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Infants and Toddlers in Supervised Custody: A Pilot Study of Visitation
Infants and Toddlers in Supervised Custody: A Pilot Study of Visitation MARGARET P. GEAN, M.D., JANET L. GILLMORE, PH.D.,
AND
JEFFREY K. DOWLER, PH.D.
A retrospective chart study was conducted defining the impact of visitation by biologic relatives on children under the age of 3 who were in foster care or other custodial circumstances. The recordsof 23 children consistingof medical, developmental, psychiatric, and social histories as well as interviews with all persons involved with the child were reviewed. Locationof visits, number of placements,and primary caregiver's attitudes toward visitation were significantlyrelated to the children's presenting symptoms. Implicationsof these findings and strategies for minimizing distress associatedwith visitation are discussed. Journal of the American Academy of Child Psychiatry, 24, 5:608-612, 1985.
The Infant/Toddler Service within our Child Psychiatry Division frequently evaluates children under 3 years of age who are in foster care or custodial circumstances that include visitation with biologic relatives. It was noted that many of these children had symptoms following such visits. Symptoms were reported to be in chronologie relation to the visits which frequently included a separation from the primary caregiver for several hours or overnight. Responses to visits included transient fussiness, prolonged fussiness and inconsolability, sleep disturbance, clinginess, developmental delays, eating disturbances, withdrawal, aggressive and regressive behavior, nonorganic failure-to-thrive and chronic attachment disorders. The symptoms persisted for minutes to days after visits (see Adjustment Disorders, OSM-II!) and at times progressed into a sustained disorder. To study the impact of visitation by biologic relatives with children under the age of 3, a series of hypotheses were developed. The first was that psychological distress and behavioral disturbances were not necessarily benign, time-limited experiences for young children. Second, the type of arrangement for the visitation could be contributing to the symptoms. Our third concern was that the emotional and cognitive
development of children under 3 years of age prevented effective use of the types of interventions offered to older children. Fourth, the feelings and behavior of the primary caregiver would have an impact on symptom formation. Finally, we wondered whether symptoms were related to disruptions in the primary caregiver-child attachment process. During the clinical evaluation, the referring agency's questions regarding symptoms were elicited and interventions were offered. The questions that they asked included: How do you know that the child is not missing the biologic family member that they visited? Are the current caregivers' feelings about the visits causative of symptoms? Is the child really attached to the present caregiver rather than to the visiting parent? Will individual psychotherapy of the child stop the symptoms? Should the visits be discontinued?
Literature Review Only seven references could be located that discussed visitation per se. The books by Goldstein et al. (1973, 1979) focused on the importance of the child's developmental needs and indicated that visitation might be detrimental in some circumstances but offered no controlled data. Fanshel's (1976) research of foster children noted that the frequency of visitation directly correlated with the success of reunion with a biologic parent. The study by Block and Libowitz (1983) of recidivism of children in foster care referred to visitation but only as it related to the recidivism. McDermott et a1. (1978) briefly referred to the consideration of terminating visitation as their study showed serious consequences to children seen in follow-up who had been in visitation that was strongly opposed by a caregiver. Weinstein's (1960) study addressed issues of the self-esteem of foster children and discussed visitation related to the child's identification with parent figures. None of these studies was con-
Received June 26, 1984; accepted Oct. 8, 1984. Dr. Gean is Assistant Professor of Psychiatry and Director of the Infant/Toddler Unit, Division of Child Psychiatry, Tufts-New England Medical Center. Dr. Gillmore wa.~ Instructor in Psychiatry and Staff Psychologist on the Child Psychiatry Inpatient Unit, Division of Child Psychiatry. Tufts-New England Medical Center at the time of this writing. Dr. Dowler is a consultant to the Infant/Toddler Unit, Division of Child Psychiatry, Tufts-New England Medical Center. Portions of this paper were presented es a poster session at the October 1983 American Academy of Child Psychiatry Meetings in San Francisco. We would like to thank Beth Grossman for her a.~sistance with this project. Address for reprints: Dr. Gean. 171 Harrison Ave., Box 395, Boston. MA 02111. 0002- 7138/85/2405-0608 $02.00;0 (ei 1985 by the American Academy of Child Psychiatry. 608
609
INFANTS AND TODDLERS IN SUPERVISED CUSTODY
trolled for the ages of children. More recently, Gean (1984) has discussed the various responses to visitation in children under 3 years of age in a theoretical paper. The role of the foster parents in the emotional life of young children was described in a clinical study by Yarrow (1965). Walker (1973) discussed the necessary qualities of foster parents to be able to assist older children to grieve the loss of prior caregivers. To ascertain if the legal system had addressed the issue of visitation symptomatology, many writings were reviewed (e.g., Derdeyn and Wadlington, 1977; Foster, 1973; Gardner, 1982; Mnookin, 1975; Polier, 1975; Schetky et a1., 1979). No articles refer to the symptom complexes associated with visitation though Proch and Howard (1984) reviewed the laws in various states with regard to their stipulations of visitation both as a means of maintaining a relationship between parents and separated children and as evidence regarding the termination of parental rights. As the visitation situation includes a separation from the primary caregiver, the daycare literature was reviewed in search of parallel symptoms. The circumstances of the separation were too disparate and, in routine circumstances, any symptoms noted did not have the quality and persistence of those seen in children with visitation (e.g., Belsky, 1978; Caldwell, 1972; Farron and Romey, 1977; Moore, 1969; Rubenstein, 1983). Similarly, older reports and studies of children in placements had limited usefulness for our study because of the shift from institutional placements to home-based foster care and divorce with visitations (e.g., Ainsworth, 1962; Bowlby, 1952; Freud and Burlingham, 1944; Goldfarb, 1945; Spitz, 1945, 1946; Tizard, 1978). Notably, it is this older work which documented the limitations of institutional care for infants and young children and prompted the shift to family-style care of children.
