Journal of Human Behavior in the Social Environment, 21:363–382, 2011

Copyright © Taylor & Francis Group, LLC

ISSN: 1091-1359 print/1540-3556 online

DOI: 10.1080/10911359.2011.555654

Understanding Responses to Foster Care:Theoretical Approaches

BARBARA RITTNERSchool of Social Work, University at Buffalo, Buffalo, New York, USA

MELISSA AFFRONTICoordinated Care Services, Inc., Rochester, New York, USA

REBEKAH CROFFORDSocial Work, Roberts Wesleyen University, Rochester, New York, USA

MARGARET COOMBESSchool of Social Work, University at Buffalo, Buffalo, New York, USA

MARSHA SCHWAM-HARRISSchool of Social Work, Hunter College, New York, New York, USA

Foster children making the transition from birth to foster homes

or from foster homes to foster homes often present problematic

behaviors. Limitations of attachment theory and reactive attach-

ment disorder are presented, and three alternative approaches for

understanding behaviors exhibited in foster settings are presented:

conservation of resources, child alienation model, and develop-

mental trauma disorder.

KEYWORDS Foster care, COR, DTD alienation

INTRODUCTION

Foster care is a confusing and transient (occasionally protracted) period insome children’s lives. History is replete with accounts of struggling familiesforced to abandon or indenture/apprentice their children to other families,rarely with any agency or government oversight (Hasci, 1995). Only inthe last century was there a shift from informal arrangements for families’

Address correspondence to Barbara Rittner, School of Social Work, University at Buffalo,

685 Baldy Hall, Buffalo, NY 14260, USA. E-mail: rittner@buffalo.edu

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placing children to more structured fostering systems, with host familiesbeing compensated for providing care to children. Governments becameincreasingly involved as agencies grew larger and began depending onmore than unpredictable charity sources for funding, especially once therewas a concerted effort to provide children with home-based rather thaninstitutional care. By the middle of the twentieth century, children werebeing proactively removed from parents and placed in out of home care ifthey were considered to be at risk (Fox & Berrick, 2007; Gil, 1984). Overtime, federal laws began the shift in governing child welfare services from alocal to a national system of care (Mitchell et al., 2005).

What was once a system dedicated to removing at-risk children andplacing them in alternative placements became a system vilified for allowingchildren to ‘‘age out of foster care,’’ creating a demand for new, more proac-tive services (Antler, 1978; Kerman, Barth, & Wildfire, 2004; Stein, 2000).Federal acts have been passed repeatedly to reduce the time children spendin care and to promote permanency planning. Rapid termination of parentalrights and adoption were initially encouraged through subsidized adoptions(Adoption Assistance Child Welfare Act, 1980, P. L. 96-272), but by the mid-1980s, concerns emerged about intact attachments to birth families leadingto disrupted adoptions (Besharov, 1991; Hollingsworth, 2000). The 1984Family Preservation and Support Services Act (P.L. 103-66) was expectedto resolve continuing dispositional problems in child welfare by deliveringenhanced services to birth families designed to prevent the need to bringchildren into care and to reduce the numbers of terminated parental rightsand adoptions. By the 1990s, children were once again lingering in foster careand experiencing multiple caretakers over prolonged periods. In 1997, theAdoption and Safe Families Act (P.L. 98-02) was passed. This act purported toprovide a more rational, though complex, approach to permanency planningby arguing for and enabling parallel planning for both return to birth familiesand termination of parental rights with subsequent adoption. The emphasison expediting permanency decisions, including recognizing kinship care as apermanency option, was expected to reduce the number of children in fostercare, increase the number of adoptions, and finalize permanent placementsmore expeditiously (Allen & Bissell, 2004; Festinger & Pratt, 2002). However,despite federal foster care policies, the system remains a complex amalgamof federal and state laws, state and local policies, procedures fraught withindigenous biases in interpretation of those laws, and implementation atlocal levels by direct service workers, judges, and foster parents, all withinthe context of community norms about acceptable parenting standards.

