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Mental health assessment of infants in foster care



Infants placed in foster care are at high risk for emotional and behavioral problems. Assessment of their mental health must account for their often-adverse life experiences prior to placement and the involvement of multiple systems that shape their lives in lieu of parents' authority. This article presents practice guidelines for infant mental health evaluations with consideration of legal requirements and the unique issues conferred by foster care.
0009–4021/2007/050735-55 $3.00 Child Welfare League of America 35
Judith Silver PhD is Director, Starting Young Program, Department of Psychology, The
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. Sheryl Dicker JD is For-
mer Executive Director, New York Permanent Judicial Commission on Justice for Chil-
dren, Albany, New York.
Mental Health Assessment of
Infants in Foster Care
Judith Silver and Sheryl Dicker
Infants placed in foster care are at high risk for emotional
and behavioral problems. Assessment of their mental
health must account for their often-adverse life experi-
ences prior to placement and the involvement of multiple
systems that shape their lives in lieu of parents’ authority.
This article presents practice guidelines for infant mental
health evaluations with consideration of legal require-
ments and the unique issues conferred by foster care.
3 6 C HI LD WELFARE VO L. 86, #5 S ep tember/Octob er 2 007
arly childhood presents an unparalleled opportunity to
improve the mental health and developmental outcomes of
high-risk infants
(Shonkoff & Phillips, 2000). Much of what
is published on early childhood assessment has focused on child-
care settings or early intervention programs for infants with devel-
opmenta l delays and disabilit ies (Knitze r, 2000; Shonkoff &
Meisels, 2000). The vast majority of these children reside with their
parents. However, infants who e xperience maltreatment and
placement in foster care
face the greatest risk for emotional and
behavioral problems.
This paper is intended to inform the professional practice of
those involved in the mental health assessment of infants in foster
care. It briefly summarizes existing guidelines for infant mental
health assessment and recommends practice modifications based
on legal requirements and other distinctive issues associated with
foster care. Mental health evaluations of these infants must
address the complexity contributed by their atypical life experi-
ences and the involvement of multiple systems that shape chil-
dren’s lives in lieu of parents’ authority. In 2003, the Child Welfare
League of America and the American Academy of Child and Ado-
lescent Psychiatry (AACAP) collaborated to develop guidelines
addressing the mental health needs of children in foster care. The
authors, a clinical child psychologist and a child welfare/disability
attorney, participated in and developed recommendations for
assessment based on work with court-involved infants (Dicker &
Gordo n, 2004; Silver, DiLorenzo, Zukoski, Ross, Amster, &
Schlegel, 1999a).
Why Assess Infants?
Infants in foster care experience longer placements, higher rates of
reentry into foster care (experiencing recurrent maltreatment and
disruption of family bonds), and high rates of behavior problems,
In this article, the term “infant” refers to children under the age of 3.
In this article, the term “foster care” is inclusive of infants placed with relatives in kinship care.
ilver and Dicker 3 7
developmental delays, and health problems (Blatt, S aletsky,
Meguid, Church, O'Hara, & Haller-Peck, 1997; Goerge & Wulczyn,
1999; National Survey of Child and Adolescent Well-Being, 2005;
Silver et al., 1999a). Because of these risk factors, mental health
assessment is critical.
Infants are exquisitely sensitive to the emotional tone of their
environments. When confronted with episodes of abuse, domestic
violence, and volatile adults, their brains respond by secreting
atypical levels of stress hormones (Dozier, Manni, Gordon, Peloso,
Gunar, & Stovall-McClough, 2006; Gunnar & Barr, 1998). Similar-
ly, severe neglect, which leaves the infant isolated, hungry, and in
pain and discomfort, also results in high levels of stress (Dozier et
al., 2006; Gunnar & Barr, 1998). Infants experience heightened
physiological arousal, manifested in symptoms of intense anxiety,
such as exaggerated startle responses, sleep and feeding disorders,
fearfulness, and irritability (Scheeringa & Gaensbauer, 2000).
Infants also experience grief and depression in response to losing
beloved family members due to foster placement, a parent’s incar-
ceration, death, or child abandonment (Zero to Three, 2005).
Infants express emotional distress in several ways. They may
demonstrate physiological dysregulation (for example, intense
irritability, heightened arousal, limited ability to self-soothe, feed-
ing and sleep disorders). Often, toddlers also present with behav-
ioral disturbances (for example, aggression, defiance, impulsivity,
overactivity, or sexualized behavior). Toddlers may exhibit intense
fears and anxiety related to situations associated with past trauma
(for example, bathing, being left alone in a room, diaper changes)
(Heller, Smyke, & Boris, 2002).
Emotional and behavioral issues among infants in foster care
may present in dramatic ways:
A 17-month-old compulsively inserts toys into her vagina
during her bath and cries hysterically when men visit her
foster home.
Address reprint requests to Judith Silver PhD, Department of Psychology, The Children’s
Hospital of Philadelphia, Philadelphia, PA. E-mail:
3 8 C HI LD WELFARE VOL. 86, #5 September/October 2007
A 30-month-old eats insatiably, shoves food in his mouth
even when choking, and takes food off others' plates.
A 12-month-old screams when asleep, has nightmares, and
cries whenever her foster parent leaves the room.
The behaviors of thes e infants can be challenging for their
caregivers, often leading to stress in the household and failed
placemen ts.