Method Subjects The subjects in this study were 23 children (10 boys and 13 girls) who were referred for evaluation and consultation. The sample consisted of children from birth to 3 years of age who had visitation with biologic relatives for some period between August 1977 and January 1983. The visitation occurred either because of parental separation (N = 4) or foster placement (N = 19). Seventeen children were white, 3 black, and 3 racially mixed. All of the children's biologic mothers were from a lower socio-economic population. The characteristics of the sample are shown in Table 1.
TABLE 1 Characteristics of the Sample (N = 23) Range
Characteristic
Mean
Age at first placement (months)" Duration of first placement (months)" No. of placements" No. of caregiver changes" No. of symptoms'
8.9
7.6
0.0-26.0
13.1
12.2
0.0-47.0
2.3 2.3 3.8
1.5 1.9 2.0
0.0-6.0 0.0-8.0 0.0-8.0
S.D.
" Some children were placed at birth. b Four children were not placed in foster care but remained with a biologic parent. 'Nine symptom categories were noted. These include fussing (39.1 %), crying episodes (43.5%), withdrawal (13.0%), eating disturbance (34.8%), toileting disturbance (30.4%), sleeping disturbance (78.3%), aggressive behavior (47.8%), clinging (34.8%), and self-stimulation (4.3%). Other symptoms (52.2%) include those symptoms which occurred only in single instances and which were not classifiable into the above categories.
Procedure A retrospective review of the children's records was conducted, using a protocol developed to describe the demographic characteristics of the sample, the clinical evaluation and recommendations, and to assess the available results of the recommendations made by the psychiatrist who evaluated the child. The protocol consisted of 65 variables organized into seven sections: demographic characteristics, placement history, visitation history, symptoms, recommendations regarding visits, attachment behavior during evaluation, and diagnostic information. The assessments included medical, developmental, psychiatric, and social histories of the children. Foster parents, adoptive parents, biologic parents, social workers, attorneys, and medical staff were also interviewed in the process of evaluating the children. All children were administered the Bayley Scales of Infant Development. In addition, interactions between the child and the examiner as well as with the current primary caregiver were observed and a separation and reunion event was undertaken with all children. When possible, the interaction with the biologic parent was observed and, in some cases, was carried out with the current caregiver present. Two raters were trained in the use of the protocol and conducted all of the ratings. Initially, Pearson correlations were used to examine the relationships among the variables relevant to our hypotheses. Significant effects emerging from this analysis were then examined in greater detail using t-tests and analysis of variance.
Results The findings are organized in terms of three major areas, namely, visitation arrangements, number of
610
GEAN ET AL.
placements, and caregiver attitudes toward visitation. The zero-order Pearson correlations among the relevant variables are shown in Table 2.