The risks that bring children into foster care will not mitigate or ebb asa result of laws or policies. At last report, foster care was being providedto almost 500,000 children annually—with an average length of stay of 28months in the system. More than 40% of the children in the foster care systemwere between 12 and 20 years of age, and more than 60,000 had been in the

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system for more than 5 years. The majority (54%) of children in foster carewere returned to their birth parent(s). Many (18%) were adopted or livedwith another relative (11%), and some were emancipated out of the system(9%). Among children in care for more than a year, only 51% had fewer thantwo substitute care placements in the first 2 years; and once children hadbeen in the system for more than 2 years, replacement rates approached 75%.More than 5% of those age 12 and older were in group homes or residentialplacements (Administration for Children and Families, 2005).

The stark reality is that most children in foster care are repeatedlyon the move. They enter an impermanent system of care, awaiting eitherreunification with their birth families or placement in foster or adoptivehomes. Because of the unpredictability of their situations, it is not surprisingthat over the years there has been considerable concern about the poten-tial consequences of multiple placements (Barth, Crea, John, Thoburn &Quinton, 2005; Barth, Berry, Carson, Goodfield, & Feinberg, 1986; Grigsby,1994; Mennen & O’Keefe, 2005; Penzerro & Lein, 1995; Pilowsky & Kates,1996; Rittner, 1995; Stokes & Strothman, 1996; Stovall & Dozier, 1998; Stovall-McClough & Dozier, 2004). In many cases, concern about the negative conse-quences of multiple placements has been framed in the context of attachmentdisorders. This study proposes reframing the issue of problems seen inplacement of children into and within foster care and moving from a relianceon attachment theory to alternative approaches. It acknowledges the issuesraised by Barth et al. (2005) regarding the utility of attachment theory withinthe myriad family relationships foster children experience precisely becauseit begs the question: attachment to whom? It suggests, instead, a morepragmatic approach to understanding the behaviors of children as they movethrough the foster care system, an approach grounded in emerging conceptsabout how children react and respond to complex traumatic events (Pynooset al., 2008), how they become alienated from adult caretakers (Kelly &Johnston, 2001), how they manage transitions in the resources they have, andhow they cope with losses of resources as a result of moves (Hobfoll, 2002).

FOSTER FAMILY RELATIONSHIPS

Limitations of Attachment Theory in Child Welfare

Attachment theory (Bowlby, 1982) has had a major presence in child welfareliterature and training for decades. Elements of the theory were criticalto making a strong case against casually moving children around withinthe foster care system without recognizing ongoing connections to birth orfoster families. Further, it shaped many of the policies that governed theprovision of preventative services to birth families before removing childrenand placing them in alternative settings (Aber, Allen, Carlson & Cicchetti,

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1989; Grisby, 1994; Hegar, 1988; Poulin, 1985; Proch & Tabor, 1987). Attach-ment schematics fueled training models heavily reliant on Ainsworth’s (1989)expansion of Bowlby’s work to explain children’s reactions to prolongedand unexpected separations from parents—a spectrum of attachment typesfrom secure to disorganized/disoriented attachments (Lawrence, Carlson, &Egeland, 2006).

Arguments to dismiss attachment theory as a foundation in child welfare,regardless of how it is measured, have been well articulated by Barth et al.(2005) and others (Dozier & Sepulveda, 2004), in part because attachmentschematics do not adequately explain foster children’s behaviors when theyconfront losses of primary relationships and adjust to unfamiliar substitutecaretakers. Clearly there are questions of timing when assessing attachmentin foster children. In a matter of days, many of these children encounterserial parent substitutes—some of whom remove them from where they live,some of whom they may be related to and care for deeply, some of whomthey do not know and may merely tolerate, and others whom they mayfind frightening. Children disrupted from one setting and placed in anotheroften react in ways suggestive of attachment problems but which are morelikely adjustment responses to new situations. Once children have been ina setting for a while, the responses observed in them are overshadowed bythe specter of impermanence in their new relationships and conflicts andconfusions about possibly staying where they are, leaving for somewhereelse, or missing where they have previously been. Further, there is remark-ably little empirical support for treating attachment in foster care, and mostof what has been described is based on case studies (Barth et al., 2005).As Dozier and Sepulveda (2004) observed, foster children with histories ofdisrupted relationships, trauma, neglect, and developmental lags are movedinto shelters and foster homes, and their behaviors are likely to reflectbewildering transitions in relationships rather than ‘‘attachment problems’’per se. In essence, the question of which characteristics in foster familiestruly predict positive or negative outcomes and why is never fully addressedin much of the foster care literature on attachment (Orme & Buehler, 2001).