A comprehensive infant mental health evaluation can identify
previously unknown and unmet emotional and developmental
needs and clarify differential diagnoses (Blatt, Saletsky, Meguid,
Church, O’Hara, & Haller-Peck, 1997; Silver, Haecker, & Forkey,
1999b); identify the infant's developmental and mental health sta-
tus, including relative strengths and weaknesses; provide the fos-
ter parent, caseworker, and court with guidance on where to refer
infants for services (Dicker & Gordon, 2004; Dicker, Gordon, &
Knitzer, 2001); help caregivers better understand difficult behav-
iors and care needs; and recommend interventions to improve the
infant's functioning and outcomes. The evaluation also may pro-
vide information pertinent to permanency decisions (Dicker &
Gordon, 2004), identifying strengths, weaknesses, and areas of
conflict in the family or environment of the proposed placement
change, reunification, or permanency plan (American Academy of
Pediatrics [AAP], 2001).
Mental Health Assessment of Infants
The infant mental health evaluation differs from that of older chil-
dren. Prof essionally recognized tools and methodology for
infants, such as Practice Parameters for the Psychiatric Assessment
of Infants and Toddlers (0–36 Months) (American Academy of
Child and Adolescent Psychiatry [AACAP], 1997), and the Diag-
Acknowledgement: We wish to acknowledge Dr. Marilyn Benoit, past president of the
American Academy of Child and Adolescent Psychiatrists, for inviting us to participate in
her presidential initiative Foster Care Mental Health Conferences. We would also like to
thank Susan Chinitz PhD and Jerilynn Radcliffe PhD for their thoughtful comments on ear-
lier drafts of this article.
ilver and Dicker 3 9
nostic Classification of Mental Health and Developmental Disor-
ders of Infancy and Early Childhood, Revised Edition (DC: 0-3R)
(Zero to Three, 2005), are available. When assessing infant mental
health, three issues are paramount: a dynamic, developmental per-
spective is essential (AACAP, 1997; AAP, 2000), assessment should
include interdisciplinary input, and assessment should occur in
the presence of the infant's parent or foster parent (AACAP, 1997;
Zero to Three, 2005).
Developmental Perspective Is Essential
The most rapid period of development occurs during the first
three years of life. The infant’s functioning is moderated by the
differential pace of development of various domains, such as
speech/language, cognitive, and social skills. During this time cer-
tain experiences must be present or later outcomes may be com-
promised during sensitive periods. An infant's opportunity to
form a secure attachment to a primary caregiver can impact early
development of emotional self-regulation (Dozier et al., 2006), and
multiple placement changes may interfere with this process.
Interdisciplinary Assessment Is Crucial
Infants require interdisciplinary evaluation because of the intricate
interface among health, developmental, and reactive mental health
conditions. For this preverbal population, it is often difficult to dif-
ferentiate between conditions acquired as a result of the infant’s
life experiences and those potentially congenital (Morrison, Frank,
Holland, & Kates, 1999).
A foster mother reports the 27-month-old doesn’t chew his
food, has difficulty swallowing, stuffs food into his mouth
even when choking, and eats beyond satiety. Although
many infants with histories of neglect and hunger may
present with some of these behaviors, he is diagnosed with
Williams Syndrome, a rare genetic condition that includes
problems in cardiovascular and musculoskeletal systems,
feeding problems, and growth delay.
4 0 C HI LD WELFARE VOL. 86, #5 September/October 2007
A newly placed 9-month-old is irritable and difficult to
comfort. Feeding is extremely trying as she arches her
back, rejects h er bottle, a nd spits up formula. Although
many of these symptom s may be associated with difficul-
ty adjusting to a new placement, she suffers from gastro-
esophageal reflux, which interferes with her ability to
feed and enjoy mealtimes. If untreated, she may exp eri-
ence intense pa in as her esophagus become s inflamed.
The caregiver-infant relationship may become impaired by
her irritability.
In these cases, medical and reactive emotional conditions
show similar behavioral presentations. Thus, the mental health
professional should work collaboratively and even evaluate joint-
ly with pediatric and allied health professionals so that the mental
health evaluation is informed by their findings (Horwitz, Owens,
& Simms, 2000).
Assess in the Presence of the Infant’s Primary Caregiver
It is essential to evaluate infants in the presence of a familiar care-
giver. Infants experience distress as a state of physiological arous-
al and internalized feelings. They are easily overwhelmed and
stressed by encounters with unknown adults. Both physiological
and behavioral regulations are facilitated when the infant is with a
familiar adult who knows effective ways to soothe him (Schuder
& Lyons-Ruth, 2004). The evaluator is more likely to obtain valid
assessments when infants have been in foster care for approxi-
mately a month and both the infant and caregiver are familiar with
each other.
Special Issues in the Assessment of Infants in Foster Care
Absence of History
When infants enter foster care, information about their current
medical needs, past medical history, family history of medical con-
ilver and Dicker 4 1
ditions, and important information on birth history typically are
unavailable. When conducting an assessm ent, the evaluator
should seek as much history as possible, including birth history,
length of gestation/prematurity, newborn health status ratings,
health and immunization records, early intervention assessments,
and related Individual Family Service Plans (IFSPs) or Individual-
ized Education Plans (IEPs) (Silver et al., 1999b). Establishing
agreements for release of records to the evaluator prior to the eval-
uation is helpful. Often, certain records are essential to conduct a
valid evaluation. For example, with premature infants younger
than 24 months, the evaluator must take into account the length of
gestation in weeks to determine whether current functioning is
appropriate or delayed.
Multiple Sources
In obtaining information about the infant’s presenting problems
and pertinent family history (including key events that occur dur-
ing this and prior placements), the evaluator should rely on mul-
tiple sources, including the child’s current foster parent, case-
worker, and birthparent whenever possible (AACAP, 1997).