Visitation Arrangements The location of the visits with the biologic relative(s), in most cases the mother, emerged as an important variable with regard to the children's distress. The frequency with which children's symptoms were related to their visits was significantly associated with visitation only at the biologic parents' home (r = 0.36, p < 0.05); 9 of the 12 children who had this form of visitation experienced symptoms before, during, and/or after every visit while the other 3 usually experienced symptoms. Specifically, toilet training problems were significantly related to such visitation arrangements (r = 0.44, P < 0.05); 6 of the 7 children who exhibited toileting difficulties had visits at the home of the biologic relativets). In contrast, visitation in the home of the primary caregiver was not significantly related to the number of symptoms displayed, nor was it associated with the frequency with which symptoms were exhibited (see Table 2). Interestingly, discussion of an anticipated visit was associated with symptom formation when the visit was planned to be located in the home of the biologic relative (r = 0.81, P < 0.001). In addition, a trend was noted that visitation in the home of the biologic relative(s) was associated with a greater number of symptoms (t = 1.97, P < 0.07; mean = 4.5 symptoms) than when visitation took place in other locations (mean = 3.0 symptoms). Number of Placements The average number of placements for these children, despite their young age, was relatively high
(mean = 2.3). These children also experienced many changes in caregivers during their first years of life (r = 0.80, p < 0.001) (see also Table 1). The number of placements experienced by the child was not related to total number of symptoms exhibited, although it was positively associated with certain types of symptoms, specifically oppositional behavior and crying, and, to some degree, clinging behavior during evaluation sessions.
Attitudes Toward Visitation A third major set of findings that emerged regarding symptoms and visitation involves the attitudes of the primary caregiver toward the visits. In those cases where the caregiver was opposed to visits (N = 13), the children exhibited a significantly greater number of symptoms (t = 2.98, p < 0.01) and were more frequently symptomatic (r = .64, P < 0.01) than when the caregiver was neutral or supportive of visitation (mean = 4.7 and 2.6 symptoms, respectively). In particular, a negative attitude toward visitation was associated with symptoms of toileting, aggression, clinging, and crying (see Table 2). Furthermore, the more anxiety the primary caregiver reported having with regard to the visitation, the greater the number of symptoms exhibited by the children (F (2, 19) = 6.23, p < 0.03); the children whose caregivers were anxious exhibited over twice as many symptoms as those whose caregivers reported no anxiety. Caregivers were anxious about visits which took place at the home of the biologic parent (r = 4.6, p < 0.05); however, anxiety was not reported to be associated with visits which took place at other locations (e.g., home of the primary caregiver, agency).
TABLE 2 Pearson Correlat ions (N = 23)
. .. _. -
Home of Biologic Parent
- - -- _
-
No. of Placements
No. of Symptoms
View Toward Visitation
._ - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
No. of symptoms Frequency of symptoms S ymptoms" Toileting problems Sleep disturbance Aggressive behavior Clinging Crying Foster parents' anxiety Age first placed - ' --
Home of Pr imary Caregiver
-
---
0.39t 0.44"
0.62""
0.44"
0.33t 0.3lt 0.46"
0.34t 0.28t
-0.30t -0.39" 0.49" 0.53"
-0.61"" -0.64"" -0.38" -0.29t -0.49"" -0.44" -0.42" -0.72"""
Not e. Correlations which exceeded an alpha level of 0.10 are not shown. • Correlat ions between ind ividual symptoms and total number of symptoms were not correlated. Fussing and eating disturbance are not included because no correlations were significant. Withdrawal and self-st imulat ion are excluded because of their rare occurrence. t p < O.f O, "p < 0.05, "" P < 0.01, and """ p < 0.001.
INFANTS AND TODDLERS IN SUPERVISED CUSTODY
Discussion A number of findings appeared in this study which we hope will encourage further in-depth consideration of the needs of children under 3 years of age who are in custodial circumstances. At the same time, a note of caution is required; the style and quality of pre- and postnatal parenting and environment in the socioeconomic class of the children's biological mothers is significantly different from that of other socioeconomic groups, thus limiting practical though not theoretical extrapolation of our data. Three areas of information are of significance and suggest clinical and theoretical ways to approach issues of placement and visitation. The findings of how the visits are arranged, the history of the child's placements, and the attitudes of the primary caregivers toward the visits are consistent with several of our hypotheses and suggest answers to questions that were asked by the referring agency. In considering the location of visits, it was noted that children were visited in one of three places: the primary caregivers home, an agency-chosen setting, or the home of the biologic relative. We found that visits in the biologic relative's home resulted in more difficulties than in other settings. A factor which may contribute to this finding is the biologic relative's differential response to a visit in their own home versus other places. We also noted that many of the children had actually lived in the biologic