- Email: [email protected]
Early specialized foster care, developmental outcomes and home salivary cortisol patterns in prenatally substance-exposed infants
Children and Youth Services Review 32 (2010) 460–465
Contents lists available at ScienceDirect
Children and Youth Services Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h
Early specialized foster care, developmental outcomes and home salivary cortisol patterns in prenatally substance-exposed infants Amedeo D'Angiulli a,b,⁎, Richard Sullivan c,1 a b c
Institute of Interdisciplinary Studies, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6 Department of Psychology, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6 School of Social Work, University of British Columbia, 2080 West Mall, Vancouver, B.C., Canada V6T 1Z2
a r t i c l e
i n f o
Article history: Received 11 May 2009 Received in revised form 3 October 2009 Accepted 14 October 2009 Available online 22 October 2009 Keywords: Early specialized foster care Developmental outcomes Home salivary cortisol Preterm infants Prenatally substance-exposed infants Prenatal polydrug exposure Clinical significance
a b s t r a c t The purpose of this study was to investigate possible associations between developmental outcomes of prenatally substance-exposed infants and early specialized foster care. Participants were volunteer foster families and 22 infants from the Vancouver Coastal Safe Babies program; this specialized care program included selective recruitment of foster parents, training and support for foster infant retention. Subdivided in two gestational groups (preterm and full-term), the infants were assessed at home using BDI-2 Screening Test to determine their development in cognitive and social domains. Salivary cortisol was sampled three times (awakening, morning and evening) on two different days to determine the infants' basal cortisol patterns. No evidence of clinically significant atypical development was found in either the preterm or fullterm group. The preterm group had consistently lower mean cortisol levels than the full-term group but when the mean cortisol concentrations were corrected for number of months spent in foster care, the differences between preterm and full-term groups were no longer significant. From a perspective of clinical significance, these results suggest that stable, committed and specialized early foster care may be associated with “better than expected” developmental outcomes in prenatally substance-exposed infants. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Children who have been prenatally exposed to multiple toxic substances such as alcohol and drugs (hereafter referred to as prenatally substance-exposed) are also more likely to receive suboptimal parental care (for a review, see Hans, 2002). Some recent studies have shown that separation, transience and instability involved by temporary foster care placement and frequent re-placement is correlated with an array of negative developmental outcomes (McIntyre, Lounsbury, Berntson and Steel, 1988; Fein, 1991). In particular, Dozier et al. (2006) found that children who had been in foster care had higher incidence of atypical patterns of what is known as the “stress hormone”, cortisol, as compared to children who had not been in foster care. These authors interpreted their findings as evidence that foster care may interfere with children's ability to self regulate. Nevertheless, this study did not use any other outcome measure than cortisol and as noted by the authors, there was not enough reliable information to examine the
⁎ Corresponding author. Institute of Interdisciplinary Studies, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600x2954; fax: +1 613 520 3985. E-mail addresses: [email protected] (A. D'Angiulli), [email protected] (R. Sullivan). 1 Tel.: +1 604 822 4278; fax: +1 604 822 8656. 0190-7409/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2009.10.007
effects of substance exposure or other critical prenatal conditions that might have influenced neuroendocrine regulation. In contrast with studies reporting negative effects of foster care, some other studies have reported typical developmental outcomes or beneficial effects associated with foster care (e.g., Koren, Nulman, Rovet, Greenbaum, Loebstein and Einarson, 1998; Fundarò, Genovese, Figliola Baldieri, Miccinesi, Rendeli, Pantanella and Salvucci, 2004). The apparently contradictory and inconclusive findings seem to involve studies that focused on the effects of temporary foster care placement in children older than 24 months. Although much evidence shows that prenatally substance-exposed infants are likely to be placed in foster care programs within months from birth (e.g., Eiden, Foote, & Schuetze, 2007) little is known specifically about the effects of early foster care specifically in this population of infants. The currently available evidence does suggest that good early foster care may provide a suitable condition for enhanced development (Dozier, Stovall, Albus and Bates, 2001), in that it may compensate for the subtle early deficits associated with prenatal drug exposure, thereby attenuating differences between prenatally exposed foster infants and non-exposed foster infants (Giusti, 1996) or non-foster normal comparison infants (Brown, Bakeman, Coles, Platzman, & Lynch, 2004). Thus, investigating the relationship between early care and the developmental outcomes of prenatally substance-exposed infants can help determine the influences of drug exposure vs. the influences of postnatal environment linked to parental drug-use (Singer, Hawkins,
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
Huang, Davillier and Baley, 2001). In turn, this increased knowledge might help design effective service strategies aimed at offering the best possible parenting environment for the welfare of these children. Among the many challenges in this type of research, there is the issue that foster parents are the least prepared and supported in their roles (Marcellus, 2005; Dozier, 2005). Very few programs have been developed for education and support of foster parents caring for infants with prenatal drug exposure despite the need for specialized infant foster care (Burry, 1999; Zukoski, 1999). One of the few existing specialized infant foster care programs is the Ministry of Children and Family Development — Vancouver Coastal Region's Safe Babies Program (henceforth, Safe Babies Program). This program was modelled after a pilot project in 1998 in Victoria, British Columbia (Marcellus, 2000, 2004, 2005) that was initiated as a partnership between the Ministry of Children and Families (now Ministry of Children and Family Development — MCFD) and the Capital Health Region (now Vancouver Island Health Authority). The program was implemented in response to the gaps and needs identified for infants with prenatal substance exposure (alcohol and drugs) living in foster care. The program was designed to educate and support foster parents caring for prenatally substance-exposed infants, and to ensure that these infants are cared for in a committed, safe, stable and supportive foster care setting that facilitates optimal physical, cognitive and emotional development. The main component of the Safe Babies Program is the recruitment of experienced and highly qualified foster parents that includes people with relevant professional qualifications in social work, paediatric medicine and nursing in addition to their experience as foster parents. In keeping with ample evidence that early permanency planning is an effective intervention leading to important development gains where birth family preservation is not an option (van IJzendoorn & Juffer, 2006), the emphasis of this program is on early admission to care and on the stability of care making these placements more like adoption placements. Indeed, consistent with this view, evidence shows that temporary residence in a foster home before adoption is associated with a more rapid catch up in cognitive, motor and emotional development (Van Londen, Juffer, & Van IJzendoorn, 2007). In addition, the other key component of the Safe Babies Program is the inclusion of various forms of support for the foster parents: 1) a community health nurse through Vancouver Coastal Health; 2) resource workers assigned to the program; 3) an advisory committee; 4) six sessions of training for prospective foster parents and their relief, covering a range of care related topics such as understanding the impact of substance abuse exposure on the infant health, safety considerations, infant CPR, partnerships with birth parents, and care for the caregivers; 5) monthly meetings with a support group; and 6) a biannual newsletter. In the present paper, we report preliminary findings on the developmental outcomes associated with the Safe Babies Program in a distinctive sample of prenatally substance-exposed infants. The purpose was to examine whether the postnatal environment provided by specialized early foster care such as the one provided through the Safe Babies Program would be associated with signs of positive developmental outcomes in the most vulnerable infants. To this end, we compared standardized measures of psychological development among foster infants who were preterm or full-term, and we compared the scores from the latter two groups to norm-referenced population scores. In addition, we measured basal cortisol levels across two days in the prenatally-exposed foster infants. The rationale was twofold. First, because the age range of the children studied by Dozier et al. (2006) was comparable to the age range of our participants, we would be able to verify whether our children also showed a similar prevalence of atypical cortisol patterns. Second, lacking a pre-foster care baseline, convergence between cortisol patterns and developmental outcomes may permit us to determine whether children's development improved or not. To assess both developmental outcomes and cortisol results, we used a clinical significance approach (see review in Campbell, 2005)
461
providing adequate evaluation criteria (grounded in the practice of the specific field) for determining meaningful effects as opposed to statistical significance. The expectation was to find some evidence of the extent to which both groups — but in particular the one most at risk, the preterm infants — would show movement into the “functional range” (Jacobson, Roberts, Berns & McGlinchey, 1999a, Jacobson, Bihun and Chiodo, 1999b) of typical developmental scores and diurnal cortisol levels. That is, from a perspective of clinical significance we expected an association between early specialized foster care and “better than expected” developmental outcomes. 2. Method 2.1. Participants The participants were volunteer foster families and twenty-two infants from the Safe Babies Program in the urban areas of the Vancouver Coastal region (representing 18% of total infants receiving this type of foster care program in the particular geographic territory between January 2003 and December 2004). The Resources Unit identified infants under the age of 24 months who had a legal status of temporary custody order or continuing custody order and for whom parental substance misuse was the main factor in the court-ordered admission to early care. The Resources Unit contacted the child's social worker and foster parents requesting voluntary participation (through written signed consent). All caregivers who participated were considered to be Safe Baby Caregivers (meaning that after recruitment and initial screening the caregiver also completed the training). Within this sample, 9 infants were preterm (i.e., born before the 32nd gestational week), the other 13 infants were full-term. In-utero exposure known from mothers' reports ranged from a minimum of two substances to a maximum of five, including: tobacco, alcohol, cocaine, crack, heroin, methadone, marijuana, ecstasy and prescription drugs. For all children included in our sample, prenatal substance use of the mothers of these infants was such that the infants were brought into early care based on positive toxicity screens or sufficient recent history of abuse or misuse to result in court-ordered admissions to care. The characteristics of these two subgroups of infants are summarized in Table 1. The subgroups differed significantly with respect to the number of infants born with low birth weight: in the preterm group, all but one infant had low birth weight, whereas, in the full-term group, just one infant had low birth weight. A marginally significant difference concerned the months spent in foster care, with the preterm infants having received on average 4 and 1/2 months more foster care than their full-term counterparts. It is important to note that all infants were in care very early, namely, within four months after birth. Because of provincial and federal government regulations on confidentiality, additional information about precise birthweight, gestational age and course of prenatal care was unavailable. During this study, all infants remained in the foster home where they were
Table 1 Group characteristics of preterm and full-term infants who were placed in the early foster care ‘Safe Babies’ program and participated in the study.