Reactive Attachment Disorder: Compounding the Problem

Assumptions of disordered attachment in foster children have engenderedthe tendency to pathologize the process of adjustment to new settings withdiagnoses such as reactive attachment disorder (RAD; American Psychiatric

Association Diagnostic and Statistical Manual [4th ed. text revision], 2000).The etiology proposed for the disorder fits the profile of many children enter-ing foster care: prolonged separations, traumatic experiences, and extremepoverty. Criterion A of RAD describes disturbed social relatedness beginningbefore age five—with significant problematic social interactions either alonga restrictive or diffuse continuum as a key element of the disorder. It is

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worth noting that RAD is almost exclusively studied in children not residingwith their birth families (Hall & Geher, 2003). Findings from studies suchas Zeanah et al. (2004), which report evidence of both types of RAD in40% of foster children, generally do not provide information on the lengthof placement with foster parents or the reciprocal level of attachment of thefoster parents to the children being evaluated. Other studies, such as Leathers(2002), measured perceptions of belonging against behavioral disturbancesin pre-adolescent and early adolescent children living in non-relative fostercare and noted that stronger attachments to foster families appeared asso-ciated with lower behavioral problems and that difficulty forming strongrelationships with foster parents appeared to predict higher replacementsrates, especially for males.

At the heart of the debate are concerns that the disorder lacks both dif-ferential diagnostic capability and discrete symptomology (Zilberstein, 2006).This is, in part, a product of the way the DSM-IV-TR (2000) frames thedisorder: It focuses on behaviors that could derive from a variety of sources,including developmental delays (an exclusion), and blames the behaviorson pathogenic relationships within families. Many of the children in thechild welfare system live in birth families with very few resources (Jones,1998). These families cope with lack of income, unstable housing, and fewfamily and friends who can provide ongoing assistance. Parents managechallenges inherent in long daily separations from their children and in livingin dangerous and deteriorated neighborhoods that provoke legitimate fearsfor safety and may invoke appropriate ‘‘hypervigilance.’’ These parents rarelyhave time, energy, or resources to provide their children with much in theway of the intellectual and social stimuli necessary for optimal cognitive andsocial skills development. Ironically, the problem with excluding develop-mental delays in this diagnosis is that it ignores a documented consequenceof severe poverty, neglect, and trauma exposure (Lieberman & Zeanah,1995; Pynoos, Steinberg, & Piacentini, 1999; van der Kolk, 2007a, 2007b;Zeanah et al., 2004). Further, exposure to trauma and neglect occurs infoster and birth families, so the assumption that this is a consequence ofparent-child relationships is seriously flawed. These children, in their shortlives, experience a variety of competent and nurturing and incompetent,neglectful, and even dangerous caretakers, some of whom are related andothers who are not. In turn, these children may evidence developmentallags in verbal skill acquisition, social skills, and indiscriminant attachmentto adults as coping strategies in response to stress, symptoms consideredcentral to the child characteristics of RAD (DSM-IV-TR, 2000; Ford, 2009).

Parental characteristics associated with RAD include a lack of emotionalavailability and support and a failure of provision for physical needs. Thesecharacteristics are also associated with severe poverty, a condition fosterchildren often experience prior to entering the system. That is not to dismisslightly the long-term impact of such neglect on the development of children.

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It has been observed that high levels of neglect appear to predispose childrento more psychological distress, physical and sexual abuse, and lifetime de-pression and dysfunction (Berrick, 1997), but these higher rates of distressare also associated with higher rates of poverty—even when parents areneither neglecting nor abusing their children (Bratter & Eschbach, 2005).

Additionally, some have argued that the symptoms of RAD could justas easily be a manifestation of a child’s temperament or the result of other,more common disorders, including oppositional defiant disorder, conductdisorder (disinhibited), depression, social phobia (inhibited), and spectrumdevelopmental disorders (both inhibited and disinhibited; Kaplan, Sadock,& Grebb, 1994). In fact, recently there have been challenges to the use ofRAD with foster children and greater focus on the problems associated withattempting to assess or treat RAD, especially in foster care settings (Blatt,2000; Marsenich, 2002). This includes Worrell’s (2000) concerns that thereis little empirical evidence to support specific treatment for children withattachment disorders, a position strongly supported by O’Connor and Zeanah(2003a, 2003b). Finally, Barth and his colleagues (2005) suggest that morepromising approaches in the child welfare system are those that enhanceparent-child daily operational relationships—that is, those things that makeday-to-day experiences less stressful and more productive.