relative's home which introduces the possibility of memories in the child causing the distress. In addition to these factors, the quality of preparation and separation from the primary caregiver for visitation (i.e., degree of acceptance and/or anxiety expressed by the primary caregiver) was noted to contribute to symptoms. The repeated disruption in the child's attachment process to a primary caregiver results in findings similar to those seen in the Robertsons' (1971) study. The number of placements and changes in primary caregivers was expected to have an impact on the child's progression through various stages of the attachment process. Children with multiple sequential caregivers were expected to have different responses than children with no or one change. Of note, our data revealed a particular configuration of symptoms (oppositional behavior, crying, clinging) in children with more changes in caregivers. Although oppositional disorders (DSM III) are defined as occurring in children over 3 years of age, our clinical observations revealed heightened oppositional behavior in children as young as 9 months of age and it was often pathologically exaggerated in the 2-year-old phase of development when inadequate or frequent changes in caregivers had occurred. One might explain the opposi-
611
tional and attachment behaviors as a compensatory attempt on the child's part to gain control over unpredictable changes in relationships. It is generally acknowledged that the primary caregiver-child relationship is socially reciprocal, that children respond to the affective states of these caregivers (Garmezy and Rutter, 1983), and that young children of necessity must have an emotionally involved caregiver to survive. In considering our information regarding the attitude of the primary caregivers, it was noted that they felt unable to protect children in their care from the trauma of separation due to visitation because of the requirements of the legal system and agency. The conflict of offering intense emotional involvement without control of what happens to a child calls forth various feelings and defenses in primary caregivers. Though the method of reporting the caregivers' attitudes and affects was unsophisticated (i.e., rating scale of opposed, neutral, or supportive with regard to visits), the caregivers who were opposed to visits had children with a greater number of symptoms. Additionally, when caregivers were asked about their own anxiety about the visits, the children had more symptoms if the caregiver was overtly anxious (using a three-point rating of no anxiety, some anxiety, or overt anxiety). A further possible explanation for the greater number of symptoms in children who visited in the biologic relatives' home was the finding that primary caregivers were more anxious about this visitation locale than other sites. These findings suggest several areas of focus to minimize distress for young children which are consistent with what is known about young children's need for continuity of psychological attachment to a primary caregiver. First, careful consideration of visit location is warranted as well as providing direct support to primary caregivers. The use of noncustodial agency resources may be essential, given the conflicting roles of employee (i.e., foster parent) and primary caregiver. The caregivers may not be able to express the intensity of their feelings nor can the agency sincerely respond, given the legal constraints of the custodial circumstance. A second focus should be on limiting both the number of placements and duration of time prior to a final resolution of the designation of a permanent caregiver. Finally, clarification to agency personnel and legal staff as to symptom formation in response to visitation is essential to ensure that the professionals know how to modify the plans that they arrange for young children on an individual basis. The long-term impact on the child's psychosocial development secondary to multiple placements and/ or ongoing symptomatic visitation needs further
612
GEAN ET AL.
study. Ideally such a study would be prospective and include comparisons with other socioeconomic groups. Evaluation prior to placement, parental separation, or visitation and longitudinal follow-up would be useful in planning for young children's needs and maximizing their opportunity for healthy psychological development.
References AINSWORTH, M. D. S. (1962), The effects of maternal deprivation: a review of findings and controversy in the context of research strategy. in: Deprivation of Maternal Care: A Reassessment of Its Effects (Public Health Papers, No. 14). Geneva: World Health Organization. BELSKY, J. (1978), The effects of daycare: a critical review. Child Develpm., 49:929-949. BLOCK, N. M. & LIBOWITZ, A. (1983), Recidivism in Foster Care. New York: Child Welfare League of America, inc. BOWLBY, J. (1952), Maternal Care and Mental Health (World Health Organization Monograph). New York: Schocken Books (1966). CALDWELL, B. (1972), What does research teach us about daycare: for children under three. Child. Today, 1:6-11. DERDEYN, A. & WADLINGTON, W. III (1977), Adoption: the rights of parents versus the best interests of their children. This Journal, 16:238-255. FANSHEL, D. (1976), Status change of children in foster care: final results of the Columbia University Longitudinal Study. Child Welfare, 55:143-171. FARRON, D. & ROMEY, C. (1977), infant daycare and attachment behaviors toward mothers and teachers. Child Develpm., 48:11121116. FOSTER, H. (1973), Adoption and child custody: best interest of the child? Buffalo Law Rev. 22:1-26. FREUD, A. & BURLINGHAM, D. (1944), Infants Without Families. London: George Allen & Unwin. GARDNER, R (1982), Family Evaluation in Child Custody Litigation. Cresskill, N.J.: Creative Therapeutics. GARMEZY, N. & RUTTER, M. (1983), Stress, Coping and Development in Children. New York, McGraw-Hill. GEAN, M. P. (1984), Psychiatric aspects of placement and visitation