N Mean age (and standard error) in months Number of Aboriginal infants Sex (male/female) Number of low birthweight infants (< 2500 g) Mean months in foster care Mean number of reported substances by mother Mean months with mother before placement a b
p < 0.001; χ(1)2 = 14.50. p = 0.07, t(20) = 1.90.
Preterm
Full-term
9 14.89 (1.99) 5 5/4 8 13.00 (1.96) 2.89 (0.51) 1.89 (0.31)
13 11.62 (2.05) 5 5/8 1a 8.54 (1.41)b 2.61 (0.40) 3.86 (1.07)
462
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
first placed; therefore, there were no placement changes or transiency that might affect the tested outcomes. 2.2. Procedures and materials The present procedures were approved by the Ministry of Child and Family Development of British Columbia and by the Research Ethics Board, University of British Columbia. Infants were assessed at home on two consecutive days by a trained research assistant who was unaware of the specific purposes of the study and did not know the profiles of the families or the infants. In the first day, the research assistant visited participating foster homes between 9:00 a.m. and 12:30 p.m. Within 15 min of arrival, consent was collected from one foster parent, and then a basal saliva sample (morning sample) was collected from the infant at 10:30 a.m. ± 50 min. A second morning saliva sample was collected approximately 30 min after the developmental assessment session at 11:00 a.m.± 24 min. A third saliva sample (evening sample) was collected at 7:15 p.m.± 65 min by the foster parents repeating the procedure observed from the research assistant. Care was taken that in these two collection moments the infants' behaviour corresponded to states between 3 (drowsy) and 5 (active alert) on Wolff's (1976) scale. The next day, the fourth saliva sample (awakening sample) was collected by the foster parent approximately 30 min after the infant was fully awake (at 8:47 a.m.± 19 min). Saliva samples were obtained using a cotton swab, which was then placed into a salivette device (Sarstedt Canada Inc., St Laurent, Quebec). Plain (e.g., not citric acid stimulated) salivette devices were used. Foster parents were instructed on how to collect the saliva samples by the research assistant during the morning saliva collection; they were also instructed on how to properly label, refrigerate, and mail the saliva samples immediately after collecting the last consecutive sample. 2.3. Measures 2.3.1. Home salivary cortisol The saliva samples were centrifuged and stored at −20 °C until assayed using a time-resolved immunoassay with fluorescence detection (DELFIA; for details see Dressendoerfer, Kirschbaum, Rohde, Stahl and Strasburger, 1992) in Kirschbaum's laboratory at the Technical University of Dresden, Germany. The intra- and interassay variability were both below 10%. Diagnostic inspection of the cortisol data showed that three infants had outlier values (i.e., values ± 3 SD from the mean) for morning concentrations in the pre and post assessment collection on first day and awakening collection on the second day. Consequently, these values were winsorized (Tukey, 1977), meaning they were replaced with the closest values within the 3 SD range, and then included in the analyses. Repeated measures ANOVA revealed no statistically significant change between pre and post developmental assessment cortisol values in the morning. In addition, pre and post assessment samples were strongly correlated (r = 0.62, p < 0.01), therefore, the two samples were collapsed; in what follows, we will refer to this collapsed variable as morning cortisol. 2.3.2. Developmental assessment Infants were assessed using the shortened form (screening test) from the Battelle Developmental Inventory, Second Edition (BDI-2; Newborg, 2004). The BDI-2 Screening Test consists of a subset of test items from the full BDI-2 item pool. The scoring procedures are similar to those of the full BDI-2, but cut-off scores are provided to identify children who may be at risk of atypical development. Normreferenced scores (scaled scores with a mean of 10, SD = 3, score range: 1–19) are provided at the subdomain level. The combined subdomain scores form the five BDI-2 Domain scores (Personal–
Social, Adaptive, Motor, Communication, Cognitive) and the overall DBI-2 Developmental Quotient (each with a standard score mean of 100, SD = 15, score range: 40–160). To assess the level of development of each infant, the research assistant proceeded through each of the subdomains following the same order (which corresponds to the order described above).
2.3.3. Control variables Before saliva collection in the morning and evening of the first day and at infant's awakening in the second day, the foster parent filled out a form recording details about the infant's meals, with specific focus on ingestion of milk or dairy products during the span of saliva collection. The form also recorded information about health and developmental concerns (e.g., hearing and vision), teething, and the use of medications. Potentially, all these variables could induce artificial concentrations in infants' salivary assays (see review in Hanrahan, McCarthy, Kleiber, Lutgendorf & Tsalikian, 2006).
2.3.4. Clinical significance criteria Two different procedures were used to operationalize clinical significance for the BDI-2 and the cortisol data. For the BDI-2 data clinical significance was defined relative to the population exhibiting developmental delays or deficits (Campbell, 2005). This method permitted us to determine whether functioning associated with the Safe Babies program fell outside of the population exhibiting atypical developmental outcomes. We adopted this approach at the individual and group level. Given the multiplicity and compounded actions of risk factors that are likely involved in influencing the development of prenatally substance-exposed foster infants, we decided to use a conservative cut-off point of 2 standard deviations to support our interpretation of clinical significance. This decision, however, is consistent with the context, goals and values of service-oriented research (as generally recommended by Jacobson & Truax, 1991) since we selected the same cut-off adopted in the broader literature (notably, see Rosenberg & Smith, 2008). Therefore, the typical developmental scores for the BDI-2 quotients and subdomains would fall above 70 and 7 (scaled score), respectively. To evaluate clinical significance for the cortisol data, we used the procedure of equivalence testing of group means. This method is based on comparison between group means across studies (Follette & Callaghan, 2001) and permits us to determine whether the cortisol values for the prenatally substance-exposed foster infants on average and across studies approximate typical limits. Because the goal in the present case was to determine whether the trends and individual means of cortisol values obtained from the prenatally substanceexposed foster infants were reliably close or indistinguishable to typical trends and means, we compared the trends and means of our infants with trends and means from typically developing comparison infants included in previous published (peer-reviewed) reports (Dozier, Stovall, Albus and Bates, 2001; Grunau, Haley, Whitfield, Weinberg, Yu and Thiessen, 2007; Goldberg, Levitan, Leung, Masellis, Basile, Nemeroffm and Atkinson, 2003; Haley, Weinberg & Grunau, 2006a; Haley, Handmaker and Lowe, 2006b These reports were specifically selected from the literature on foster infants and/or prenatally substance-exposed infants studied in comparable settings (including home cortisol collection and similar sociocultural and geographical contexts). To aggregate means of cortisol values from typically developing comparison infants reported in the selected studies we included means of cortisol concentration values that fell within overlapping 95% confidence intervals across studies, we then derived the broadest, most inclusive intervals of typical mean values (see Table 3). Finally, to compare our full-term and preterm infants we also used tests of statistical significance.
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
463
3. Results
3.3. Cortisol data
3.1. Preliminary analysis
Table 3 shows a summary of the cortisol data from preterm and full-term foster infants; it also shows comparison aggregate data from the literature. The means of the prenatally substance-exposed foster infants overlap with those from the comparison, showing they are in the typical range. This finding is in contrast with the findings by Dozier et al. (2001) in foster infants that may or not have been prenatally exposed to substances. To examine diurnal trends, the cortisol data were then analyzed using linear contrasts based on a mixed-model ANOVA with sampling time (awakening vs. morning vs. evening) as repeated measure factor, and gestation (preterm vs. full-term) as between-subjects factor. Repeated measure effects were estimated using the Greenhose–Geisser adjustment. There were no significant interaction effects (F(1, 18)=1.56, MSe=0.06, p=0.23; η2 =0.08), while both main effects were significant. Cortisol declined as a function of sampling time (F(1, 18) = 14.94, MSe = 0.10, p < 0.01; η2 = 0.45), following a similar pattern in both preterm and full-term infants. That is, cortisol levels were highest at awakening, dropped off sharply to about 40% later in the morning, and then declined further in the evening. This trend is consistent with what is currently known about the typical patterns of circadian cortisol rhythm in infants (Watamura, Donzella, Kertes & Gunnar, 2004). The main effect of gestation indicated that preterm infants had consistently lower cortisol levels than their full-term counterparts (F(1, 18)= 4.04, MSe = 0.10, p <0.05; η2 =0.20). However, when the ANOVA analysis included as a covariate the number of months that the infants spent in the foster care program, the effects of gestation were no longer significant (F(1, 17)=2.66, MSe=0.10, p=0.12; η2 =0.14).