Establishment of an Alliance with the Family
In general, the evaluator needs to establish an alliance with the
infant’s family to encourage the exchange of information both dur-
ing and following the evaluation (AACAP, 1997). For infants in
foster care, this situation is complicated by the biological parents’
availability to the evaluator and possible concerns about the
adversarial nature of the child welfare and court systems. Parents
may be reluctant to speak to the evaluator, fearing this discussion
will prevent their child’s return. Alternatively, foster parents may
feel undermined by their lack of standing in court despite their
devotion to the infant. The evaluator must be sensitive to these
dynamics and be strongly encouraged to reach out both to the
infant’s biological and foster parents for information.
4 2 C HI LD WELFARE VOL. 86, #5 September/October 2007
Legal Issues
The court is the central decision maker in foster care cases, approv-
ing all placements and reviewing all case plans. The court can
order release of records, an assessment of the infant, or the sharing
of the assessment report with the child welfare agency, foster par-
ent, primary care physician, early intervention provider, mental
health provider, attorneys, or Court Appointed Special Advocate.
Although the court order granting custody to the child welfare
agency includes the authority to consent to emergency and routine
medical care, if reunification is the goal it is good practice to keep
the biological parents involved in these matters. Efforts should be
made to obtain consent from the biological parents to release birth
medical discharge records as well as pertinent health, early inter-
vention, and mental health records. Parental consent to the infant’s
mental health assessment and to release its report also should be
sought (Dicker & Gordon, 2001). If parental rights have been termi-
nated, this consent must be obtained from the court. Table 1
describes critical legal information the evaluator should consider.
When Should Assessments Occur?
High-risk infants, such as those placed in foster care, require mul-
tiple points of assessment over the first three years of life because
of the dynamic nature of development during these years. The
interplay of frequent maturational changes, the often-uneven
emergence of skills in different developmental domains, and
infants’ unique vulnerabilities to stress and deprivation warrant
ongoing examination (AACAP, 1997).
Within 30 days of entering placement, all children should
receive a comprehensive pediatric evaluation, with pediatric follow-
up according to guidelines of the Early Periodic Screening, Diag-
nostic, and Treatment (EPSDT) schedule (AAP, 2000; AAP, 2001;
Child Welfare League of America, 2007). Children under three
should then receive an interdisciplinary developmental evaluation
that includes the use of standardized measures between 30 and 60
ilver and Dicker 4 3
Critical Legal Information
Stage of the Case:
Has the court:
ordered removal of the child from the biological home?
held an adjudication hearing to determine if the child was maltreated?
issued a dispositional order including placement, visitation, and services for the chid
and the parents?
held a permanency hearing? What permanency goals were ordered (i.e., adoption,
return home, placement with relatives)?
entered an order terminating parental rights?
set adoption as a goal and scheduled a hearing?
Permanency Status:
With whom is the child placed?
What are the visitation orders?
Have parental rights been terminated?
What is the permanency goal?
Consent Issues:
Has the biological parent:
signed a release of information? Has the court issued an order for the release of
granted consent to referral, evaluations, and services? Has the court issued an order
for referral, evaluations, and services?
Contact Information:
Child’s attorney and CASA
Child welfare caseworker
Child welfare private provider agency caseworker
Primary health care provider
Parent’s attorney
Foster parents and biological parents
Contents of Court Orders:
Permanency goal
Services for child and parents (EI /Preschool Special Education Program, Early Head
Start or Head Start)
4 4 C HI LD WELFARE VOL. 86, #5 September/October 2007
days in placement. The mental health evaluation should occur at
the same time or shortly following the developmental evaluation.
Initial developmental and mental health evaluations are best
conducted after the infant has had a month to adjust to the new
caregiver(s). Prior to this period the infant may still be acutely
reacting to the loss of the primary caregiver due to entering place-
ment. This initial assessment provides a baseline of developmental
and mental health status against which to compare the infant’s
growth and progress in the future. Ideally, reevaluations should
take place every six months until the infant is 36 months old, with
annual mental health/developmental evaluations thereafter, or as
needed. This frequency is suggested due both to the distinctive
nature of this stage of life, when specific disorders emerge, and
because of problems regarding continuity of care inherent in the
child welfare system. During this stage of life we see the emergence
of developmental disorders (such as autistic spectrum disorders),
developmental delays ( when an infan t f unctions significantly
below their chronological age in one or more areas of develop-
ment), and relational disorders (such as attachment disorders), all
warranting intervention to address the condition and improve the
infant’s functioning. Many conditions emerging in early childhood
present differently at subsequent stages of development, thus seri-
al evaluations are needed to monitor the infant over time.
Another trigger for the mental health evaluation for an infant is
when a parent, foster parent, caseworker, teacher, or health care
professional expresses concern about the infant’s emotional or
behavioral functioning. A comprehensive, interdisciplinary evalu-
ation is urgently needed when infants appear to be losing previ-
ously acquired developmental skills. The infant should first be seen
by the primary health care provider (PCP) to identify whether the
behavior changes and loss of skills may be due to medical condi-
tions, such as the onset of neurological disorders (for example,
seizure disorders, tuberous sclerosis, and postnatal exposure to toxins
like lead) and other conditions. The PCP may be able to rule out a
medical problem or may decide that referral to a specialist is war-
ilver and Dicker 4 5
ranted to further evaluate for physical etiologies. The developmen-
tal and mental health evaluations should follow the PCP appoint-
ment but may be conducted during the time the infant is waiting
to see the specialist. The developmental and mental health evalu-
ation(s) aim to identify whether the infant’s deterioration is a func-
tion of the emergence of an autistic spectrum disorder, or an emo-
tional reactive condition (for example, depression following sepa-
ration from family), or due to an adverse environment (for exam-
ple, exposure to violence, neglect or abuse), which can result in
posttraumatic stress and other anxiety disorders. The evaluator
must also consider whether the quality of the current foster home
plays a role in the infant’s deterioration. Finally, comprehensive
evaluations should be conducted when the infant changes place-
ment or prior to reunification or adoption (Blatt et al., 1997). This
evaluation provides a baseline for monitoring the infant’s adapta-
tion after the transition.