of children under 3 years of age. in: Frontiers of Infant Psychiatry, Vol. II, ed. J. Call, E. Galenson & R Tyson. New York: Basic Books. GOLDFARB, W. (1945), Psychological privation in infancy and subsequent adjustment. Amer. J. Orthopsychiat., 15:247-255. GOLDSTEIN, J., SOLNIT, A. & FREUD, A. (1973), Beyond the Best Interests of the Child. New York: The Free Press. - - - - - - (1979), Before the Best Interest of the Child. New York: The Free Press. McDERMOTT, J. F. JR., WEN-SHING, T., CHAR, W. F. & FUKUNAGA, C. S. (1978), Child custody decision making. This Journal, 17:104116. MNOOKIN, R. (1973), Foster care: in whose best interest? Harvard Educ. Rev., 43:599-638. MOORE, T. (1969), Effects on the children. In: Working Mothers and Their Children, ed. S. Yudkin & A. Holmes. London: Sphere Books. POLlER, J. (1975), Professional abuse of children: responsibility for the delivery of services. Amer. J. Orthopsychiat., 45:357-362. PROCH, K. & HOWARD, J. (1984), Parental visiting in foster care: law and practice. Child Welfare, 63:139-147. ROBERTSON, J. & ROBERTSON, J. (1971), Young children in brief separation. The Psychoanalytic Study of the Child, 26:264-315. RUBENSTEIN, J. L. (1983), The effects of maternal employment on young children. in: Advances in Applied Developmental Psychology, Vol. 2, ed. F. Morrison, C. Lord & D. Keating. Academic Press (in press). SCHETKY, D., ANGELL, R, MORRISON, C. & SACK, W. (1979), Parents who fail, This Journal, 18:366-383. SPITZ, R (1945), Hospitalism. The Psychoanalytic Study of the Child,I:53-74. - - (1946), Anaclitic depression. The Psychoanalytic Study of the Child, 2:313-342. TIZARD, B. (1978), The effects of early institutional rearing on the development of eight-year-old children. J. Child Psychol. Psychiat., 19:99-118. WALKER, W. (1973), Persistence of mourning in the foster child as related to the foster mother's level of maturity. Smith Coli. Stud. Soc. Work, 41:173-246. WEINSTEIN, E. (1960), The Self-Image of the Foster Child. New York: Russell Sage Foundation. YARROW, L. (1965), An Approach to the Study of Reciprocal interactions in Infancy: Infant-Caretaker Pairs in Foster Care and Adoption. Paper presented at Biennial Meeting of Society for Research in Child Development, Minneapolis, Minn.
AND
JEFFREY K. DOWLER, PH.D.
A retrospective chart study was conducted defining the impact of visitation by biologic relatives on children under the age of 3 who were in foster care or other custodial circumstances. The recordsof 23 children consistingof medical, developmental, psychiatric, and social histories as well as interviews with all persons involved with the child were reviewed. Locationof visits, number of placements,and primary caregiver's attitudes toward visitation were significantlyrelated to the children's presenting symptoms. Implicationsof these findings and strategies for minimizing distress associatedwith visitation are discussed. Journal of the American Academy of Child Psychiatry, 24, 5:608-612, 1985.
The Infant/Toddler Service within our Child Psychiatry Division frequently evaluates children under 3 years of age who are in foster care or custodial circumstances that include visitation with biologic relatives. It was noted that many of these children had symptoms following such visits. Symptoms were reported to be in chronologie relation to the visits which frequently included a separation from the primary caregiver for several hours or overnight. Responses to visits included transient fussiness, prolonged fussiness and inconsolability, sleep disturbance, clinginess, developmental delays, eating disturbances, withdrawal, aggressive and regressive behavior, nonorganic failure-to-thrive and chronic attachment disorders. The symptoms persisted for minutes to days after visits (see Adjustment Disorders, OSM-II!) and at times progressed into a sustained disorder. To study the impact of visitation by biologic relatives with children under the age of 3, a series of hypotheses were developed. The first was that psychological distress and behavioral disturbances were not necessarily benign, time-limited experiences for young children. Second, the type of arrangement for the visitation could be contributing to the symptoms. Our third concern was that the emotional and cognitive
development of children under 3 years of age prevented effective use of the types of interventions offered to older children. Fourth, the feelings and behavior of the primary caregiver would have an impact on symptom formation. Finally, we wondered whether symptoms were related to disruptions in the primary caregiver-child attachment process. During the clinical evaluation, the referring agency's questions regarding symptoms were elicited and interventions were offered. The questions that they asked included: How do you know that the child is not missing the biologic family member that they visited? Are the current caregivers' feelings about the visits causative of symptoms? Is the child really attached to the present caregiver rather than to the visiting parent? Will individual psychotherapy of the child stop the symptoms? Should the visits be discontinued?