While we had no missing data for the developmental assessments and all control variables were available, at least one instance of partially missed, insufficient or unusable saliva sample occurred for seven infants at one of the four saliva collection points. Two other infants had no usable saliva samples across the four collection times; as result, these two infants were excluded from cortisol analyses. Such exclusion did not change results with respects to the measures for which these two infants had complete data, hence, they were retained in all other analyses. To offset the limitations of partially missing repeated measures data and to be able to conduct ANOVA analyses, our F-ratios were estimated with imputation using the expectation– maximization algorithm for maximum likelihood estimation under assumption of data missing at random (Schafer & Graham, 2002). This procedure allows computation of unbiased error terms with unbalanced cells preserving the original mean differences — even in the case of small sample sizes like ours (see Cohen, Cohen, West & Aiken, 2003).
3.2. Developmental assessment data The BDI-2 data are summarized for preterm and full-term groups in Table 2. Only two children reported subdomain and total quotients that may indicate developmental delays, according to the cut-off of −2 SD from the population mean. Thus, in general, the individual BDI-2 scores did not indicate clinically significant atypical development. Considering now the groups, mean group score differences below 2 SD from norm on the BDI-2 for both domain quotients and subdomain scores would correspond to t-values below −9.23. By this criterion, as a whole the foster infants scored at norm in all BDI-2 developmental domains (−6.30
3.4. Relations between cortisol and developmental assessment data Correlation analyses revealed only a significant association between evening cortisol levels and the communication domain quotient (r = 0.44, p < 0.05). In particular, this association concerned the receptive communication (r = 0.52, p < 0.01) and the adult interaction subdomains (r = 0.43, p < 0.05). After controlling for time spent in foster care, evening cortisol levels was still significantly correlated to receptive communication scores (partial r = 0.48, p < 0.05), and marginally to the communication domain quotient and the adult interaction subdomain (for both partial r = 0.38, p = 0.09). Thus, generally the infants who had higher evening cortisol levels tended to have higher receptive communication and interaction abilities. 3.5. Potential confounders
Table 2 Means (and standard errors) of BDI-2 developmental domain quotients and subdomain scaled scores in preterm and full-term infants. Preterm BDI-2 Developmental Domain Adaptive Personal–Social Communication Motor Cognitive Total BDI-2 Developmental Subdomain Perception and concepts Attention and memory Fine motor Gross motor Expressive communication Receptive communication Self-concept and social role Adult interaction Self-care ⁎ t(20) = 2.34, p < 0.05.
87.22 85.44 75.11 85.33 98.11 82.44
9.78 9.67 5.33 9.00 5.11 5.33 7.89 6.33 7.44
(5.14) (3.64) (5.30) (4.94) (3.36) (4.59)
(0.60) (0.47) (0.99) (1.19) (1.39) (1.07) (0.73) (0.88) (1.03)
Nonparametric analyses were conducted to check the influences of the control variables such as teething, reported health and developmental
Full-term 93.00 90.00 85.23 96.62 95.23 90.08
10.00 8.46 8.62 10.15 7.46 7.00 7.69 8.38 8.54
(4.53) (4.23) (3.20) (4.11) (3.85) (4.01)
(0.63) (0.96) (0.94)⁎ (0.93) (1.02) (0.73) (0.80) (0.97) (0.90)
Table 3 Daily home cortisol levels in preterm, full-term foster infants and typically developing comparison samples across studies. Group
Sampling time Awakening
Uncorrected means Preterm Full-term Comparisona
0.39 (0.11) 0.71 (0.08) >0.19, <0.86
Means corrected for months in foster care Preterm 0.44 (0.10) Full-term 0.71 (0.08)
Morning
Evening
0.22 (0.07) 0.31 (0.05) >0.04, <0.35
0.16 (0.10) 0.28 (0.08) < 0.28
0.24 (0.07) 0.31 (0.05)
0.22 (0.09) 0.27 (0.08)
Note. The numerical values in the table are in µg/dl. a Data derived from Dozier et al. (2001), Grunau et al. (2007), Goldberg, Levitan, Leung, Masellis, Basile, Nemeroffm and Atkinson (2003), Haley et al. (2006a), Haley et al. (2006b); see Section 2.3.4 for a detailed explanation on how the intervals of typical cortisol values were derived.
464
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
issues and the ingestion of dairy products or specific foods. None of the analyses showed significant effects. 4. Discussion In summary, the results indicated that within our sample of prenatally substance-exposed infants in foster care, the preterm infants showed significantly lower fine motor skills than their fullterm counterparts but at the same time they were at norm in all other developmental domains and subdomains. Overall, there was no compelling evidence of clinically significant atypical development in either group of infants. Thus, the developmental assessment findings suggest an association between the Safe Babies Program and positive developmental outcomes in the foster infants, especially on the preterm group, as the results indicate that the infants included in the latter group could be considered within the broad spectrum of typical developmental scores and typical pattern of daily cortisol levels. The pattern of results may be alternatively explained by the literature findings that, within 12–24 months of age, prenatally exposed infants tend to catch-up with normal infants in the control groups (e.g., Chasnoff, Griffith, Freier and Murray, 1992; Frank, Augustyn, Knight, Pell, & Zuckerman, 2001). However, such explanation seems implausible in light of the fact that had we defined “atypical development” in terms of statistical significance or a less conservative cut-off for clinical significance we would have recorded persisting deficits in a few developmental areas for both groups of foster infants. Thus, a more parsimonious interpretation of the present findings (in line with current practice in the field but not overgeneralizing the import of the conservative cut-off presently used) is that these infants show some evidence of return to typical functioning, that is, some signs of progress towards recovery. Converging evidence for the association between positive developmental outcomes and the foster care environment comes from the cortisol data. We found no reliable evidence of disrupted neuroendocrine regulation reported in previous research (Dozier et al., 2001). The mean concentration levels found at each collection point in our sample were not far from those found in other studies focusing on similar infants with similar risk factors and age ranges (e.g., Jacobson, Roberts, Berns & McGlinchey, 1999a,Jacobson, Bihun and Chiodo, 1999b; Haley et al., 2006a; Haley et al., 2006b; Grunau, Haley, Whitfield, Weinberg, Yu and Thiessen, 2007). In addition, the trends observed in both groups seem very similar to the basal daily patterns observed in typically developing infants between 3 and 24 months (Gunnar & Donzella, 2002; Dozier et al., 2001; Gunnar, Brodersen, Krueger & Rigatuso, 1996). However, consistent with some literature (e.g., Haley, Grunau, Weinberg, & Whitfield, 2004; Mangano, Gardner & Karmel, 1992), the preterm group reported consistently lower mean cortisol levels than the full-term group. Importantly, when the mean cortisol concentrations were corrected for number of months spent in foster care, the differences between preterm and full-term groups were no longer significant. Together with the other cortisol data, the latter result suggests that early specialized foster care may be associated with some attenuation of the adverse effects of prenatal substance exposure observed in these preterm infants. Given the importance of early, specialized foster care programs, what are the challenges to implementing programs such as Safe Babies? And which infants or families do particularly well? At present, qualitative work aimed at addressing these questions is still in progress. However, within the confines of the information available to us, we can at least provide some tentative answers. A summary review of individual cases and families suggests that infants tend to be progressively more responsive and communicative in families where the foster parents have relevant professional backgrounds, training and experience (i.e., social work, nursing, psychology, etc.). In agreement with the group analyses, this case-based review shows
that early admission to care is significant to the success of a program such as Safe Babies, with critical point for admission to care being 4 months after birth. Finally, informal communications with the members of the Resources unit (reported in Hayes, Sullivan, Bhagat, D'Angiulli, Ford, Kiviste, McGillis, Penner, Ratanshi, & Tye, 2006) indicate that the most common challenges for the success of early specialized foster care is a careful process of screening and recruitment, providing continuity of support to newly recruited care givers and coordination with different agencies involved in the management of each individual placement. 5. Conclusions Selective recruitment, training and support for retention may attenuate some of the problems associated with foster care as a temporary solution less likely to be associated with positive outcomes (Ackerman & Dozier, 2005; Dozier, 2005). This does not necessarily contradict the exploratory finding of Dozier et al. (2006) that conditions associated with out of home placement may interfere with children's ability to regulate neuroendocrine functioning, but rather suggests that out of home care arrangements may have either positive or negative effects that require careful investigation and follow-up. We infer that stable, committed foster care arrangements may promote development not predicted by prenatal conditions or gestational age. Although the present findings need to be confirmed with larger samples, and with longitudinal follow-ups, they provide preliminary evidence that early specialized foster care is associated with “better than expected” developmental outcomes in prenatally substance-exposed infants. Therefore, we conclude that programs like Vancouver Coastal Safe Babies, which include selective recruitment as well as properly designed support and education for foster parents, may provide a good model for early preventive services targeting a very specific population of vulnerable infants. Acknowledgments We thank Virginia Hayes for useful comments and discussion. We thank, Janet Kidd and Shannon Piedt for data collection and Dr Laurie Ford for consultation on the developmental assessment portion of this study and for overseeing data collection. We extend our acknowledgment to the BC Ministry of Child and Family Development, and in particular to Lyna Kiviste, Tye Bee Lee, Radhika Bagat and Maria Pirito. We also thank Dr Ruth Grunau, Dr David Haley, and Prof Joanne Weinberg for helpful discussions on cortisol analysis and interpretation of results. We thank especially Prof Clemens Kirschbaum for processing the cortisol samples. This study was made possible through funding from the Human Early Learning Partnership. We do not have conflicting interests to declare. References Ackerman, J. P., & Dozier, M. (2005). The influence of foster parent investment on children’s representations of self and attachment figures. Applied Developmental Psychology, 26, 507−520. Brown, J. V., Bakeman, R., Coles, C. D., Platzman, K. A., & Lynch, M. E. (2004). Prenatal cocaine exposure: A comparison of 2-year-old children in parental and nonparental care. Child Development, 72, 1282−1295. Burry, C. L. (1999). Evaluation of a training program for foster parents of infants with prenatal substance effects. Child Welfare, 78, 197−214. Campbell, T. C. (2005). An introduction to clinical significance: An alternative index of intervention effect for group experimental designs. Journal of Early Intervention, 27, 210−227. Chasnoff, I., Griffith, D., Freier, C., & Murray, J. (1992). Cocaine/polydrug use in pregnancy: Two-year follow-up. Pediatrics, 89, 284−289. Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/ correlation analysis for the behavioral sciences, 3rd ed. Mahwah, NJ: Erlbaum. Dozier, M., Stovall, K. C., Albus, K. E., & Bates, B. (2001). Attachment for infants in foster care: The role of caregiver state of mind. Child Development, 72(5), 1467−1477.