Alternate Approaches

It is useful for foster care investigators and workers, foster parents, guardians,and clinicians to understand the impact on children of extreme poverty, ex-posure to various types of abuse, and the process of entering into and movingthrough the foster care system. We propose three alternative approachesnot commonly utilized in child welfare as a means of thinking about theexperiences children have before, during, and after foster care: conservationof resources, child alienation model, and developmental trauma disorder.

CONSERVATION OF RESOURCES: A BETTER ECOLOGICAL FIT

In part, support for a move away from pathologizing of behaviors as dis-ordered attachment is articulated by Nilsen (2003), who observed that chil-dren’s attachments are fundamentally adaptable and that a problem in onesetting may not necessarily be a problem in another. As children enter anysystem of care, they experience many losses and may well manifest anxiety,depression, stressful interpersonal behaviors, withdrawal, externalizing be-haviors, and moodiness as they adjust to new settings. Harden (2004) andSwick (2007) recommend that foster parents try to understand the historiesand current circumstances of the children in their care through the lens ofan ecological perspective, wherein all systems are considered relevant andinfluential.

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Conservation of resources (COR) theory is a useful framework to ex-amine those factors at a global level that contribute to adjustment problemssome children exhibit in foster care. It is a derivative of stress theory andecological perspectives and was first hypothesized by Hobfoll (1986) toilluminate the interconnections among loss, threat of loss, or failure to gainresources and the consequent impact on abilities to adapt to and cope withstress (Hobfoll, 1988, 1989, 2002). Resources are defined as those thingspeople value, and value is determined by the meaning attributed to theparticular resource via shared cultural views (Hobfoll & Spielberger, 1992).COR posits that resources include (1) ‘‘objects (e.g., transportation, shel-ter), (2) conditions (e.g., tenure, seniority, a good marriage), (3) personalcharacteristics (e.g., social competence, self-esteem, sense of mastery), and(4) energies (e.g., money, credit, insurance’’; Hobfoll & Lilly, 1993, p. 129).

As children enter into substitute care, they lose their environment (ob-jects), their familial connections (conditions), their sense of who they are andwhat is expected of them as part of a given family (personal characteristics),and the comfort of daily patterns and most of their belongings (energies).In addition, many of these children come into care from ‘‘circumstances’’marginalized by poverty and marked by unstable housing, community vi-olence, fragmented social supports, and interpersonal connections and, asHobfoll and Lilly observed, are, as a result, ‘‘less empowered [with] morevulnerable resources’’ (Hobfoll & Lilly, 1993, p. 129).

COR provides a way to understand how children experience transitionsinto and through foster homes and why they may perceive that experience asinvolving the loss of most of the resources they have. It also helps to revealthe stark reality that foster children are generally powerless to produce theirown resources and are largely dependent on the adults in the various socialsystems with which they interact to provide resources for them. As a result,they are likely to be very anxious and uncertain as to whether they can regainresources in new settings and whether the resources they are provided arethe ones they need or want.

It is axiomatic that having appropriate resources enhances capacitiesto adjust to stress and that inappropriate resources or a lack of resourcesincreases vulnerabilities to increased stress reactions. Johnson, Palmieri, Jack-son, and Hobfoll (2007) explored whether women with more resources,including psychosocial supports, were more resilient and whether such re-sources aid in recovering from posttraumatic stress disorder (PTSD; DSM-IV-

TR, 2000; see also Hobfoll, Johnson, Ennis, & Jackson, 2003). They reportedthat most of the women in their study lived in poverty, well more than halfhad histories of sexual assault, and many met criteria for PTSD, but thosewith relatively more resources were also more resilient and able to replacelost resources more quickly. Further, Schumm, Hobfoll, and Keogh (2004)found women with both physical and sexual abuse histories had higher ratesof PTSD, interpersonal problems, revictimization, and interpersonal resource

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losses (e.g., ending of positive intimate relationships, unstable housing, joblosses, and fragmented social relationships). These findings were furthersupported by findings of higher rates of depression and PTSD in a lon-gitudinal study of low-income, inner-city women with multiple events ofphysical abuse (Schumm, Stines, Hobfoll, & Jackson, 2005). These studiesare substantially applicable to foster care because of the parallels found inthe lives of children in foster care: complex trauma histories, higher ratesof severe poverty, marginal resources availability, and difficulty in replacinglost resources (Schumm et al., 2004, 2005).