Components of the Evaluation
Review of the Results of Recent Pediatric Assessment and
Treatment Plan
Highlight any medical conditions, recommendations for addition-
al medical specialty evaluations, or tests.
Developmental Assessment
Assess with standardized meas u res to determine an infant’s
developmental status. This information may be obtained from
other sources, including the infant's most recent EPSDT screen
from a pediatric well-child visit or a multidisciplinary develop-
mental evaluation for early intervention or special education serv-
ices. Recent legislation (Keeping Children and Families Safe Act,
2003; Individuals with Disabilities Education Improvement Act
[IDEA], 2004) mandate that all children under three involved with
a substantiated case of maltreatment must be referred to Part C
early intervention services. Although this mandate only involves
4 6 C HI LD WELFARE VOL. 86, #5 September/October 2007
one evaluation, we strongly recommend that infants who do not
qualify for early intervention services receive reevaluations bian-
nually until 3 years of age due to concerns about both the discon-
tinuities inherent in the child welfare system (for example, changes
in placements and, by extension, the PCP, compounded by the
high turnover of caseworkers) and the rapid pace of development.
New caregivers may not recognize e merging developmental
delays or disorders when these infants change foster homes or if
their caseworker has changed.
Mental Health Assessment
Reason for referral. This is used to record caseworkers’, foster care-
givers’, and biological parents’ reports of concerning behaviors
and exposure to adverse experiences. It is “essential to gather
information from those who are most familiar with the child’s cur-
rent and past functioning” (AACAP, 1997). Thus, the evaluator
should not rely exclusively upon the caseworker’s report, but
should obtain information from the infant’s multiple caregivers.
The evaluator should consider reasons for placement, family and
foster family life events, and traumatic experiences (including
exposure to violence).
Family relational history. The nature of the relationship between infant
and parent is critical due to infants’ profound dependence upon par-
ents (AACAP, 1997). Yet when an infant is placed in foster care, the
evaluator should inquire about the foster caregiver’s perceptions,
attitudes, and expectations of the infant, including whether they are
age- and developmentally appropriate. Some foster parents misin-
terpret infants rejecting behaviors as meaning that they do not need
nurturing when they are hurt or upset. Paradoxically, the infants’
off-putting behaviors often are symptoms of attachment problems
(Stovall & Dozier, 2000). As a corollary, note the number of prior
placements and reasons for placement disruptions.
Infant’s social relatedness. This includes notably the infant’s interest in
household members (adults and children) and tendency to imitate
ilver and Dicker 4 7
others. Social relatedness involves the infant’s ability to initiate, man-
age, and communicate in social interactions (Morrison et al., 1999).
Does she turn to the foster parents for comfort when feeling threat-
ened? Is she able to rely on them for emotional support when anxious
or does she routinely fail to seek comfort whenever hurt or upset?
Social relatedness is fundamentally impacted by the infant’s previous
experiences with caregivers who provided physical and emotional
care for a prolonged period, notably biological parents and foster par-
ents (including those from previous placements) (Howes, 1999).
Infants’ social relatedness also is influenced by the behaviors
and emotional attunement of their current caregivers. For exam-
ple, during an evaluation a 20-month-old made no vocalizations,
and her affect was flat. Obviously anxious, she did not cry in
protest nor turn to her foster mother for support who, in turn, did
not attend to her needs. When the toddler started to fall from her
chair the foster mother watched passively, without trying to pre-
vent her fall. Despite words to the contrary, the foster mother’s
actions imp lied indifference. Subsequently, the toddler was
removed from that home and placed in a preadoptive foster home.
Six months later she appeared transformed. The toddler demon-
strated a wide range of affect, was socially responsive, and cele-
brated her achievements on test items, turning to her new, atten-
tive foster mother with obvious pride, which was reciprocated.
In contrast to children whose deficits in social relatedness are
due to experiences of unempathic, unresponsive caregiver rela-
tionships, some children are predisposed to atypical social relat-
edness due to genetic or biological congenital factors and may
have autism or other related Pervasive Developmental Disorders
(PDD). The primary deficits in this spectrum of disorders include
impaire d communic ation and social -emotional development
(Robins, Fein, Barton, & Green, 2001). If autism/PDD is suspected,
referral to a specialist is warranted.
The evaluator may have difficulty in determining this diagno-
sis when a toddler has experienced severe neglect and poor quality
attachment relationships (Morrison et al., 1999), as he may present
4 8 C HI LD WELFARE VOL. 86, #5 September/October 2007
with symptoms similar to those seen in children on the autism
spectrum. However, when these children are placed in a nurturing
foster home their autistic symptoms usually abate (Hoksbergen,
ter Laak, Rijk, van Dijkum, & Stoutjeskijk, 2005).
Relationships with other children. For example, those living in the
household, including the caregivers’ biological children and the
new arrivals and departures of other foster children. Inquire about
episodes of aggression, biting, or being bullied by others.
Infant’s contact with the biological family. This includes parental and
sibling visitation or lack thereof and its impact upon the infant.
Assessment of the infant’s behavioral organization. Inquire about the
infant’s temperament. How does the infant regulate his physio-
logical state, alertness, and activity patterns? How persistent is he
with goal-directed activities? How distractible? How does the tod-
dler regulate his emotions and calm himself? How does he adapt
to new situations? What situations set him off, what does he do
during a tantrum, what is their duration, and what soothes him?
It is important to consider whether this behavior is age-typical, a
function of delayed language development, or symptomatic of
intense distress.