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465 Dozier, M. (2005). Challenges of foster care. Attachment & Human Development, 7(1), 27−30. Dozier, M., Manni, M., Gordon, M. K., Gunnar, M. R., Stovall-McClough, K. C., Eldreth, D., & Levine, S. (2006). Foster children's diurnal production of cortisol: An exploratory study. Child Maltreatment, 11(2), 189−197. Dressendoerfer, R. A., Kirschbaum, C., Rohde, W., Stahl, F., & Strasburger, C. J. (1992). Synthesis of a cortisol–biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. Journal of Steroid Biochemical Molecular Biology, 43, 683−692. Eiden, R. D., Foote, A., & Schuetze, P. (2007). Maternal cocaine use and caregiving status: Group differences in caregiver and infant risk variables. Addictive Behaviors, 32, 465−476. Fein, E. (1991). Issues in foster family care: Where do we stand? American Journal of Orthopsychiatry, 61, 578−583. Follette, W. C., & Callaghan, G. M. (2001). The evolution of clinical significance. Clinical Psychology: Science and Practice, 8, 431−435. Frank, D. A., Augustyn, M., Knight, W. G., Pell, T., & Zuckerman, B. (2001). Growth, development, and behavior in early childhood following prenatal cocaine exposure: A systematic review. Journal of the American Medical Association, 285, 1613−1625. Fundarò, C., Genovese, O., Figliola Baldieri, N., Miccinesi, N., Rendeli, C., Pantanella, A., & Salvucci, S. (2004). Long-term neurodevelopmental outcome of children exposed to illicit substances during pregnancy: The role of home environmental factors. Italian Journal of Pediatrics, 30, 118−124. Giusti, L. M. (1996). Development of children in foster care: Comparison of Battelle screening test performance of children prenatally exposed to cocaine and nonexposed children. Physical and Occupational Therapy in Pediatrics, 16, 155−171. Goldberg, S., Levitan, R., Leung, E., Masellis, M., Basile, V. S., Nemeroffm, C. B., & Atkinson, L. (2003). Cortisol concentrations in 12- to 18-month-old infants: Stability over time, location, and stressor. Biological Psychiatry, 54, 719−726. Grunau, R. E., Haley, D. W., Whitfield, M. F., Weinberg, J., Yu, W., & Thiessen, P. (2007). Altered basal cortisol levels at 3, 6, 8 and 18 months in preterm infants born extremely low gestational age. Journal of Pediatrics, 150, 151−156. Gunnar, M. R., & Donzella, B. (2002). Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology, 27, 199−220. Gunnar, M. R., Brodersen, L., Krueger, K., & Rigatuso, J. (1996). Dampening of adrenocortical responses during infancy: Normative changes and individual differences. Child Development, 67, 877−889. Haley, D. W., Weinberg, J., & Grunau, R. E. (2006). Cortisol, contingency learning, and memory in preterm and full-term infants. Psychoneuroendocrinology, 31, 108−117. Haley, D. W., Handmaker, N. S., & Lowe, J. (2006). Infant stress reactivity and prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 30, 2055−2064. Haley, D. W., Grunau, R. E., Weinberg, J., & Whitfield, M. F. (2004). Parenting stress and infant cortisol responses in preterm and full-term infants at 3 months. Pediatric Research, 55, 80A. Hanrahan, K., McCarthy, A. M., Kleiber, C., Lutgendorf, S., & Tsalikian, E. (2006). Strategies for salivary cortisol collection and analysis in research with children. Applied Nursing Research, 19, 95−101. Hans, S. L. (2002). Studies of prenatal exposure to drugs: Focusing on parental care of children. Neurotoxicology and Teratology, 24, 1−9. Hayes, V. E., Sullivan, R., Bhagat, R., D'Angiulli, A., Ford, L., Kiviste, L., McGillis, S., Penner, N., Ratanshi, N., & Tye, B. -L. (2006). Evaluating specialized care for infants prenatally
465
exposed to substances: The Vancouver Coastal Safe Babies Program. Paper presented at the What Determines the Public's Health? Canadian Public Health Association 97th Annual Conference, Vancouver, BC, May. Koren, G., Nulman, I., Rovet, J., Greenbaum, R., Loebstein, M., & Einarson, T. R. (1998). Long term neurodevelopmental risks in children exposed in utero to cocaine: The Toronto Adoption Study. Annals of the New York Academy of Sciences, 846, 306−313. Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, B. (1999). Methods for defining and determining clinical significance of treatment effects: Description, application, and alternatives. Journal of Consulting and Clinical Psychology, 67, 300−307. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12−19. Jacobson, S. W., Bihun, J. T., & Chiodo, L. M. (1999). Effects of prenatal alcohol and cocaine exposure on infant cortisol levels. Development and Psychopathology, 11, 195−208. Mangano, C., Gardner, J., & Karmel, B. (1992). Differences in salivary cortisol levels in cocaine exposed and noncocaine-exposed NICU infants. Developmental Psychobiology, 25, 93−103. Marcellus, L. (2005). Foster care services for infants with prenatal substance abuse: Developing capacity in the caregiving environment. In R. J. Flynn, P. M. Dudding, & J. G. Barber (Eds.), Promoting resilience in child welfare (pp. 115−130). Ottawa, ON: University of Ottawa Press. Marcellus, L. (2004). Developmental evaluation of the Safe Babies Project: Application of the COECA model. Issues in Comprehensive Pediatric Nursing, 27, 107−119. Marcellus, L. (2000). The Safe Babies project. Canadian Nurse, 96, 22−26. McIntyre, A., Lounsbury, K. R., Berntson, D., & Steel, H. (1988). Psychosocial characteristics of foster children. Journal of Applied Developmental Psychology, 9, 125−137. Newborg, J. (2004). Battelle Developmental Inventory, 2nd ed. Itasca, IL: Riverside. Rosenberg, S. A., & Smith, E. G. (2008). Rates of part c eligibility for young children investigated by child welfare. Topics in Early Childhood Special Education, 28, 68−74. Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147−177. Singer, L. T., Hawkins, S., Huang, J., Davillier, M., & Baley, J. (2001). Developmental outcomes and environmental correlates of very low birthweight, cocaine-exposed infants. Early Human Development, 64(2), 91−103. Tukey, J. W. (1977). Exploratory data analysis. Reading, MA: Addison-Wesley. van IJzendoorn, M. H., & Juffer, F. (2006). The Emmanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional, and cognitive development. Journal of Child Psychology and Psychiatry, 47, 1228−1245. Van Londen, W. M., Juffer, F., & Van IJzendoorn, M. H. (2007). Attachment, cognitive and motor development in adopted children: Short-term outcomes after international adoption. Journal of Pediatric Psychology, 32, 1259−1263. Zukoski, M. (1999). Foster parent training. In J. A. Silver, B. J. Amster, & T. Haecker (Eds.), Young children and foster care: A guide for professionals (pp. 473−490). Baltimore: Paul H. Brookes. Watamura, S. E., Donzella, B., Kertes, D. A., & Gunnar, M. R. (2004). Developmental changes in baseline cortisol activity in early childhood: Relations with napping and effortful control. Developmental Psychobiology, 45, 125−133. Wolff, P. (1976). The role of biological rhythms in psychological development. Bulletin of Menninger Clinic, 31, 197−218.