Finally, also according to COR, resource losses across multiple domainsengender a greater probability that those resources will be less likely to bereplaced, compelling increasingly primitive survival responses to additionalstressors (Litz, Gray, Bryant, & Adler, 2002). From the perspective of fosterchildren, their tendency to be reactive, self-protective, and defensive mayreflect the primitive coping strategies observed in COR research, especiallyas they enter a system with very few resources and little expectation thateven their most basic needs will be met.

CHILD/PARENTAL ALIENATION WITHIN FOSTER CARE

Also worth considering are parallels to an emerging field of inquiry intothe negative behaviors and distress children display when their families areengaged in high conflict divorces (Gardner, 1992, 1998; Kelly & Johnston,2001). Many of the factors associated with these divorces parallel factorschildren experience as they move through the foster care system. ThoughGardner (1992) argues that hostility on the part of one parent toward theother with a child predisposed and encouraged to support the hostility leadsto a syndrome of unreasonably biased, disordered, and even pathologicalrelationships toward a non-custodial parent (parental alienation syndromeas he labels it), Kelly and Johnston (2001) argue that there is little empiricalsupport for parental alienation as a syndrome (Gardner, 1992). Instead, theysuggest that most children going through high-conflict divorces fall alonga complex continuum of child-parent relationships in which children mayremain connected to or become alienated from parents for a variety oflegitimate and concern provoking reasons.

Using the Kelly and Johnston (2001) model offers some utility in un-derstanding how children leave the care of biological parents, enter intorelationships with caretaking adults in the foster care system, and either formalliances with caretakers or feel estranged from them. Entry into the fostercare system, viewed from a child’s perspective, may share features with highconflict divorces in the potential for acrimony among the various parties:biological family members, clinicians, foster parents, attorneys for the stateor the parents or the children’s guardians ad litem, child welfare workers,and other children residing in foster homes. Children in foster homes may

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be encouraged to or spontaneously may speak angrily about birth parents,including expressions of hostility and rage for their perceived abandonment.They may be informed, infer, or declare that their parents never cared forthem or constantly placed them at risk—allegations that may or may notbe true. Worse, like children in high-conflict divorce proceedings, they mayfind an audience that is more than willing to encourage and believe thatthe negative feelings toward their birth parents are justified and legitimate,provide intended or unintended positive feedback to them for expressingnegative feelings, and reject supportive and sympathetic statements profferedby them about birth parents as misplaced loyalties. Children, in turn, mayfeel under pressure to report and expand on details of their experiences intheir families or enhance details at granular levels because various adults—foster parents, foster care investigators, foster care workers, judges, attorneys,mental health practitioners, and so on—repeatedly ask them to provideparticulars of the circumstances that led to placement and specifics abouteach experience with biological parents during visitations. They may alsoperceive that acquiescing to pressure to report on birth families will helpthem garner needed resources, despite birth parents instructing their childrenthat disclosures of any details of their visits or their home life constitutedisloyalty.

Children may be physically inspected after visits for evidence of physicalabuse and repeatedly questioned about the smallest details of visits. Dysregu-lated behaviors may be interpreted as evidence of their rejections of/by theirbirth parents, and the distress that they experience subsequent to separatingfrom parents may be considered evidence of ongoing maltreatment. Birthparents may inspect children closely, looking for signs of maltreatment,question them about their experiences in substitute care, encourage negativereports about their experiences with foster families, or may insist that fosterparents do not really care about them or are ‘‘in it or the money.’’ Childrenmay feel pressured to falsely report maltreatment or may be reluctant to re-port actual maltreatment for fear of retaliation by birth parents, foster parents,foster siblings, and the various other adults in the system. It is understandablethat children, especially children who feel ambivalence toward their birthparents, may begin to resist visitations. The interpretations of such resistancemay be framed within the context of RAD or attachment problems, when itmay, in fact, reflect their attempts to accommodate an impossible situationor may be manifestations of their coping strategies in the face of high stressand traumatic experiences.