Assessment of the infan ts response to s tress. How does the infant
deal with feeding, sleeping, t oileting, bathing, diapering, sepa-
ration, and frustration/distress? Observe how she copes with
the stress of the evaluation, and makes u se of her caregiver for
emotional su pport.
Assessment of the toddler’s quality of play. Play should be considered
in terms of the insights it provides into the infant’s preoccupa-
tions, emotional tone, and developmental status. Play themes can
be revealing, such as traumatic play in which a toddler repeats
episodes of violence or abuse (for example, adult dolls repeatedly
hitting each other) or sexualized play (for example, two dolls sim-
ulating sexual intercourse) (S. Chinitz, personal communication,
October 17, 2006). The toddler’s emotional expression during play
ilver and Dicker 4 9
should be noted. The examiner should also become familiar with
developmental milestones associated with play (Gitlin-Weiner,
Sandgrund, & Schaefer, 2000).
Assessment of the infant’s strengths. This includes the caregiver’s, par-
ent’s, and caseworker’s reports, as well as evaluator observations.
Ask the parent and foster parent what they like about the child.
Assessment for signs and symptoms of maltreatment. This includes
neglect and physical, sexual, and emotional abuse (AAP, 2001).
The evaluator should observe the infant’s appearance, such as the
presence of bruises, burn marks, sparse hair, circles under the eyes,
and whether the infant or toddler appears thin. Behaviorally,
infants may cringe or arch their backs when the evaluator benign-
ly approaches or lifts his or her hand (S. Chinitz, personal com-
munication, October 17, 2006). They may seem hypervigilant,
presenting a wary watchfulness and serious demeanor, as if on
“high alert.”
Assessment for risks of placement disruption (AAP, 2001). This
includes caregiver burnout, ambivalence or indifference, or esca-
lation of the infant’s behavior problems.
Diagnostic and clinical formulation. The mental health assessment of
an infant in foster care aims to improve understanding of the
infant’s developmental and interpersonal strengths and weak-
nesses relative to others the same age; identify symptoms; and for-
mulate a diagnosis (when warranted) and intervention plan pro-
viding guidance about what caregivers should do to enhance the
infant’s social-emotional functioning and well-being. This plan
should conceptualize the infant’s symptoms within the
context of psychosoc ial stressors and the infant’s functional,
emotional, and developmental capacities. The DC: 0-3R is the pre-
ferred diagnostic classification approach because of its attention to
developmental process and its emphasis on the primacy of infant-
caregiver relationships.
5 0 C HI LD WELFARE VOL. 86, #5 September/October 2007
Report Guidelines
The evaluation report should address issues inherent in foster
care, such as emotional/behavioral indicators of neglect or abuse,
attachment issues, and, when warranted, how infants may be
affected by visitation, reunification, or change in placement. The
report should highlight whether the infant presents significant
caregiving challenges, such as developmental delays, a chronic ill-
ness, or behavior problems.
It is critical that the report also address the infant’s strengths
and family strengths (both foster parents’ and biological parents’).
It should note whether any support systems are in place or need
strengthening. If the infant has special needs, it should be deter-
mined whether the adults are able to provide for that child, such
as following-up with doctor and specialist appointments and
advocating for special education services (Dicker & Gordon, 2004).
The evaluation report should highlight both positive attributes
and problematic conditions and alert the court and child welfare
authority to consider these factors in devising a realistic perma-
nency plan to prevent failed reunifications and later reentry into
foster care.
Collaboration with the Child Welfare System
Child welfare professionals may receive limited training on child
development, health, and early childhood mental health, which
may then affect decision making regarding removal, placement,
and permanency. They need to know what questions to ask to
help them identify risks to infants’ healthy development and
understand how infants’ developmental and emotional needs
impact a caregiver’s capacity to parent that child (Dicker & Gor-
don, 2004). They also require a broad knowledge of programs that
assess and serve infants and their families, including early inter-
vention, Early Head Start and Head Start preschool programs, and
infant mental health programs. Evaluations should be written in
accessible language, avoidi ng professional jargon and clearly
ilver and Dicker 5 1
connecting infants’ developmental and mental health needs to the
issues of placement, services, visitation, and permanency (Dicker,
Gordon, & Knitzer, 2001).
Collaboration with the Early Intervention and Preschool
Special Education Service Systems
One of the richest entitlements for infants in foster care and their
families is through Part C of the Individuals with Disabilities Edu-
cation Improvement Act (P.L. 108-446, 2004; IDEA). Part C early
intervention provides an entitlement for children under age 3 who
experience developmental delays or have physical or mental con-
ditions with a high probability of resulting in delay. Part C early
intervention is an entitlement for both infant and parent; infants
receive specialized assessments and services, and their caregivers
receive services to improve their ability to enhance their infant’s
development. Legal parents (biological and adoptive) and foster
parents may receive services, including parent training, counsel-
ing, support groups, and respite under the Part C program. The
Individualized Family Service Plan (IFSP), the blueprint for serv-
ices under Part C, enumerates those services. Part C early inter-
vention programs are administered by lead state agencies (for
example, Departments of Health, Children’s Services, or Develop-
mental Disabilities). Unlike other health-related services, the child
welfare agency is prohibited from consenting to the early inter-
vention evaluation, IFSP, or services. The parent, guardian, or fos-
ter parents, if permitted under state law, must consent. If no par-
ent is available, the lead agency or the court must appoint an edu-
cational “surrogate parent” (Dicker & Gordon, 2001; Dicker &
Gordon, 2002).
Under the Keeping Children and Families Safe Act of 2003,
amending the Child Abuse Prevention and Treatment Act, state
child protection agencies must have “provisions and procedures
for referral of a child under age 3 involved in a substantiated case
of child abuse or neglect to early intervention services funded
under Part C of the Individuals with Disabilities Education Act
5 2 C HI LD WELFARE VOL. 86, #5 September/October 2007
(P.L. 108-36).” A parallel provision was enacted in the 2004 reau-
thorized Individuals with Disabilities Education Improvement Act
(P.L. 108-446). Thus, infants in foster care increasingly should
receive this vital service.
