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Researchers and practitioners alike recognize the value of attachment theory to explain the relational dynamics, behavioral disorders, and long-range developmental sequelae of abused and neglected children who are involved in the child welfare system. Foster/adoptive families and new child welfare professionals frequently receive education about attachment as part of their training (Nilsen 2003). Clinicians often refer to attachment theory in decisions about parent–child relationships and permanency planning and in discussions about behaviors of children who have been abused, neglected, or removed from their homes (Barth et al. 2005; Berlin et al. 2005; Gauthier et al. 2004; Oppenheim and Goldsmith 2007; Redding et al. 2000). Clinicians use attachment concepts to understand the distress that foster children experience in the visitation process following removal from biological parents (Haight et al. 2003; McWey and Mullis 2004). Additionally, researchers use attachment measures to focus on the empirical link between disorganized attachment and the mental health issues of abused and neglected children (Fish and Chapman 2004; O’Connor and Zeanah 2003; Walker 2007). Researchers and clinicians together design attachment-based interventions to enhance the relationship of children with their biological or foster parents (Ackerman and Dozier 2005; Dozier et al. 2002a, b). Attachment theory and research is “arguably the most popular theory for explaining parent-child behavior by professionals involved with child welfare systems” (Barth et al. 2005, p. 257).

Nevertheless, the internal and external pressures on child welfare agencies often impede the implementation of attachment-based programs, despite the theory’s popularity. To serve vulnerable populations, to compete for grants, and to meet Federal Performance Improvement Plans, managers and workers within the child welfare system are investing funds in training and devoting time to implementing practices determined effective by intervention research. Toward that end, attachment theory (Bowlby 1969, 1973, 1980, 1988; Cassidy and Shaver 2008) has attracted the attention of administrators interested in intervention research that promotes positive parent–child relationships and permanency planning. The theory emerged from an expansive body of research, and some attachment-based interventions are now empirically-supported treatments (Cassidy and Shaver 2008). However, translating attachment research into direct practice in clinical settings has been difficult (Nilsen 2003).

This chapter will explore some of the challenges in implementing in child welfare agencies the well researched, broadly accepted theoretical and practice base underlying attachment. Following a summary of the numbers of children and families served by child welfare , the chapter will present an overview of five attachment-based practice models that hold promise for addressing the needs of the child welfare population. The chapter will also present an examination of factors that encumber or support the implementation of attachment-based models in child welfare settings and a discussion of the goals of child welfare services and factors particular to child welfare organizations . The chapter will conclude with recommendations for practitioners and organizations in the child welfare field .

The Scope of Child Welfare

A federally mandated service implemented by the states, child welfare is part of the safety infrastructure of communities. Its mission is to prevent or ameliorate the abuse , neglect , dependency, and exploitation of children (Busch and Folaron 2005). While each state writes individual definitions based on standards set in federal law, the Department of Health and Human Services defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm” (U.S. Department of Health and Human Services (USDHHS) Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau 2010, p. vii). The four types of maltreatment—neglect, physical abuse , psychological abuse, and sexual abuse—can occur separately but often take place simultaneously. All forms of maltreatment have serious implications for a child’s attachment patterns and emotional development (Baer and Martinez 2006; Strijker et al. 2008).

The National Child Abuse and Neglect Data System (NCANDS) collects data on child abuse and neglect rates from the states, while the Adoption and Foster Care Analysis and Reporting System (AFCARS) reports foster care and adoption data. In fiscal year 2009, hotline workers received an estimated 3.3 million allegations of child maltreatment , representing over 6 million children. State child protective service agencies accepted approximately 62 % of these referrals for a response (USDHHS 2010), and investigations determined that 78.3 % of children suffered neglect, 17. 8% experienced physical abuse, 9.5 % were subjected to sexual abuse , and 7.6 % faced psychological maltreatment (USDHHS 2010). (Children can suffer from multiple types of maltreatment; therefore, the percentages add up to more than 100 %.) Among victims of child abuse and neglect, 48.2 % were girls and 51.1 % were boys (less than 1 % gender unrecorded). Of the victims, 87 % were among three races or ethnicities—White (44 %), African–American (22.3 %), and Hispanic (20.7 %) (USDHHS 2010). Particularly children from birth to age one who are vulnerable to abuse and neglect, had the highest rate of victimization at 20.6 per 1,000 (USDHHS 2010). This has implications because the foundation of attachment develops in the first years of life (Cassidy 2008; Marvin and Britner 2008). Further, longitudinal research on high-risk populations confirms that attachments in infancy have predictive value for future functioning (Weinfield et al. 2008).

Although most children remain in their homes with supportive services to ensure safety, in 2009 child welfare workers placed one-fifth (20.8 %) of child victims in foster care following an investigation (USDHHS 2010). As of September 30, 2009, there were 423,773 children in foster care in the United States, and the median length of stay was 15.4 months (AFCARS 2010). When in foster care for an extended period or in multiple substitute care placements, the child experiences a greater risk for attachment disorders (Dozier and Rutter 2008; Putnam 2005; Strijker et al. 2008).

In 2009, a majority (51 %) of children placed in substitute care returned to their families or exited care to live with relatives (8 %), but workers placed 20 % of children exiting foster care in adoptive homes (AFCARS 2010). Adoption is the goal of choice for children not able to return to their families or to live in an appropriate kinship placement; however, it may present an additional attachment complication for many children (Deklyen and Greenberg 2008; Dozier and Rutter 2008). As of September 30, 2009, there were 114,556 children in the US child welfare system waiting for adoption. During 2009, public child welfare agencies assisted in the adoption of 57,466 US children, and the majority of children waiting for an adoptive placement had been in care for more than 2 years (AFCARS 2010). Children waiting for an adoptive placement were of median age 4.1 when they were removed and placed in foster care , and the waiting children were of median age 7.5 (AFCARS 2010). These figures are significant because the age of the child at adoption and the length of time a child is in out-of-home care create risk factors for attachment disorders (Deklyen and Greenberg 2008; Dozier and Rutter 2008; Putnam 2005). The following section reviews the implications of these statistics on attachment patterns for children affected by abuse and neglect .

