state of a scientific knowledge base but also for pointing to directions for future research—a parsimonious perspective on the field is necessary. Several main inferences on typical and atypical development can be made from the foster care literature: First, foster care research adds to the general understanding about the effects of early adversity on development and to specific studies documenting that early adversity effects (beginning prenatally) are cumulative, with those occurring earlier and for longer periods having the greatest impact. This research replicates and extends the findings in other areas (including research on animals and humans) with respect to the pervasive impact of early adversity on typical development. In particular, it highlights that development can get off course from not only traumatic events that occur in the life of the child, but also the absence of expected environmental input in the form of nurturing and responsive care (i.e., neglect). One disclaimer is that when considering the tendency for there to be poorer outcomes for foster children, it is important to bear in mind that foster care is typically an outcome of adversity rather than the cause of poor adjustment, although certain experiences in foster care can exacerbate the impact of early adversity. Foster care research further makes clear that the disruptions to typical development emanating from early adversity may affect broad and interrelated domains of psychological and biological functioning. Of particular note is the finding that early neglect appears to disrupt the development of neuroendocrine systems that play a critical role in maintaining homeostatic balance in the presence of stress. This may help explain the vulnerability to future stress that has been observed among individuals exposed to early adversity. In addition to neuroendocrine effects, early adversity appears to affect the structure, function, and possibly the connectivity among crucial brain regions that underlie key capacities such as executive functions and threat detection. One of the unique aspects of foster care research with respect to elucidating the effects of early adversity on child development is that it enables us to understand the effects of specific dimensions of adversity on particular

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underlying neurobiological systems. The aforementioned results related to the effects of placement transitions on executive functioning are one example of this. One important future direction for foster care research is to continue to explore the impact of specific types of early adversity that occur more commonly in foster care. For example, children who experience prenatal ethanol exposure and subsequently spend their early years in a succession of foster homes with different caregivers might be examined in comparison with those remaining with their biological parents and those adopted at birth. This would allow for a much more precise understanding of the combined effects of prenatal teratogenic exposure and early adversity than currently exists. It will be especially important for work in this area to be multilevel in nature, thereby continuing to contribute to the translational knowledge base that exists with respect to the psychological and biological effects of adversity. Second, foster care research provides conclusive evidence that, despite the health risks posed by early adversity, typical development can occur under less than optimal rearing conditions. On average, foster children fare poorly on many measures of well-being. However, as is nearly ubiquitous in studies of foster children, some individuals’ development appears relatively on course despite significant early adversity. From an evolutionary perspective, our ability to survive as a species would certainly have been reduced were this not the case, but it can still be easy to overlook this phenomenon given the extent to which the risks associated with being in foster care (or other forms of adversity) are highlighted in the literature and media. Historically, such positive outcomes have been vaguely attributed to defined concepts of innate resilience. Research in this area poses methodological challenges; however, it is important that future investigations focus on better understanding the variables, especially those that are malleable, that increase the likelihood of typical development following early adversity. Such variables may exist at many levels. Thus, research will do well to focus on the constitutional and environmental influences on resilience and on the complex interrelations among these influences. Third, foster care research suggests that, when early adversity leads development off course, subsequent improvements in environmental conditions have the potential to realign trajectories positively. Further, although early intervention seems to produce positive change, environmental improvements later in development can have a positive impact. These intervention studies do more than inform foster care policy. Studies of this nature provide proof of concept

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about the plasticity of behavior and biology—even in the context of deterministic life circumstances. Several disclaimers are necessary, however, in this area. First, not all children whose development is compromised by early adversity respond to interventions. In particular, it appears that as adverse experiences accumulate—especially in the context of combined prenatal and early adversity—they may limit the plasticity of these systems. In addition, genetic factors are likely to play a role. Because most research on interventions has been focused on detecting main effects, the knowledge base in this area is limited and more work is needed to better understand the variables associated with recovery from the effects of early adversity. Second, it is important to point out that the foster care intervention research on biological plasticity following adversity is quite limited and focuses primarily on the HPA axis. Moreover, at this point, the biological evidence comes only from studies of infants and young foster children. It is not clear at present whether the same plasticity can be observed in other biological systems or in older foster children. Several additional issues warrant attention with respect to what foster care intervention research can tell us about typical and atypical development. First, although the ability to mitigate the effects of early adversity is evident in this research, the specific intervention mechanisms at work are far less well understood. The existing evidence-based interventions for foster children typically consist of multiple components that focus on the child and caregiver. Although the interventions are theory based, the existing studies provide only limited information about whether the interventions effectively target the domains hypothesized to be most necessary to affect outcomes. With numerous intervention components, it may be that some produce more of an impact than others do. However, because studies evaluating these interventions are quite costly and take many years to conduct, the ability to deconstruct interventions and test the impact of their individual and combined components is limited. A related issue is to examine for whom interventions are most effective. There is no question that the development of a scientific knowledge base within the foster care literature showing that the effects of early adversity can be mitigated is a major accomplishment. Yet we know that these interventions are not universally effective and that it may be possible to identify certain phenotypes that are more or less likely to respond to existing interventions. Work in this area is fundamentally translational in nature because it reciprocally informs our understanding of how to best support foster children and our understanding of issues

related to individual differences in neural and behavioral plasticity. In this chapter, we have attempted to characterize the foster care research literature as it pertains to typical and atypical development. Although many of the conclusions should create ongoing concern and motivate continued efforts to reduce adversity in all children, there is also reason for optimism, both in terms of the clear ability of some children to overcome adversity and in terms of the extant knowledge base about how to facilitate positive outcomes. The ongoing research in this area will likely continue to inform this topic; as such, future updates of this discussion are warranted.

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Cicchetti c12.tex

Queries in Chapter 12 Q1.

Please check shorten running heads for this chapters.

Q2.

Indicate here if you mean Linares, Mintalto, et al. or Linares, Singer, et al.

Q3.

Indicate here if you mean Linares, Mintalto, et al. or Linares, Singer, et al.

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