Although some states may continue Part C early intervention
services for children up to age 5, most 3- to 5-year-old children
with delays receive services under the IDEA Preschool Special
Education Grants Program (P.L. 108-446), which is administered
by local school districts and provides special education and relat-
ed services for children who have a specific, diagnosed disability
that affects their ability to learn. Unlike EI, this is not a family-cen-
tered program. The blueprint for services is the Individualized
Education Plan (IEP), not the IFSP. Mental health evaluators can
assist the early intervention programs and child welfare and court
systems by helping to link the infant’s IFSP/IEP plan to the per-
manency plan.
Infant well-being is impacted both by biological and psychosocial
factors. Infants placed in foster care are extremely vulnerable on
both accounts. Mental health evaluations must take into account
the infants’ atypical life experiences and the complexity imparted
by the wide variety of stakeholders, including parents, foster par-
ents, child welfare professionals, attorneys, and judges. Mental
health assessment should link the infant to prevention and inter-
vention services and contribute to permanency planning.
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... Several individuals and organizations have provided recommendations for which elements should be included in a comprehensive assessment program (AAP, 2006;AACAP, 2003;Romanelli et al., 2009;Silver, 2007;Leslie, 2003;Perry, 1999;Milburn, 2008;AAP, 2001;AAP, 2006 ). ...
... It is also important to evaluate the child in the context of their current and past placements. This will help foster parents better understand the needs of the child and assist in promoting an environment that helps the child thrive (AACAP, 2003;AAP, 2006;Milburn, 2008;Silver, 2007). Finally, a comprehensive assessment program should have the capacity to evaluate all children, including infants, where a dynamic, developmental perspective is essential due to their rapid development (Perry, 1999;Silver, 2007). ...
... This will help foster parents better understand the needs of the child and assist in promoting an environment that helps the child thrive (AACAP, 2003;AAP, 2006;Milburn, 2008;Silver, 2007). Finally, a comprehensive assessment program should have the capacity to evaluate all children, including infants, where a dynamic, developmental perspective is essential due to their rapid development (Perry, 1999;Silver, 2007). In order to ensure this type of comprehensive assessment, several authors have recommended that the assessment take place through a centralized location such as a specialized foster care clinic (Leslie, 2003;Bruhn, 2008). ...
... The timeline becomes problematic when automatic referrals generate at the time of infants' and toddlers' foster care placements. For example, Silver and Dicker (2007) argued that foster parents need additional time before securing bonds with their foster infants and toddlers, a necessity when executing norm-referenced assessments that require caregiver input. Their position statement indicated that foster parents are the ultimate decision-makers. ...
... 186). Silver and Dicker (2007) accounted for the lack of professional development that exacerbates the concern: "Child welfare professionals may receive limited training on child development, health, and early childhood mental health (emphasis added)" (p. 50). ...
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A significant population of foster care infants and toddlers access early special education services under the parameters of the Individuals with Disabilities Education Act (IDEA)-Part C. A dearth of literature exists about special education interventionists’ services for this particular population. In response, we conducted a government-funded multiple case study with 50 special education intervention participants who described their provision of services for foster care infants and toddlers. Although the intent was to report how best to enhance the services, an unexpected deviation from the original research plan occurred when the funders rejected one of the essential findings and requested its deletion from the overall grant report. This article traces the study’s progression towards the inevitable outcome and how we negotiated appeasing the funders while maintaining rigorous qualitative research practices, all within the parameters of external grant/government-funded scholarship.
... They may exhibit intense fears and anxiety related to situations associated with past trauma (for example, bathing, being left alone in a room, diaper changes) (Albus & Dozier, 1999;Heller, Smyke, & Boris, 2002). Their behavior may become challenging to the caregivers, leading to stress in the household and to an increased chance of early placement breakdown (Chamberlain et al., 2006;Gunnar & Barr, 1998;Silver & Dicker, 2007). Behavioral problems increase the risk of an early placement breakdown in case of caregivers who are not able to cope with the stressful situation (Barth et al., 2007). ...
... Les différentes études en Europe, aux USA, en Australie et en Nouvelle-Zélande mettent en relief la prévalence des difficultés psychologiques (Dale, Baker, Anastasio, & Purcell, 2007 ;Tarren-Sweeney & Hazel, 2006 ;2008). Cependant les recherches sur l'évaluation de la santé mentale des jeunes enfants sont peu fréquentes et difficiles à mener (Silver & Dicker, 2007). Ces dernières années une revue de la littérature scientifique sur vingt études concernant les USA, l'Europe et l'Australie sur la santé mentale des enfants placés donnent des résultats très alarmants pour une population non-clinique dont les scores de perturbations psychologiques sont très proches de ceux des enfants suivis en psychiatrie de l'enfant (Tarren-Sweeney, 2008). ...