Literature Review Only seven references could be located that discussed visitation per se. The books by Goldstein et al. (1973, 1979) focused on the importance of the child's developmental needs and indicated that visitation might be detrimental in some circumstances but offered no controlled data. Fanshel's (1976) research of foster children noted that the frequency of visitation directly correlated with the success of reunion with a biologic parent. The study by Block and Libowitz (1983) of recidivism of children in foster care referred to visitation but only as it related to the recidivism. McDermott et a1. (1978) briefly referred to the consideration of terminating visitation as their study showed serious consequences to children seen in follow-up who had been in visitation that was strongly opposed by a caregiver. Weinstein's (1960) study addressed issues of the self-esteem of foster children and discussed visitation related to the child's identification with parent figures. None of these studies was con-
Received June 26, 1984; accepted Oct. 8, 1984. Dr. Gean is Assistant Professor of Psychiatry and Director of the Infant/Toddler Unit, Division of Child Psychiatry, Tufts-New England Medical Center. Dr. Gillmore wa.~ Instructor in Psychiatry and Staff Psychologist on the Child Psychiatry Inpatient Unit, Division of Child Psychiatry. Tufts-New England Medical Center at the time of this writing. Dr. Dowler is a consultant to the Infant/Toddler Unit, Division of Child Psychiatry, Tufts-New England Medical Center. Portions of this paper were presented es a poster session at the October 1983 American Academy of Child Psychiatry Meetings in San Francisco. We would like to thank Beth Grossman for her a.~sistance with this project. Address for reprints: Dr. Gean. 171 Harrison Ave., Box 395, Boston. MA 02111. 0002- 7138/85/2405-0608 $02.00;0 (ei 1985 by the American Academy of Child Psychiatry. 608
609
INFANTS AND TODDLERS IN SUPERVISED CUSTODY
trolled for the ages of children. More recently, Gean (1984) has discussed the various responses to visitation in children under 3 years of age in a theoretical paper. The role of the foster parents in the emotional life of young children was described in a clinical study by Yarrow (1965). Walker (1973) discussed the necessary qualities of foster parents to be able to assist older children to grieve the loss of prior caregivers. To ascertain if the legal system had addressed the issue of visitation symptomatology, many writings were reviewed (e.g., Derdeyn and Wadlington, 1977; Foster, 1973; Gardner, 1982; Mnookin, 1975; Polier, 1975; Schetky et a1., 1979). No articles refer to the symptom complexes associated with visitation though Proch and Howard (1984) reviewed the laws in various states with regard to their stipulations of visitation both as a means of maintaining a relationship between parents and separated children and as evidence regarding the termination of parental rights. As the visitation situation includes a separation from the primary caregiver, the daycare literature was reviewed in search of parallel symptoms. The circumstances of the separation were too disparate and, in routine circumstances, any symptoms noted did not have the quality and persistence of those seen in children with visitation (e.g., Belsky, 1978; Caldwell, 1972; Farron and Romey, 1977; Moore, 1969; Rubenstein, 1983). Similarly, older reports and studies of children in placements had limited usefulness for our study because of the shift from institutional placements to home-based foster care and divorce with visitations (e.g., Ainsworth, 1962; Bowlby, 1952; Freud and Burlingham, 1944; Goldfarb, 1945; Spitz, 1945, 1946; Tizard, 1978). Notably, it is this older work which documented the limitations of institutional care for infants and young children and prompted the shift to family-style care of children.
Method Subjects The subjects in this study were 23 children (10 boys and 13 girls) who were referred for evaluation and consultation. The sample consisted of children from birth to 3 years of age who had visitation with biologic relatives for some period between August 1977 and January 1983. The visitation occurred either because of parental separation (N = 4) or foster placement (N = 19). Seventeen children were white, 3 black, and 3 racially mixed. All of the children's biologic mothers were from a lower socio-economic population. The characteristics of the sample are shown in Table 1.
TABLE 1 Characteristics of the Sample (N = 23) Range
Characteristic
Mean
Age at first placement (months)" Duration of first placement (months)" No. of placements" No. of caregiver changes" No. of symptoms'
8.9
7.6
0.0-26.0
13.1
12.2
0.0-47.0
2.3 2.3 3.8
1.5 1.9 2.0
0.0-6.0 0.0-8.0 0.0-8.0
S.D.
" Some children were placed at birth. b Four children were not placed in foster care but remained with a biologic parent. 'Nine symptom categories were noted. These include fussing (39.1 %), crying episodes (43.5%), withdrawal (13.0%), eating disturbance (34.8%), toileting disturbance (30.4%), sleeping disturbance (78.3%), aggressive behavior (47.8%), clinging (34.8%), and self-stimulation (4.3%). Other symptoms (52.2%) include those symptoms which occurred only in single instances and which were not classifiable into the above categories.