Taken in the context of child alienation, many negative behaviors maywell derive from system dynamics of all the stakeholders as children movethrough a complex system with conflicted and confused loyalties. As a steptoward correcting the effects of alienation, commitments by foster parentsto provide optimal environments (within the limits of their capabilities andresources) for the children in their care may well play a role in successful

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placements (Brown & Campbell, 2007; Buehler, Cox, & Cuddeback, 2003;Dozier, 2005; Dozier & Lindhiem, 2006; Harden, Meisch, Vick, & Pandohie-Johnson, 2008; Hurl & Tucker, 1993). If child alienation is considered as acomponent of foster children’s experiences, it is imperative that caseworkersbegin to consider the actual impact of traumatic events on these children.

DEVELOPMENTAL TRAUMA DISORDER: UNDERSTANDING

TRAUMA IN CHILDREN

In most cases, everything about coming into foster care is traumatic (Simmel,Barth, & Brooks, 2006), and many of the children entering the system haveexperienced complex trauma. There is no question that being removed fromparents and placed in shelters and/or foster homes is stressful to childrenregardless of how dysfunctional or dangerous their biological families are.Many of these families have prior encounters with the system, and the specterof ‘‘removal’’ associated with both investigations and supervision increasesthe stress on these families and compounds it when it actually happens(English, 1991). As van der Kolk (2007b) and Pynoos et al. (1999) argue, whatis experienced as traumatic to a child may not even concern an adult or maygenerate only minimal distress. For example, being unintentionally separatedin a mall for 30 minutes is distressing to adults but is terrifying to toddlers. Theimpact of trauma on the development of the brain and emotional regulatorysystem in children is not fully understood, but trauma exposure in childhood,including severe neglect, seems to be associated with pervasive and long-range problems in the ways that children view themselves and their worldand in their ability to cope and respond appropriately to stressors (van derKolk, 2007a, 2007b). Developmental trauma disorder (DTD) is a proposeddiagnostic category to describe how complex trauma events force childrento shift into survival mode in response to increased victimization, creatingreactive behaviors and dysregulated interpersonal relationships (Ford, 2009).

Foster children come into care with histories of exposure to multiplestressors. These stressors vary from minor to extreme severity and from singleto multiple events. In many cases, children may be emotionally or physicallyharmed in their households and neighborhoods; they may experience singleor multiple physical or sexual assaults; and they may witness violence beingperpetrated toward others, including those in their families or in their com-munities. There are debates about the degree to which exposure to violencein their homes directly harms them, and the reality is that some children aremore resilient than others (Margolin & Vickerman, 2007). Not all incidentsof abuse and neglect result in child protective services (CPS) investigationsbecause many are unreported or because there are other moderating factors(a parent flees with the children from an abusive relationship, for example).Further, though many CPS investigations result in supportive resources beingprovided that help to secure and protect families, investigations may also

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rupture families by separating children from parents and scattering siblings.Long before CPS becomes involved, children who eventually enter the fostercare system often experience the duress of unpredictable behaviors exhibitedby caretakers with mental health and/or substance related problems, oftenco-occurring with violence in their homes and neighborhoods that placesthem either at additional risk or in harm’s way. It is not surprising that inrecent years, children in foster care are likely to be assessed for PTSD; adiagnosis of PTSD may well be warranted. Conversely, children who arechronically neglected, ignored, or live in extreme poverty that marginalizestheir families in substandard and often dangerous housing and forces theminto frequent moves or periods of homelessness or those who are psycholog-ically abused by family members and bullied by community members maybe just as adversely affected by their situations but may not meet criteria forPTSD. An important question is, should they?

In recent years, many of those evaluating the impact on children ofadverse childhood events have begun to consider the impact of those eventson neurophysiological and cognitive development and on subsequent socialfunctioning (Briere & Spinazzola, 2009; Ford, 2009). There is strong evidencethat infants and young children exposed to violence, severe neglect, andemotional abuse are likely to lag in neurocognitive development, identityintegration, emotional regulation, and the ability to form relationships (Ford;Simmeon et al., 2001). Basel van der Kolk’s (2005) longitudinal retrospectivestudy of 17,337 adults suggests that childhood trauma histories of physicaland sexual abuse were highly correlated with increased episodes of moodand anxiety disorders, significantly higher rates of risk behaviors such aspoly-substance use, suicide attempts, multiple sexual partners beginningin early adolescence, and domestic violence as both victims and perpetra-tors (see also Pynoos et al., 2006). His findings are consistent with thosedescribed by Stalker, Palmer, Wright, and Gebotys (2005) that enduringtrauma symptoms are associated with depersonalization and dissociation,multiple hospitalizations, and difficult interpersonal relationships in a sampleof inpatients with severe childhood trauma histories.