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L'evaluation des difficultes psychologiques et de la sante mentale des enfants pris en charge par les institutions de protection de l'enfance devient un objet de recherche important sur le plan international. Cette preoccupation est indissociable de l'augmentation considerable du nombre des enfants pris en charge de par le monde par des institutions de protection, d'une plus grande attention a leur sante mentale et d'une evaluation des qualites des structures d'accueil Dans cette recherche nous proposons une premiere etape de validation d'un nouvel outil, le Questionnaire Guide d'evaluation. Le QGE est ici utilise pour l'evaluation indicative des difficultes psychologiques des enfants places en urgence dans trois structures d'accueil du departement de Paris, les resultats sont ensuite compares a ceux de la LCE, Liste des Comportements de l'Enfant, traduite de la CBCL d'Achenbach et largement validee en France et sur le plan international. Le QGE est une echelle generaliste d'hetero-evaluation pour des enfants de 4 a 6 ans, qui integre l'etat de stress traumatique quand un evenement particulierement traumatogene est reperable dans la vie de l'enfant. Le QGE qui permet de systematiser les perceptions des parents ou des acteurs de premiere ligne comme les educateurs referents dans une institution est potentiellement tres utile pour favoriser une meilleure et plus rapide evaluation des difficultes psychologiques des jeunes enfants et de mieux repondre a leurs besoins. Les premiers resultats presentes mettent en evidence les qualites de l'outil.
... The DAWBA computes the likelihood of a clinical diagnosis and produces output that is then collated and rated by clinicians. A limitation of these commonly-used tools is that, in general, they are only designed for use with children aged 3-5 years and older; arguably, there is a need for validated assessment tools that are sensitive to the particular needs of looked after infants, which would enable early interventions (Silver and Dicker, 2007). ...
... ZERO TO THREE Journal,(22) 4,[14][15] Ibid.. 6 Ibid. 7 Silver, J. & Dicker, S. (2007). Mental health assessment of infants in foster care. ...
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Background: Infants, children, and youth in foster care have frequently experienced prenatal substance exposure (PSE), neglect, and maltreatment as well as disruptions in their relationships with families. They also have great capacity for overcoming early adversities. In this synthesis of two previously conducted scoping reviews, we aimed to identify and describe literature that identifies a range of interventions that support the health and development of this population. Methods: This review integrates and extends two previously conducted scoping reviews, one focusing on infants and one focusing on children and youth, to synthesize themes across these developmental stages. The Joanna Briggs Institute scoping review methodology was employed for the current and previous reviews. A three-step search strategy identified published studies in the English language from January 2006 to February 2020. Results: One-hundred and fifty-three sources were included in this review. Four themes were identified: (1) early screening, diagnosis, and intervention; (2) providing theoretically grounded care; (3) supporting parents and foster care providers; and (4) intersectoral collaboration. Conclusion: Infants, children, and youth with PSE are overrepresented in foster care. Child welfare system planning should take a multi-sectoral approach to addressing the cumulative needs of this population and their care providers over developmental ages and stages. Although research remains limited, early screening, diagnosis, and developmentally and FASD-informed intersectoral interventions are critical for optimizing outcomes.
Objective: The objective of this scoping review was to describe the characteristics of interventions and programs that support the health and development of infants in foster care who have prenatal substance exposure, their foster care providers, and birth families. Introduction: Infants in foster care may have experienced prenatal substance exposure, neglect, and maltreatment, as well as disruptions in their relationships with primary caregivers. Despite multiple vulnerabilities, they also have great capacity for overcoming early adversities. Enhanced foster care has been identified as a key influence on the positive development of infants in the child welfare system. Inclusion criteria: This scoping review considered publications that described interventions and programs designed to support foster care providers who care for infants less than 12 months of age with prenatal substance exposure. This review included research studies and gray literature. This scoping review focused on sources that described caregiving interventions and elements of programs that took place within the context of family or home-based foster care. Methods: A three-step search strategy was used to identify publications in the English language from January 2000 to December 2019. A literature search was conducted using MEDLINE, Academic Search Premier, PsycINFO, and CINAHL databases. Titles and abstracts were initially screened to assess if publications met the inclusion criteria, followed by full-text review. Publications that met the inclusion criteria were assessed by two independent reviewers using a data extraction tool developed for this review. Findings were thematically analyzed on the basis of similarity in focus and descriptively presented with tables and figures to support the findings. Results: Eighty-one publications were included, including 48 research papers and 33 gray literature sources. Thematic analysis of the focus of each publication resulted in identification of four core themes: i) mental health promotion for infants in care; ii) child welfare program elements; iii) identification of infants and families at risk of requiring foster care; and iv) outcomes for infants in care and their families. The interventions and programs identified during this scoping review were primarily focused on supporting social-emotional development. With the significant focus on infant mental health, supporting birth parents to stay attached to their infants was a key focus of the majority of publications. The concept of being able to proactively identify risk factors that were associated with infants requiring foster care emerged in relation to how family preservation could be supported. Strategies identified as contributing to the development of successful interventions and programs included having foster care providers participate as collaborators in designing services, designing services that are adaptable to a range of contexts, involving community partners outside child welfare, and having developmentally appropriate programs. Conclusions: Infants represent a significant proportion of children in foster care. A developmental perspective is needed for child welfare service planning to address their unique needs. Intervention during the early years holds significant potential for promoting positive developmental pathways and family preservation.