Contents lists available at ScienceDirect
Children and Youth Services Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h
Early specialized foster care, developmental outcomes and home salivary cortisol patterns in prenatally substance-exposed infants Amedeo D'Angiulli a,b,⁎, Richard Sullivan c,1 a b c
Institute of Interdisciplinary Studies, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6 Department of Psychology, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6 School of Social Work, University of British Columbia, 2080 West Mall, Vancouver, B.C., Canada V6T 1Z2
a r t i c l e
i n f o
Article history: Received 11 May 2009 Received in revised form 3 October 2009 Accepted 14 October 2009 Available online 22 October 2009 Keywords: Early specialized foster care Developmental outcomes Home salivary cortisol Preterm infants Prenatally substance-exposed infants Prenatal polydrug exposure Clinical significance
a b s t r a c t The purpose of this study was to investigate possible associations between developmental outcomes of prenatally substance-exposed infants and early specialized foster care. Participants were volunteer foster families and 22 infants from the Vancouver Coastal Safe Babies program; this specialized care program included selective recruitment of foster parents, training and support for foster infant retention. Subdivided in two gestational groups (preterm and full-term), the infants were assessed at home using BDI-2 Screening Test to determine their development in cognitive and social domains. Salivary cortisol was sampled three times (awakening, morning and evening) on two different days to determine the infants' basal cortisol patterns. No evidence of clinically significant atypical development was found in either the preterm or fullterm group. The preterm group had consistently lower mean cortisol levels than the full-term group but when the mean cortisol concentrations were corrected for number of months spent in foster care, the differences between preterm and full-term groups were no longer significant. From a perspective of clinical significance, these results suggest that stable, committed and specialized early foster care may be associated with “better than expected” developmental outcomes in prenatally substance-exposed infants. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Children who have been prenatally exposed to multiple toxic substances such as alcohol and drugs (hereafter referred to as prenatally substance-exposed) are also more likely to receive suboptimal parental care (for a review, see Hans, 2002). Some recent studies have shown that separation, transience and instability involved by temporary foster care placement and frequent re-placement is correlated with an array of negative developmental outcomes (McIntyre, Lounsbury, Berntson and Steel, 1988; Fein, 1991). In particular, Dozier et al. (2006) found that children who had been in foster care had higher incidence of atypical patterns of what is known as the “stress hormone”, cortisol, as compared to children who had not been in foster care. These authors interpreted their findings as evidence that foster care may interfere with children's ability to self regulate. Nevertheless, this study did not use any other outcome measure than cortisol and as noted by the authors, there was not enough reliable information to examine the
⁎ Corresponding author. Institute of Interdisciplinary Studies, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600x2954; fax: +1 613 520 3985. E-mail addresses: [email protected] (A. D'Angiulli), [email protected] (R. Sullivan). 1 Tel.: +1 604 822 4278; fax: +1 604 822 8656. 0190-7409/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2009.10.007
effects of substance exposure or other critical prenatal conditions that might have influenced neuroendocrine regulation. In contrast with studies reporting negative effects of foster care, some other studies have reported typical developmental outcomes or beneficial effects associated with foster care (e.g., Koren, Nulman, Rovet, Greenbaum, Loebstein and Einarson, 1998; Fundarò, Genovese, Figliola Baldieri, Miccinesi, Rendeli, Pantanella and Salvucci, 2004). The apparently contradictory and inconclusive findings seem to involve studies that focused on the effects of temporary foster care placement in children older than 24 months. Although much evidence shows that prenatally substance-exposed infants are likely to be placed in foster care programs within months from birth (e.g., Eiden, Foote, & Schuetze, 2007) little is known specifically about the effects of early foster care specifically in this population of infants. The currently available evidence does suggest that good early foster care may provide a suitable condition for enhanced development (Dozier, Stovall, Albus and Bates, 2001), in that it may compensate for the subtle early deficits associated with prenatal drug exposure, thereby attenuating differences between prenatally exposed foster infants and non-exposed foster infants (Giusti, 1996) or non-foster normal comparison infants (Brown, Bakeman, Coles, Platzman, & Lynch, 2004). Thus, investigating the relationship between early care and the developmental outcomes of prenatally substance-exposed infants can help determine the influences of drug exposure vs. the influences of postnatal environment linked to parental drug-use (Singer, Hawkins,
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
Huang, Davillier and Baley, 2001). In turn, this increased knowledge might help design effective service strategies aimed at offering the best possible parenting environment for the welfare of these children. Among the many challenges in this type of research, there is the issue that foster parents are the least prepared and supported in their roles (Marcellus, 2005; Dozier, 2005). Very few programs have been developed for education and support of foster parents caring for infants with prenatal drug exposure despite the need for specialized infant foster care (Burry, 1999; Zukoski, 1999). One of the few existing specialized infant foster care programs is the Ministry of Children and Family Development — Vancouver Coastal Region's Safe Babies Program (henceforth, Safe Babies Program). This program was modelled after a pilot project in 1998 in Victoria, British Columbia (Marcellus, 2000, 2004, 2005) that was initiated as a partnership between the Ministry of Children and Families (now Ministry of Children and Family Development — MCFD) and the Capital Health Region (now Vancouver Island Health Authority). The program was implemented in response to the gaps and needs identified for infants with prenatal substance exposure (alcohol and drugs) living in foster care. The program was designed to educate and support foster parents caring for prenatally substance-exposed infants, and to ensure that these infants are cared for in a committed, safe, stable and supportive foster care setting that facilitates optimal physical, cognitive and emotional development. The main component of the Safe Babies Program is the recruitment of experienced and highly qualified foster parents that includes people with relevant professional qualifications in social work, paediatric medicine and nursing in addition to their experience as foster parents. In keeping with ample evidence that early permanency planning is an effective intervention leading to important development gains where birth family preservation is not an option (van IJzendoorn & Juffer, 2006), the emphasis of this program is on early admission to care and on the stability of care making these placements more like adoption placements. Indeed, consistent with this view, evidence shows that temporary residence in a foster home before adoption is associated with a more rapid catch up in cognitive, motor and emotional development (Van Londen, Juffer, & Van IJzendoorn, 2007). In addition, the other key component of the Safe Babies Program is the inclusion of various forms of support for the foster parents: 1) a community health nurse through Vancouver Coastal Health; 2) resource workers assigned to the program; 3) an advisory committee; 4) six sessions of training for prospective foster parents and their relief, covering a range of care related topics such as understanding the impact of substance abuse exposure on the infant health, safety considerations, infant CPR, partnerships with birth parents, and care for the caregivers; 5) monthly meetings with a support group; and 6) a biannual newsletter. In the present paper, we report preliminary findings on the developmental outcomes associated with the Safe Babies Program in a distinctive sample of prenatally substance-exposed infants. The purpose was to examine whether the postnatal environment provided by specialized early foster care such as the one provided through the Safe Babies Program would be associated with signs of positive developmental outcomes in the most vulnerable infants. To this end, we compared standardized measures of psychological development among foster infants who were preterm or full-term, and we compared the scores from the latter two groups to norm-referenced population scores. In addition, we measured basal cortisol levels across two days in the prenatally-exposed foster infants. The rationale was twofold. First, because the age range of the children studied by Dozier et al. (2006) was comparable to the age range of our participants, we would be able to verify whether our children also showed a similar prevalence of atypical cortisol patterns. Second, lacking a pre-foster care baseline, convergence between cortisol patterns and developmental outcomes may permit us to determine whether children's development improved or not. To assess both developmental outcomes and cortisol results, we used a clinical significance approach (see review in Campbell, 2005)
461
providing adequate evaluation criteria (grounded in the practice of the specific field) for determining meaningful effects as opposed to statistical significance. The expectation was to find some evidence of the extent to which both groups — but in particular the one most at risk, the preterm infants — would show movement into the “functional range” (Jacobson, Roberts, Berns & McGlinchey, 1999a, Jacobson, Bihun and Chiodo, 1999b) of typical developmental scores and diurnal cortisol levels. That is, from a perspective of clinical significance we expected an association between early specialized foster care and “better than expected” developmental outcomes. 2. Method 2.1. Participants The participants were volunteer foster families and twenty-two infants from the Safe Babies Program in the urban areas of the Vancouver Coastal region (representing 18% of total infants receiving this type of foster care program in the particular geographic territory between January 2003 and December 2004). The Resources Unit identified infants under the age of 24 months who had a legal status of temporary custody order or continuing custody order and for whom parental substance misuse was the main factor in the court-ordered admission to early care. The Resources Unit contacted the child's social worker and foster parents requesting voluntary participation (through written signed consent). All caregivers who participated were considered to be Safe Baby Caregivers (meaning that after recruitment and initial screening the caregiver also completed the training). Within this sample, 9 infants were preterm (i.e., born before the 32nd gestational week), the other 13 infants were full-term. In-utero exposure known from mothers' reports ranged from a minimum of two substances to a maximum of five, including: tobacco, alcohol, cocaine, crack, heroin, methadone, marijuana, ecstasy and prescription drugs. For all children included in our sample, prenatal substance use of the mothers of these infants was such that the infants were brought into early care based on positive toxicity screens or sufficient recent history of abuse or misuse to result in court-ordered admissions to care. The characteristics of these two subgroups of infants are summarized in Table 1. The subgroups differed significantly with respect to the number of infants born with low birth weight: in the preterm group, all but one infant had low birth weight, whereas, in the full-term group, just one infant had low birth weight. A marginally significant difference concerned the months spent in foster care, with the preterm infants having received on average 4 and 1/2 months more foster care than their full-term counterparts. It is important to note that all infants were in care very early, namely, within four months after birth. Because of provincial and federal government regulations on confidentiality, additional information about precise birthweight, gestational age and course of prenatal care was unavailable. During this study, all infants remained in the foster home where they were
Table 1 Group characteristics of preterm and full-term infants who were placed in the early foster care ‘Safe Babies’ program and participated in the study.