At the National Center for Child Traumatic Stress, co-directed by RobertPynoos and his researchers (see Pynoos et al., 2008, 1999), longitudinal dataare being evaluated to determine the types of traumas children experienced,when they experienced it, the duration of the trauma, and the long-termimpact of the trauma on their development and functioning. They and others(see Ford, 2009; van der Kolk, 2005) have proposed that exposure to com-plex trauma in infancy and early childhood causes sufficient developmentalproblems to support its more properly being described as DTD.

DTD is a more age-sensitive symptom profile of the nature and sequelaeof both interpersonal and mass trauma on young children and toddlers thatyields ways to assess and treat those children in comprehensive rather thanpiecemeal approaches (Pfefferbaum et al., 2006; Pynoos et al., 1999, 2006;

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van der Kolk, 2007a, 2007b). Among the important themes emerging inDTD research is the understanding that complex childhood trauma altersnormative developmental processes across many domains and appears tohave a deleterious impact on cognitive, adaptive, social, and emotionalgrowth and on altered memory structures. It is not surprising that childrenin the foster care system fit the DTD profile as the very experiences thatbring them into the system are those studied in DTD research. Under therubric of DTD, complex trauma exposure leads to the creation of alternativemechanisms for responding to the environment. Exposure can result in thebrains of young children shifting from a learning/experiencing mode to oneof primitive survival. As Ford reports, ‘‘: : : the survival brain is fixated onautomatic, nonconscious scanning for and escapes from threats’’ (p. 35).Transitioning from birth to foster home or foster home to foster home is likelyto be perceived as threatening. Ford and others (Pynoos et al., 1999, 2008;van der Kolk, 2007a) make a case for DTD as more relevant than attachmentin understanding why children in the foster care system are often so highlyunpredictable and aggressive and, in particular, why they tend to respondin protective, dysregulated, and reactive ways to unfamiliar stimuli.

Recent studies strongly suggest that beginning in early infancy, childrenare assembling comprehensive schemata of themselves, their caretakers, andtheir worlds, all of which shift as new information and skills are acquiredand others are pruned and discarded as needs for them extinguish (Parvizi& Damasio, 2001). New findings suggest that children as young as 6 monthsshow evidence of extremely good memory/perceptual processing, includingfor faces (Nelson, 1993; Pascalis, de Haan, & Nelson, 2002), but the kindsof severe trauma events that result in children’s being placed in foster caretend to distort how memory is stored and retrieved, resulting in attention,learning, and verbal processing deficits, especially in infants and toddlers(Ford, 2009). It is not surprising, therefore, that many children in the fostercare system are unable to articulate their experiences in meaningful or helpfulways to workers or clinicians or to develop self-reflection as a means ofregulating reactive responses, especially to perceived threats. If this is thecase, it helps to explain why so many children in the foster care systemappear to have few (sometimes none) or very inaccurate memories of theadverse experiences that brought them into care or occurred while in care.Rovee-Collier (1997) observed that adults and children store memories ofsignificant events mutually in the hippocampus (explicit memory) and in theamygdale (implicit and more emotional/visceral memory) and that severetrauma seems to disconnect these two areas of memory processing, suggest-ing why young children more often retain implicit than explicit memoriesthat drive survival behaviors and why they are more likely to experienceemotional dysregulation and self-harming behaviors when confronted withtriggers for those memories (Rovee-Collier; van der Kolk, 2007). This mayalso help to explain why some foster children seem to have extreme reactions

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to apparently neutral stimuli, such as the one described in a case studypresented by Kaplow et al. (2006). They describe the impact on a 19-monthold girl of her father’s murder of her mother by gunshot while she was inher mother’s arms. The girl’s subsequent ‘‘irrational’’ fear of a red coat wornby her grandmother was apparently associated with her mother’s blood.