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The comorbidity of disorders, though it is an extremely common phenomenon, remains unexplained. Among the developmental disorders that are most often diagnosed together are dyslexia and ADHD. The goal of this book is to present a neuropsychological analysis of memory deficits among children with concomitant dyslexia and ADHD. Assuming the perspective of development neuropsychology, the book presents contemporary theoretical perspectives on the specific nature of the double diagnosis of dyslexia and ADHD in children, and general models of the comorbidity of disturbances. This is followed by a discussion of the processes and models of memory from a neuropsychological perspective, with particular attention to microgenetic theory. The specific nature of memory processes in children is also described, in the course of both normal and pathological development. The empirical section of the book presents the results of the author’s own research on memory deficits, as well as their cognitive moderators - attention, language, executive functions, and cognitive style - in four research groups of pupils in the 4th to 6th year of primary school: dyslexic children (n = 60), ADHD (n = 60), both together (n = 60), and children without disturbances as background (n = 60). Carefully chosen methods for evaluating memory were applied, and indicated the occurrence of problems in respect to verbal, visual, and visuospatial memory among all the children from the three clinical groups. Although analysis showed some differences between them, the differentiation is not markedly specific. When the deficits found among the children from the criterial group, i.e. with the double diagnosis, are compared, it turned out that their memory problems are primarily a factor of dyslexia and ADHD, and not something qualitatively unique, i.e. they do not constitute a new, specific symptom. These research results made it possible to differentiate the moderators of memory that are characteristics for each of the clinical groups: 1. In children with ADHD alone, the axial moderators proved to be attention and executive functions; 2. in children with dyslexia, the moderators affecting verbal memory turned out to be language functions, while in respect to visual and visuospatial memory, this role was played primarily by attention; 3. among the children from the criterial group, i.e. with concomitant dyslexia and ADHD, the moderators proved to be attention, language functions, and executive functions. The results presented here are fully consistent with the microgenetic model of the formation of the symptom. The formation of the symptom in children with dyslexia, with ADHD, and with both disorders can constitute a bridge connecting all neurodevelopmental disorders. Beginning with common, non-specific mutations, through distributed differences in the development of brain structures and non-specific symptoms in early childhood, to proximate disturbances of cognitive functions in children with fully symptomatic disturbances, we can observe the visible formation of a common symptom, which consists in the combination of the symptoms of two disorders. Microgenetic theory completes the concept of proximate etiology as a model for double diagnosis. This is the theoretical foundation that allows for a full understanding of the mechanism of comorbidity of neurodevelopmental disorders. The monograph concludes with a summary of the research results, which verify the microgenetic theory of symptom formation, and the development of the author’s own neuropsychological model of memory disturbances in children with a double diagnosis, based on that theory. Directions for further research are indicated. This microgenetic interpretation of the comorbidity of dyslexia and ADHD constitutes the first such attempt, not only in Poland, but in the world.
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Post-Traumatic Stress Disorder (PTSD) develops after psychological trauma and causing fear, helplessness or horror. This disorder is characterized by re-experiencing the traumatic event, avoidance of stimuli associated with the trauma and hyperarousal. About 5% to 9% of the general population develops PTSD depending on the nature of the trauma. In this review will be focused on the history, epidemiology and etiology of PTSD.
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The "Handbook of Early Childhood Intervention" has been designed to serve as a key resource for those who are interested in young children with disabilities or developmental vulnerabilities, and their families. Its intent is to integrate the theory, research, and practical knowledge that guide current practice in this field, and to frame the agenda for its continued growth and maturation. The overall goal of the "Handbook" is to present sophisticated, state-of-the art material in a format that is accessible to a broad audience that cuts across such diverse disciplines as education, psychology, social service, pediatrics, nursing, speech and language pathology, occupational and physical therapy, public health, and child care. Within and across each of these professional domains, the "Handbook of Early Childhood Intervention" will serve as a definitive source for those involved in academic training programs, research and scholarly endeavors, policy development, and service provision. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Greater numbers of young children with complicated, serious physical health, mental health, or developmental problems are entering foster care during the early years when brain growth is most active. Every effort should be made to make foster care a positive experience and a healing process for the child. Threats to a child's development from abuse and neglect should be understood by all participants in the child welfare system. Pediatricians have an important role in assessing the child's needs, providing comprehensive services, and advocating on the child's behalf. The developmental issues important for young children in foster care are reviewed, including: 1) the implications and consequences of abuse, neglect, and placement in foster care on early brain development; 2) the importance and challenges of establishing a child's attachment to caregivers; 3) the importance of considering a child's changing sense of time in all aspects of the foster care experience; and 4) the child's response to stress. Additional topics addressed relate to parental roles and kinship care, parent-child contact, permanency decision-making, and the components of comprehensive assessment and treatment of a child's development and mental health needs.
These practice parameters describe the psychiatric assessment of infants and toddlers (0–36 months) and support the growth of infant and toddler psychiatry, a rapidly developing field. Infants and toddlers are brought to clinical attention because of concerns about emotional, behavioral, relational, or developmental difficulties. It is axiomatic that the infant or toddler must be understood, evaluated, and treated within the context of the family. A perspective that is developmental, relational, and multidimensionas and that borrows from the knowledge of multiple disciplines is essential. Collaborative efforts support the urgent need and incomparable opportunity to understand and to intervene early and preventively with young children and their families.
The traditional perspective on trauma views trauma from the perspective of the traumatic event and its characteristics. How life threatening was the event? How unanticipated? How often repeated? Who was the perpetrator? The psychological sequellae of trauma are thus most often viewed as following from the characteristics of the event. Characteristics of the child experiencing the trauma, as well as his or her social context, have received less attention except that a consensus exists that large individual differences do exist in how traumatic events are experienced. In this chapter we do not focus on characteristics of traumatic events or trauma responses. Instead, we argue here that the impact of trauma on the developing child cannot be understood apart from the social and psychological resources available to buffer the effects of fearful arousal on the child's psychobiological functioning. We intend to elaborate the view here that trauma in infancy has special characteristics and must be defined differently than trauma at later ages. Finally, new evidence suggests that the infant does not come equipped with a particular level of stress tolerance at birth that continues into the preschool and school years. In developing a view of the regulatory processes in the caregiver-infant system that contribute to dysregulation, we integrate insights from the literature on early brain development and early dysfunction of the hypothalamicpituitary-adrenocortical (HPA) axis with an intersubjective and bioregulatory model of the early functioning of the attachment system. We recontextualize the functioning of the attachment relationship over the first year within a revised evolutionary framework. This framework anticipates dual-level mechanisms embedded in the infant-caregiver relationship governing the regulation of fearful arousal in infancy, including both direct physiological mechanisms and intersubjective processes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)