N Mean age (and standard error) in months Number of Aboriginal infants Sex (male/female) Number of low birthweight infants (< 2500 g) Mean months in foster care Mean number of reported substances by mother Mean months with mother before placement a b
p < 0.001; χ(1)2 = 14.50. p = 0.07, t(20) = 1.90.
Preterm
Full-term
9 14.89 (1.99) 5 5/4 8 13.00 (1.96) 2.89 (0.51) 1.89 (0.31)
13 11.62 (2.05) 5 5/8 1a 8.54 (1.41)b 2.61 (0.40) 3.86 (1.07)
462
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
first placed; therefore, there were no placement changes or transiency that might affect the tested outcomes. 2.2. Procedures and materials The present procedures were approved by the Ministry of Child and Family Development of British Columbia and by the Research Ethics Board, University of British Columbia. Infants were assessed at home on two consecutive days by a trained research assistant who was unaware of the specific purposes of the study and did not know the profiles of the families or the infants. In the first day, the research assistant visited participating foster homes between 9:00 a.m. and 12:30 p.m. Within 15 min of arrival, consent was collected from one foster parent, and then a basal saliva sample (morning sample) was collected from the infant at 10:30 a.m. ± 50 min. A second morning saliva sample was collected approximately 30 min after the developmental assessment session at 11:00 a.m.± 24 min. A third saliva sample (evening sample) was collected at 7:15 p.m.± 65 min by the foster parents repeating the procedure observed from the research assistant. Care was taken that in these two collection moments the infants' behaviour corresponded to states between 3 (drowsy) and 5 (active alert) on Wolff's (1976) scale. The next day, the fourth saliva sample (awakening sample) was collected by the foster parent approximately 30 min after the infant was fully awake (at 8:47 a.m.± 19 min). Saliva samples were obtained using a cotton swab, which was then placed into a salivette device (Sarstedt Canada Inc., St Laurent, Quebec). Plain (e.g., not citric acid stimulated) salivette devices were used. Foster parents were instructed on how to collect the saliva samples by the research assistant during the morning saliva collection; they were also instructed on how to properly label, refrigerate, and mail the saliva samples immediately after collecting the last consecutive sample. 2.3. Measures 2.3.1. Home salivary cortisol The saliva samples were centrifuged and stored at −20 °C until assayed using a time-resolved immunoassay with fluorescence detection (DELFIA; for details see Dressendoerfer, Kirschbaum, Rohde, Stahl and Strasburger, 1992) in Kirschbaum's laboratory at the Technical University of Dresden, Germany. The intra- and interassay variability were both below 10%. Diagnostic inspection of the cortisol data showed that three infants had outlier values (i.e., values ± 3 SD from the mean) for morning concentrations in the pre and post assessment collection on first day and awakening collection on the second day. Consequently, these values were winsorized (Tukey, 1977), meaning they were replaced with the closest values within the 3 SD range, and then included in the analyses. Repeated measures ANOVA revealed no statistically significant change between pre and post developmental assessment cortisol values in the morning. In addition, pre and post assessment samples were strongly correlated (r = 0.62, p < 0.01), therefore, the two samples were collapsed; in what follows, we will refer to this collapsed variable as morning cortisol. 2.3.2. Developmental assessment Infants were assessed using the shortened form (screening test) from the Battelle Developmental Inventory, Second Edition (BDI-2; Newborg, 2004). The BDI-2 Screening Test consists of a subset of test items from the full BDI-2 item pool. The scoring procedures are similar to those of the full BDI-2, but cut-off scores are provided to identify children who may be at risk of atypical development. Normreferenced scores (scaled scores with a mean of 10, SD = 3, score range: 1–19) are provided at the subdomain level. The combined subdomain scores form the five BDI-2 Domain scores (Personal–
Social, Adaptive, Motor, Communication, Cognitive) and the overall DBI-2 Developmental Quotient (each with a standard score mean of 100, SD = 15, score range: 40–160). To assess the level of development of each infant, the research assistant proceeded through each of the subdomains following the same order (which corresponds to the order described above).
2.3.3. Control variables Before saliva collection in the morning and evening of the first day and at infant's awakening in the second day, the foster parent filled out a form recording details about the infant's meals, with specific focus on ingestion of milk or dairy products during the span of saliva collection. The form also recorded information about health and developmental concerns (e.g., hearing and vision), teething, and the use of medications. Potentially, all these variables could induce artificial concentrations in infants' salivary assays (see review in Hanrahan, McCarthy, Kleiber, Lutgendorf & Tsalikian, 2006).
2.3.4. Clinical significance criteria Two different procedures were used to operationalize clinical significance for the BDI-2 and the cortisol data. For the BDI-2 data clinical significance was defined relative to the population exhibiting developmental delays or deficits (Campbell, 2005). This method permitted us to determine whether functioning associated with the Safe Babies program fell outside of the population exhibiting atypical developmental outcomes. We adopted this approach at the individual and group level. Given the multiplicity and compounded actions of risk factors that are likely involved in influencing the development of prenatally substance-exposed foster infants, we decided to use a conservative cut-off point of 2 standard deviations to support our interpretation of clinical significance. This decision, however, is consistent with the context, goals and values of service-oriented research (as generally recommended by Jacobson & Truax, 1991) since we selected the same cut-off adopted in the broader literature (notably, see Rosenberg & Smith, 2008). Therefore, the typical developmental scores for the BDI-2 quotients and subdomains would fall above 70 and 7 (scaled score), respectively. To evaluate clinical significance for the cortisol data, we used the procedure of equivalence testing of group means. This method is based on comparison between group means across studies (Follette & Callaghan, 2001) and permits us to determine whether the cortisol values for the prenatally substance-exposed foster infants on average and across studies approximate typical limits. Because the goal in the present case was to determine whether the trends and individual means of cortisol values obtained from the prenatally substanceexposed foster infants were reliably close or indistinguishable to typical trends and means, we compared the trends and means of our infants with trends and means from typically developing comparison infants included in previous published (peer-reviewed) reports (Dozier, Stovall, Albus and Bates, 2001; Grunau, Haley, Whitfield, Weinberg, Yu and Thiessen, 2007; Goldberg, Levitan, Leung, Masellis, Basile, Nemeroffm and Atkinson, 2003; Haley, Weinberg & Grunau, 2006a; Haley, Handmaker and Lowe, 2006b These reports were specifically selected from the literature on foster infants and/or prenatally substance-exposed infants studied in comparable settings (including home cortisol collection and similar sociocultural and geographical contexts). To aggregate means of cortisol values from typically developing comparison infants reported in the selected studies we included means of cortisol concentration values that fell within overlapping 95% confidence intervals across studies, we then derived the broadest, most inclusive intervals of typical mean values (see Table 3). Finally, to compare our full-term and preterm infants we also used tests of statistical significance.
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
463
3. Results
3.3. Cortisol data
3.1. Preliminary analysis
Table 3 shows a summary of the cortisol data from preterm and full-term foster infants; it also shows comparison aggregate data from the literature. The means of the prenatally substance-exposed foster infants overlap with those from the comparison, showing they are in the typical range. This finding is in contrast with the findings by Dozier et al. (2001) in foster infants that may or not have been prenatally exposed to substances. To examine diurnal trends, the cortisol data were then analyzed using linear contrasts based on a mixed-model ANOVA with sampling time (awakening vs. morning vs. evening) as repeated measure factor, and gestation (preterm vs. full-term) as between-subjects factor. Repeated measure effects were estimated using the Greenhose–Geisser adjustment. There were no significant interaction effects (F(1, 18)=1.56, MSe=0.06, p=0.23; η2 =0.08), while both main effects were significant. Cortisol declined as a function of sampling time (F(1, 18) = 14.94, MSe = 0.10, p < 0.01; η2 = 0.45), following a similar pattern in both preterm and full-term infants. That is, cortisol levels were highest at awakening, dropped off sharply to about 40% later in the morning, and then declined further in the evening. This trend is consistent with what is currently known about the typical patterns of circadian cortisol rhythm in infants (Watamura, Donzella, Kertes & Gunnar, 2004). The main effect of gestation indicated that preterm infants had consistently lower cortisol levels than their full-term counterparts (F(1, 18)= 4.04, MSe = 0.10, p <0.05; η2 =0.20). However, when the ANOVA analysis included as a covariate the number of months that the infants spent in the foster care program, the effects of gestation were no longer significant (F(1, 17)=2.66, MSe=0.10, p=0.12; η2 =0.14).