Procedure A retrospective review of the children's records was conducted, using a protocol developed to describe the demographic characteristics of the sample, the clinical evaluation and recommendations, and to assess the available results of the recommendations made by the psychiatrist who evaluated the child. The protocol consisted of 65 variables organized into seven sections: demographic characteristics, placement history, visitation history, symptoms, recommendations regarding visits, attachment behavior during evaluation, and diagnostic information. The assessments included medical, developmental, psychiatric, and social histories of the children. Foster parents, adoptive parents, biologic parents, social workers, attorneys, and medical staff were also interviewed in the process of evaluating the children. All children were administered the Bayley Scales of Infant Development. In addition, interactions between the child and the examiner as well as with the current primary caregiver were observed and a separation and reunion event was undertaken with all children. When possible, the interaction with the biologic parent was observed and, in some cases, was carried out with the current caregiver present. Two raters were trained in the use of the protocol and conducted all of the ratings. Initially, Pearson correlations were used to examine the relationships among the variables relevant to our hypotheses. Significant effects emerging from this analysis were then examined in greater detail using t-tests and analysis of variance.
Results The findings are organized in terms of three major areas, namely, visitation arrangements, number of
610
GEAN ET AL.
placements, and caregiver attitudes toward visitation. The zero-order Pearson correlations among the relevant variables are shown in Table 2.
Visitation Arrangements The location of the visits with the biologic relative(s), in most cases the mother, emerged as an important variable with regard to the children's distress. The frequency with which children's symptoms were related to their visits was significantly associated with visitation only at the biologic parents' home (r = 0.36, p < 0.05); 9 of the 12 children who had this form of visitation experienced symptoms before, during, and/or after every visit while the other 3 usually experienced symptoms. Specifically, toilet training problems were significantly related to such visitation arrangements (r = 0.44, P < 0.05); 6 of the 7 children who exhibited toileting difficulties had visits at the home of the biologic relativets). In contrast, visitation in the home of the primary caregiver was not significantly related to the number of symptoms displayed, nor was it associated with the frequency with which symptoms were exhibited (see Table 2). Interestingly, discussion of an anticipated visit was associated with symptom formation when the visit was planned to be located in the home of the biologic relative (r = 0.81, P < 0.001). In addition, a trend was noted that visitation in the home of the biologic relative(s) was associated with a greater number of symptoms (t = 1.97, P < 0.07; mean = 4.5 symptoms) than when visitation took place in other locations (mean = 3.0 symptoms). Number of Placements The average number of placements for these children, despite their young age, was relatively high
(mean = 2.3). These children also experienced many changes in caregivers during their first years of life (r = 0.80, p < 0.001) (see also Table 1). The number of placements experienced by the child was not related to total number of symptoms exhibited, although it was positively associated with certain types of symptoms, specifically oppositional behavior and crying, and, to some degree, clinging behavior during evaluation sessions.
Attitudes Toward Visitation A third major set of findings that emerged regarding symptoms and visitation involves the attitudes of the primary caregiver toward the visits. In those cases where the caregiver was opposed to visits (N = 13), the children exhibited a significantly greater number of symptoms (t = 2.98, p < 0.01) and were more frequently symptomatic (r = .64, P < 0.01) than when the caregiver was neutral or supportive of visitation (mean = 4.7 and 2.6 symptoms, respectively). In particular, a negative attitude toward visitation was associated with symptoms of toileting, aggression, clinging, and crying (see Table 2). Furthermore, the more anxiety the primary caregiver reported having with regard to the visitation, the greater the number of symptoms exhibited by the children (F (2, 19) = 6.23, p < 0.03); the children whose caregivers were anxious exhibited over twice as many symptoms as those whose caregivers reported no anxiety. Caregivers were anxious about visits which took place at the home of the biologic parent (r = 4.6, p < 0.05); however, anxiety was not reported to be associated with visits which took place at other locations (e.g., home of the primary caregiver, agency).
TABLE 2 Pearson Correlat ions (N = 23)
. .. _. -
Home of Biologic Parent
- - -- _
-
No. of Placements
No. of Symptoms
View Toward Visitation
._ - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
No. of symptoms Frequency of symptoms S ymptoms" Toileting problems Sleep disturbance Aggressive behavior Clinging Crying Foster parents' anxiety Age first placed - ' --
Home of Pr imary Caregiver
-
---
0.39t 0.44"
0.62""
0.44"
0.33t 0.3lt 0.46"
0.34t 0.28t
-0.30t -0.39" 0.49" 0.53"
-0.61"" -0.64"" -0.38" -0.29t -0.49"" -0.44" -0.42" -0.72"""
Not e. Correlations which exceeded an alpha level of 0.10 are not shown. • Correlat ions between ind ividual symptoms and total number of symptoms were not correlated. Fussing and eating disturbance are not included because no correlations were significant. Withdrawal and self-st imulat ion are excluded because of their rare occurrence. t p < O.f O, "p < 0.05, "" P < 0.01, and """ p < 0.001.