Viewing extreme stress reactions from a developmental perspective(DTD) facilitates understanding how certain exposures may not only betraumatic but may, in turn, influence children’s adjustment to substitute care,their ability to form relationships with caretakers, and their seemingly age-inappropriate dysregulation under stress. DTD presents ways to understandwhy children who come into foster homes with significant traumatic ex-periences often have multifaceted long-term sequelae that include devel-opmental milestone lags, depression and dissociative disorders, significantsocial deficits, higher levels of internalizing and externalizing behaviors, andpatterns of destructive and aggressive behaviors (Mongillo, Briggs-Gowan,Ford, & Carter, 2009; Scheeringa, Zaneah, Myers, & Putnam, 2003; Saltzman,Pynoos, Layne, Steinberg, & Aisenberg, 2001). Rather than perceiving theproblem from the narrow lens of attachment and RAD, DTD offers a broaderunderstanding of the multiple-cognitive and social domain impact of theseevents on children as they move through the foster care system and providesmultiple, potential avenues of intervention to directly address and treatcomplex trauma experiences (see Kaplow et al., 2006).

CONCLUSION

Barth and his colleagues make a powerful case for greater reliance onevidence-based approaches in child welfare and repudiate excessive relianceon attachment theory and related constructs (Barth et al., 2005). However,it is difficult to develop strategies to promote optimal functioning in theabsence of ways to understand what might drive problematic behaviors aschildren move through foster care systems. Understanding behavior in thecontext of trauma, recognizing the tensions that exist among the people inthese children’s lives, and acknowledging the sense of loss of resources anddifficulty in replacing those resources these children experience provide amore complex way of understanding behaviors evidenced in foster care aschildren adjust to new surroundings and unfamiliar caretakers.

Beginning at a systems level, it is imperative to recognize that manychildren enter foster care with experiences of diminished and depleted re-sources associated with poverty and that these children have little likelihoodof replacing lost resources as they move from one place to the next. CORprovides a framework for understanding why these children often hoard orgobble food when they can (Geiser & Malinowski, 1978), become extremelyupset when they are separated from their few belongings, and why providing

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them with familiar foods, hygiene products (including soaps and laundryproducts), and access to siblings and family members is so vitally important.Shifting their perspective from pathologizing the behaviors to recognizingexperiences of loss will allow foster parents and child welfare workers toidentify means to build an infrastructure tailored to an individual child’sparticular history and will provide that child with the resources needed toaccommodate current circumstances. Such approaches may include ensuringthat transitional objects (familiar blankets, toys, cups, and the like) accom-pany children into their new environments and identifying ways to makeintegration of those items acceptable to foster parents. Because it is not un-common for foster parents to reject the introduction of items into their homesperceived as filthy or contaminated, this approach may require helping fosterparents understand why replacing those items may not adequately meet thechildren’s needs. Likewise, ensuring that children have access to siblingsand other important people in their lives who predate placement providesa sense of what Nelson (1993) referred to as autobiographical memory, partof what Hobfoll and Lilly (1993) consider personal characteristic resources.Finally, activities to help children develop a sense of continuity of self arecritically important, especially for older children. Playing in sports leaguesor visiting with or talking to friends from their prior communities are waysto regain ‘‘energies’’ as they settle into their new settings.

It may prove difficult to prevent the adversarial relationships that canoccur when children are in the foster care system. However, delimitingthe direct exposure of children to the conflicts and avoiding mechanismsthat triangulate children unnecessarily are imperative. Efforts must be madeto provide training to case workers and court personnel to delimit theircontribution to the alienation of children from their caretakers (birth andfoster). Recognizing that children in foster care are required to respond tomultiple situations involving conflicted loyalties is crucial, especially whenthey are pressured into reporting the actions of neglect or abuse at the handsof their birth parents or in their foster homes. Child alienation provides a lenswith which to understand why children are tentative when being integratedinto new and unfamiliar families because it addresses the ongoing conflictualdynamics which often in force.

Finally, clinicians working with these children would benefit from un-derstanding how complex trauma has shaped the children’s lives and thecomplex ways in which they respond to their environments. Trauma assess-ments must be sensitive to developmental issues and the impact of severetrauma histories. Shifting assessments from the adult models inherent inPTSD to the more age-appropriate insights available from DTD will allowinterventions to address the neurocognitive, social, emotional dysregulation,and functional lags evidenced in so many of the children in foster care. All ofthese approaches provide mechanisms to help these children become moreadaptive to their environments.

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