While we had no missing data for the developmental assessments and all control variables were available, at least one instance of partially missed, insufficient or unusable saliva sample occurred for seven infants at one of the four saliva collection points. Two other infants had no usable saliva samples across the four collection times; as result, these two infants were excluded from cortisol analyses. Such exclusion did not change results with respects to the measures for which these two infants had complete data, hence, they were retained in all other analyses. To offset the limitations of partially missing repeated measures data and to be able to conduct ANOVA analyses, our F-ratios were estimated with imputation using the expectation– maximization algorithm for maximum likelihood estimation under assumption of data missing at random (Schafer & Graham, 2002). This procedure allows computation of unbiased error terms with unbalanced cells preserving the original mean differences — even in the case of small sample sizes like ours (see Cohen, Cohen, West & Aiken, 2003).
3.2. Developmental assessment data The BDI-2 data are summarized for preterm and full-term groups in Table 2. Only two children reported subdomain and total quotients that may indicate developmental delays, according to the cut-off of −2 SD from the population mean. Thus, in general, the individual BDI-2 scores did not indicate clinically significant atypical development. Considering now the groups, mean group score differences below 2 SD from norm on the BDI-2 for both domain quotients and subdomain scores would correspond to t-values below −9.23. By this criterion, as a whole the foster infants scored at norm in all BDI-2 developmental domains (−6.30
3.4. Relations between cortisol and developmental assessment data Correlation analyses revealed only a significant association between evening cortisol levels and the communication domain quotient (r = 0.44, p < 0.05). In particular, this association concerned the receptive communication (r = 0.52, p < 0.01) and the adult interaction subdomains (r = 0.43, p < 0.05). After controlling for time spent in foster care, evening cortisol levels was still significantly correlated to receptive communication scores (partial r = 0.48, p < 0.05), and marginally to the communication domain quotient and the adult interaction subdomain (for both partial r = 0.38, p = 0.09). Thus, generally the infants who had higher evening cortisol levels tended to have higher receptive communication and interaction abilities. 3.5. Potential confounders
Table 2 Means (and standard errors) of BDI-2 developmental domain quotients and subdomain scaled scores in preterm and full-term infants. Preterm BDI-2 Developmental Domain Adaptive Personal–Social Communication Motor Cognitive Total BDI-2 Developmental Subdomain Perception and concepts Attention and memory Fine motor Gross motor Expressive communication Receptive communication Self-concept and social role Adult interaction Self-care ⁎ t(20) = 2.34, p < 0.05.
87.22 85.44 75.11 85.33 98.11 82.44
9.78 9.67 5.33 9.00 5.11 5.33 7.89 6.33 7.44
(5.14) (3.64) (5.30) (4.94) (3.36) (4.59)
(0.60) (0.47) (0.99) (1.19) (1.39) (1.07) (0.73) (0.88) (1.03)
Nonparametric analyses were conducted to check the influences of the control variables such as teething, reported health and developmental
Full-term 93.00 90.00 85.23 96.62 95.23 90.08
10.00 8.46 8.62 10.15 7.46 7.00 7.69 8.38 8.54
(4.53) (4.23) (3.20) (4.11) (3.85) (4.01)
(0.63) (0.96) (0.94)⁎ (0.93) (1.02) (0.73) (0.80) (0.97) (0.90)
Table 3 Daily home cortisol levels in preterm, full-term foster infants and typically developing comparison samples across studies. Group
Sampling time Awakening
Uncorrected means Preterm Full-term Comparisona
0.39 (0.11) 0.71 (0.08) >0.19, <0.86
Means corrected for months in foster care Preterm 0.44 (0.10) Full-term 0.71 (0.08)
Morning
Evening
0.22 (0.07) 0.31 (0.05) >0.04, <0.35
0.16 (0.10) 0.28 (0.08) < 0.28
0.24 (0.07) 0.31 (0.05)
0.22 (0.09) 0.27 (0.08)
Note. The numerical values in the table are in µg/dl. a Data derived from Dozier et al. (2001), Grunau et al. (2007), Goldberg, Levitan, Leung, Masellis, Basile, Nemeroffm and Atkinson (2003), Haley et al. (2006a), Haley et al. (2006b); see Section 2.3.4 for a detailed explanation on how the intervals of typical cortisol values were derived.
464
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465
issues and the ingestion of dairy products or specific foods. None of the analyses showed significant effects. 4. Discussion In summary, the results indicated that within our sample of prenatally substance-exposed infants in foster care, the preterm infants showed significantly lower fine motor skills than their fullterm counterparts but at the same time they were at norm in all other developmental domains and subdomains. Overall, there was no compelling evidence of clinically significant atypical development in either group of infants. Thus, the developmental assessment findings suggest an association between the Safe Babies Program and positive developmental outcomes in the foster infants, especially on the preterm group, as the results indicate that the infants included in the latter group could be considered within the broad spectrum of typical developmental scores and typical pattern of daily cortisol levels. The pattern of results may be alternatively explained by the literature findings that, within 12–24 months of age, prenatally exposed infants tend to catch-up with normal infants in the control groups (e.g., Chasnoff, Griffith, Freier and Murray, 1992; Frank, Augustyn, Knight, Pell, & Zuckerman, 2001). However, such explanation seems implausible in light of the fact that had we defined “atypical development” in terms of statistical significance or a less conservative cut-off for clinical significance we would have recorded persisting deficits in a few developmental areas for both groups of foster infants. Thus, a more parsimonious interpretation of the present findings (in line with current practice in the field but not overgeneralizing the import of the conservative cut-off presently used) is that these infants show some evidence of return to typical functioning, that is, some signs of progress towards recovery. Converging evidence for the association between positive developmental outcomes and the foster care environment comes from the cortisol data. We found no reliable evidence of disrupted neuroendocrine regulation reported in previous research (Dozier et al., 2001). The mean concentration levels found at each collection point in our sample were not far from those found in other studies focusing on similar infants with similar risk factors and age ranges (e.g., Jacobson, Roberts, Berns & McGlinchey, 1999a,Jacobson, Bihun and Chiodo, 1999b; Haley et al., 2006a; Haley et al., 2006b; Grunau, Haley, Whitfield, Weinberg, Yu and Thiessen, 2007). In addition, the trends observed in both groups seem very similar to the basal daily patterns observed in typically developing infants between 3 and 24 months (Gunnar & Donzella, 2002; Dozier et al., 2001; Gunnar, Brodersen, Krueger & Rigatuso, 1996). However, consistent with some literature (e.g., Haley, Grunau, Weinberg, & Whitfield, 2004; Mangano, Gardner & Karmel, 1992), the preterm group reported consistently lower mean cortisol levels than the full-term group. Importantly, when the mean cortisol concentrations were corrected for number of months spent in foster care, the differences between preterm and full-term groups were no longer significant. Together with the other cortisol data, the latter result suggests that early specialized foster care may be associated with some attenuation of the adverse effects of prenatal substance exposure observed in these preterm infants. Given the importance of early, specialized foster care programs, what are the challenges to implementing programs such as Safe Babies? And which infants or families do particularly well? At present, qualitative work aimed at addressing these questions is still in progress. However, within the confines of the information available to us, we can at least provide some tentative answers. A summary review of individual cases and families suggests that infants tend to be progressively more responsive and communicative in families where the foster parents have relevant professional backgrounds, training and experience (i.e., social work, nursing, psychology, etc.). In agreement with the group analyses, this case-based review shows
that early admission to care is significant to the success of a program such as Safe Babies, with critical point for admission to care being 4 months after birth. Finally, informal communications with the members of the Resources unit (reported in Hayes, Sullivan, Bhagat, D'Angiulli, Ford, Kiviste, McGillis, Penner, Ratanshi, & Tye, 2006) indicate that the most common challenges for the success of early specialized foster care is a careful process of screening and recruitment, providing continuity of support to newly recruited care givers and coordination with different agencies involved in the management of each individual placement. 5. Conclusions Selective recruitment, training and support for retention may attenuate some of the problems associated with foster care as a temporary solution less likely to be associated with positive outcomes (Ackerman & Dozier, 2005; Dozier, 2005). This does not necessarily contradict the exploratory finding of Dozier et al. (2006) that conditions associated with out of home placement may interfere with children's ability to regulate neuroendocrine functioning, but rather suggests that out of home care arrangements may have either positive or negative effects that require careful investigation and follow-up. We infer that stable, committed foster care arrangements may promote development not predicted by prenatal conditions or gestational age. Although the present findings need to be confirmed with larger samples, and with longitudinal follow-ups, they provide preliminary evidence that early specialized foster care is associated with “better than expected” developmental outcomes in prenatally substance-exposed infants. Therefore, we conclude that programs like Vancouver Coastal Safe Babies, which include selective recruitment as well as properly designed support and education for foster parents, may provide a good model for early preventive services targeting a very specific population of vulnerable infants. Acknowledgments We thank Virginia Hayes for useful comments and discussion. We thank, Janet Kidd and Shannon Piedt for data collection and Dr Laurie Ford for consultation on the developmental assessment portion of this study and for overseeing data collection. We extend our acknowledgment to the BC Ministry of Child and Family Development, and in particular to Lyna Kiviste, Tye Bee Lee, Radhika Bagat and Maria Pirito. We also thank Dr Ruth Grunau, Dr David Haley, and Prof Joanne Weinberg for helpful discussions on cortisol analysis and interpretation of results. We thank especially Prof Clemens Kirschbaum for processing the cortisol samples. This study was made possible through funding from the Human Early Learning Partnership. We do not have conflicting interests to declare. References Ackerman, J. P., & Dozier, M. (2005). The influence of foster parent investment on children’s representations of self and attachment figures. Applied Developmental Psychology, 26, 507−520. Brown, J. V., Bakeman, R., Coles, C. D., Platzman, K. A., & Lynch, M. E. (2004). Prenatal cocaine exposure: A comparison of 2-year-old children in parental and nonparental care. Child Development, 72, 1282−1295. Burry, C. L. (1999). Evaluation of a training program for foster parents of infants with prenatal substance effects. Child Welfare, 78, 197−214. Campbell, T. C. (2005). An introduction to clinical significance: An alternative index of intervention effect for group experimental designs. Journal of Early Intervention, 27, 210−227. Chasnoff, I., Griffith, D., Freier, C., & Murray, J. (1992). Cocaine/polydrug use in pregnancy: Two-year follow-up. Pediatrics, 89, 284−289. Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/ correlation analysis for the behavioral sciences, 3rd ed. Mahwah, NJ: Erlbaum. Dozier, M., Stovall, K. C., Albus, K. E., & Bates, B. (2001). Attachment for infants in foster care: The role of caregiver state of mind. Child Development, 72(5), 1467−1477.