INFANTS AND TODDLERS IN SUPERVISED CUSTODY
Discussion A number of findings appeared in this study which we hope will encourage further in-depth consideration of the needs of children under 3 years of age who are in custodial circumstances. At the same time, a note of caution is required; the style and quality of pre- and postnatal parenting and environment in the socioeconomic class of the children's biological mothers is significantly different from that of other socioeconomic groups, thus limiting practical though not theoretical extrapolation of our data. Three areas of information are of significance and suggest clinical and theoretical ways to approach issues of placement and visitation. The findings of how the visits are arranged, the history of the child's placements, and the attitudes of the primary caregivers toward the visits are consistent with several of our hypotheses and suggest answers to questions that were asked by the referring agency. In considering the location of visits, it was noted that children were visited in one of three places: the primary caregivers home, an agency-chosen setting, or the home of the biologic relative. We found that visits in the biologic relative's home resulted in more difficulties than in other settings. A factor which may contribute to this finding is the biologic relative's differential response to a visit in their own home versus other places. We also noted that many of the children had actually lived in the biologic relative's home which introduces the possibility of memories in the child causing the distress. In addition to these factors, the quality of preparation and separation from the primary caregiver for visitation (i.e., degree of acceptance and/or anxiety expressed by the primary caregiver) was noted to contribute to symptoms. The repeated disruption in the child's attachment process to a primary caregiver results in findings similar to those seen in the Robertsons' (1971) study. The number of placements and changes in primary caregivers was expected to have an impact on the child's progression through various stages of the attachment process. Children with multiple sequential caregivers were expected to have different responses than children with no or one change. Of note, our data revealed a particular configuration of symptoms (oppositional behavior, crying, clinging) in children with more changes in caregivers. Although oppositional disorders (DSM III) are defined as occurring in children over 3 years of age, our clinical observations revealed heightened oppositional behavior in children as young as 9 months of age and it was often pathologically exaggerated in the 2-year-old phase of development when inadequate or frequent changes in caregivers had occurred. One might explain the opposi-
611
tional and attachment behaviors as a compensatory attempt on the child's part to gain control over unpredictable changes in relationships. It is generally acknowledged that the primary caregiver-child relationship is socially reciprocal, that children respond to the affective states of these caregivers (Garmezy and Rutter, 1983), and that young children of necessity must have an emotionally involved caregiver to survive. In considering our information regarding the attitude of the primary caregivers, it was noted that they felt unable to protect children in their care from the trauma of separation due to visitation because of the requirements of the legal system and agency. The conflict of offering intense emotional involvement without control of what happens to a child calls forth various feelings and defenses in primary caregivers. Though the method of reporting the caregivers' attitudes and affects was unsophisticated (i.e., rating scale of opposed, neutral, or supportive with regard to visits), the caregivers who were opposed to visits had children with a greater number of symptoms. Additionally, when caregivers were asked about their own anxiety about the visits, the children had more symptoms if the caregiver was overtly anxious (using a three-point rating of no anxiety, some anxiety, or overt anxiety). A further possible explanation for the greater number of symptoms in children who visited in the biologic relatives' home was the finding that primary caregivers were more anxious about this visitation locale than other sites. These findings suggest several areas of focus to minimize distress for young children which are consistent with what is known about young children's need for continuity of psychological attachment to a primary caregiver. First, careful consideration of visit location is warranted as well as providing direct support to primary caregivers. The use of noncustodial agency resources may be essential, given the conflicting roles of employee (i.e., foster parent) and primary caregiver. The caregivers may not be able to express the intensity of their feelings nor can the agency sincerely respond, given the legal constraints of the custodial circumstance. A second focus should be on limiting both the number of placements and duration of time prior to a final resolution of the designation of a permanent caregiver. Finally, clarification to agency personnel and legal staff as to symptom formation in response to visitation is essential to ensure that the professionals know how to modify the plans that they arrange for young children on an individual basis. The long-term impact on the child's psychosocial development secondary to multiple placements and/ or ongoing symptomatic visitation needs further
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GEAN ET AL.
study. Ideally such a study would be prospective and include comparisons with other socioeconomic groups. Evaluation prior to placement, parental separation, or visitation and longitudinal follow-up would be useful in planning for young children's needs and maximizing their opportunity for healthy psychological development.
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