A. D'Angiulli, R. Sullivan / Children and Youth Services Review 32 (2010) 460–465 Dozier, M. (2005). Challenges of foster care. Attachment & Human Development, 7(1), 27−30. Dozier, M., Manni, M., Gordon, M. K., Gunnar, M. R., Stovall-McClough, K. C., Eldreth, D., & Levine, S. (2006). Foster children's diurnal production of cortisol: An exploratory study. Child Maltreatment, 11(2), 189−197. Dressendoerfer, R. A., Kirschbaum, C., Rohde, W., Stahl, F., & Strasburger, C. J. (1992). Synthesis of a cortisol–biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. Journal of Steroid Biochemical Molecular Biology, 43, 683−692. Eiden, R. D., Foote, A., & Schuetze, P. (2007). Maternal cocaine use and caregiving status: Group differences in caregiver and infant risk variables. Addictive Behaviors, 32, 465−476. Fein, E. (1991). Issues in foster family care: Where do we stand? American Journal of Orthopsychiatry, 61, 578−583. Follette, W. C., & Callaghan, G. M. (2001). The evolution of clinical significance. Clinical Psychology: Science and Practice, 8, 431−435. Frank, D. A., Augustyn, M., Knight, W. G., Pell, T., & Zuckerman, B. (2001). Growth, development, and behavior in early childhood following prenatal cocaine exposure: A systematic review. Journal of the American Medical Association, 285, 1613−1625. Fundarò, C., Genovese, O., Figliola Baldieri, N., Miccinesi, N., Rendeli, C., Pantanella, A., & Salvucci, S. (2004). Long-term neurodevelopmental outcome of children exposed to illicit substances during pregnancy: The role of home environmental factors. Italian Journal of Pediatrics, 30, 118−124. Giusti, L. M. (1996). Development of children in foster care: Comparison of Battelle screening test performance of children prenatally exposed to cocaine and nonexposed children. Physical and Occupational Therapy in Pediatrics, 16, 155−171. Goldberg, S., Levitan, R., Leung, E., Masellis, M., Basile, V. S., Nemeroffm, C. B., & Atkinson, L. (2003). Cortisol concentrations in 12- to 18-month-old infants: Stability over time, location, and stressor. Biological Psychiatry, 54, 719−726. Grunau, R. E., Haley, D. W., Whitfield, M. F., Weinberg, J., Yu, W., & Thiessen, P. (2007). Altered basal cortisol levels at 3, 6, 8 and 18 months in preterm infants born extremely low gestational age. Journal of Pediatrics, 150, 151−156. Gunnar, M. R., & Donzella, B. (2002). Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology, 27, 199−220. Gunnar, M. R., Brodersen, L., Krueger, K., & Rigatuso, J. (1996). Dampening of adrenocortical responses during infancy: Normative changes and individual differences. Child Development, 67, 877−889. Haley, D. W., Weinberg, J., & Grunau, R. E. (2006). Cortisol, contingency learning, and memory in preterm and full-term infants. Psychoneuroendocrinology, 31, 108−117. Haley, D. W., Handmaker, N. S., & Lowe, J. (2006). Infant stress reactivity and prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 30, 2055−2064. Haley, D. W., Grunau, R. E., Weinberg, J., & Whitfield, M. F. (2004). Parenting stress and infant cortisol responses in preterm and full-term infants at 3 months. Pediatric Research, 55, 80A. Hanrahan, K., McCarthy, A. M., Kleiber, C., Lutgendorf, S., & Tsalikian, E. (2006). Strategies for salivary cortisol collection and analysis in research with children. Applied Nursing Research, 19, 95−101. Hans, S. L. (2002). Studies of prenatal exposure to drugs: Focusing on parental care of children. Neurotoxicology and Teratology, 24, 1−9. Hayes, V. E., Sullivan, R., Bhagat, R., D'Angiulli, A., Ford, L., Kiviste, L., McGillis, S., Penner, N., Ratanshi, N., & Tye, B. -L. (2006). Evaluating specialized care for infants prenatally
465
exposed to substances: The Vancouver Coastal Safe Babies Program. Paper presented at the What Determines the Public's Health? Canadian Public Health Association 97th Annual Conference, Vancouver, BC, May. Koren, G., Nulman, I., Rovet, J., Greenbaum, R., Loebstein, M., & Einarson, T. R. (1998). Long term neurodevelopmental risks in children exposed in utero to cocaine: The Toronto Adoption Study. Annals of the New York Academy of Sciences, 846, 306−313. Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, B. (1999). Methods for defining and determining clinical significance of treatment effects: Description, application, and alternatives. Journal of Consulting and Clinical Psychology, 67, 300−307. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12−19. Jacobson, S. W., Bihun, J. T., & Chiodo, L. M. (1999). Effects of prenatal alcohol and cocaine exposure on infant cortisol levels. Development and Psychopathology, 11, 195−208. Mangano, C., Gardner, J., & Karmel, B. (1992). Differences in salivary cortisol levels in cocaine exposed and noncocaine-exposed NICU infants. Developmental Psychobiology, 25, 93−103. Marcellus, L. (2005). Foster care services for infants with prenatal substance abuse: Developing capacity in the caregiving environment. In R. J. Flynn, P. M. Dudding, & J. G. Barber (Eds.), Promoting resilience in child welfare (pp. 115−130). Ottawa, ON: University of Ottawa Press. Marcellus, L. (2004). Developmental evaluation of the Safe Babies Project: Application of the COECA model. Issues in Comprehensive Pediatric Nursing, 27, 107−119. Marcellus, L. (2000). The Safe Babies project. Canadian Nurse, 96, 22−26. McIntyre, A., Lounsbury, K. R., Berntson, D., & Steel, H. (1988). Psychosocial characteristics of foster children. Journal of Applied Developmental Psychology, 9, 125−137. Newborg, J. (2004). Battelle Developmental Inventory, 2nd ed. Itasca, IL: Riverside. Rosenberg, S. A., & Smith, E. G. (2008). Rates of part c eligibility for young children investigated by child welfare. Topics in Early Childhood Special Education, 28, 68−74. Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147−177. Singer, L. T., Hawkins, S., Huang, J., Davillier, M., & Baley, J. (2001). Developmental outcomes and environmental correlates of very low birthweight, cocaine-exposed infants. Early Human Development, 64(2), 91−103. Tukey, J. W. (1977). Exploratory data analysis. Reading, MA: Addison-Wesley. van IJzendoorn, M. H., & Juffer, F. (2006). The Emmanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional, and cognitive development. Journal of Child Psychology and Psychiatry, 47, 1228−1245. Van Londen, W. M., Juffer, F., & Van IJzendoorn, M. H. (2007). Attachment, cognitive and motor development in adopted children: Short-term outcomes after international adoption. Journal of Pediatric Psychology, 32, 1259−1263. Zukoski, M. (1999). Foster parent training. In J. A. Silver, B. J. Amster, & T. Haecker (Eds.), Young children and foster care: A guide for professionals (pp. 473−490). Baltimore: Paul H. Brookes. Watamura, S. E., Donzella, B., Kertes, D. A., & Gunnar, M. R. (2004). Developmental changes in baseline cortisol activity in early childhood: Relations with napping and effortful control. Developmental Psychobiology, 45, 125−133. Wolff, P. (1976). The role of biological rhythms in psychological development. Bulletin of Menninger Clinic, 31, 197−218.