Attachment Implications for Abused and Neglected Children

There is the potential for a concerning developmental trajectory for maltreated children served by the child welfare system . Children who experience abuse , neglect , and multiple foster care placements often struggle to attach to new caregivers (Dozier and Rutter 2008; Strijker et al. 2008), are at risk for developing insecure or disorganized/disoriented attachment behavior (Baer and Martinez2006; Lyons-Ruth and Jacobvitz 2008; Main and Solomon 1990; Putnam 2005), and experience symptoms of psychopathology, particularly when they have an accumulation of risk factors (Putnam 2005). According to Putnam (2005), “a range of adult psychiatric conditions are clinically associated with child abuse” (p. 86), including major depression, borderline personality disorder, bulimia, substance abuse disorders, dissociative disorders, and Post-Traumatic Stress Disorder. As a foundation for discussing attachment-based interventions and their implementation, the following describes the risks for attachment disorders among abused and neglected children.

Disorganized/Disoriented Attachment

A large body of empirical research validates an association between child maltreatment and disorganized attachment (Baer and Martinez 2006; Lyons-Ruth and Jacobvitz 2008; van IJzendoorn et al. 1999; Webster et al. 2009). Disorganized/disoriented attachment is generally the outcome of “extreme circumstances,” such as “the absence of an attachment relationship (usually due to institutional rearing), severe abuse or neglect , or traumatic disruption or loss of an attachment relationship” (Deklyen and Greenberg 2008, p. 681). Based on empirical research, Main and Solomon (1990) originally distinguished disorganized/disoriented attachment from the two forms of insecure attachment (avoidant and ambivalent/resistant) and from secure attachment . Child attachment classifications emerged from observations and assessment of the child’s behavioral response to separation and reunion in the Strange Situation Procedure, Ainsworth’s well-validated tool for measuring attachment (Ainsworth et al. 1978). When parents reappeared after separations in the Strange Situation, the behaviors of some children were incoherent, confused, and seeming to lack observable goals or intentions. The children froze and showed signs of incomplete, interrupted movement , plus odd, misdirected, and disorganized behaviors. Main and Solomon (1990) proposed that these children failed to develop an organized strategy for self-regulation of their emotions during times of distress. They gave contradictory, yet simultaneous signals of approach and avoidance when in the presence of the parent and demonstrated their fright without a means of resolving their apprehension.

Using the Strange Situation Procedure (Ainsworth et al. 1978), a recent comparative study of two high-risk, ethnically diverse groups of preschoolers showed that maltreated children had lower rates of attachment security and higher rates of disorganized attachment compared to nonmaltreated children (Stronach et al. 2011). In two other studies, 82 % and 90 % of maltreated children had attachment systems that were disorganized (Lyons-Ruth and Jacobvitz 2008). Nevertheless, not all maltreated children have disorganized/disoriented attachments and may instead demonstrate behaviors that are insecure or even secure.

Main and Solomon’s (1990) empirical classification of disorganized/disoriented attachment differs from the clinical classification of Reactive Attachment Disorder (RAD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association 1994), which primarily describes symptomatology. Expanding the empirical and clinical descriptions of disorganized attachment , the classification system of Zeanah and Boris (2000) gives more attention to the context of disorganized behavior. They delineate three types of disordered attachment in early childhood: (1) “nonattachment,” in which the child has no discriminated attachment figure, most common among children who have been institutionalized; (2) “disordered attachment,” in which a child has selective attachment with disturbed behavior, such as self-harm or role reversal; and (3) “disruption of attachments,” in which children demonstrate strong grief reactions due to disruptions in their attachment with a primary attachment figure (Deklyen and Greenberg 2008). These contextual distinctions are particularly important when considering the origins of attachment behaviors of abused, neglected, institutionalized, and foster children in child welfare . However, Deklyen and Greenberg (2008) state that “much more research is needed, particularly with respect to children in the child protective system, to clarify the forms that attachment disorders are likely to take and to inform the design of more effective interventions” (p. 654).

The Child–Parent Relationship

The quality of the relationship between the attachment figure and child establishes the foundation for the developing child’s sense of security. Weinfield et al. (2008) point out, “Individual differences in these attachment relationships reflect differences in the history of care … these patterns of interaction, rather than individual behaviors, reveal the underlying character of the relationship” (pp. 78–79). Children who have a secure history of interaction with their parents are able to turn to them for reassurance, even when parental behavior has been threatening. In contrast, distressed children develop insecure attachment when parents are repeatedly indifferent (leading to avoidant attachment ) or inconsistent (leading to ambivalent/resistant attachment)—patterns considered adaptive, though not optimal. Severely maltreated children, however, develop “breakdowns in the organization of attachment behavior, or …reflect striking episodes of disorientation” (Weinfield et al. 2008, p. 81) because they have had repeated interactions with caregivers whose own behaviors reflect disorientation, often due to their unresolved loss or trauma .

Abusive caregivers are frightening to children, especially infants . When the child feels frightened, yet has no place to turn for comfort, the dynamic disorganizes the child’s attachment system. Van IJzendoorn and Bakermans-Kranenburg (2003) described the phenomenon:

The best example of a disorganized attachment is the relationship between the abused child and the abusive parent. The abusive parent fulfills two incompatible roles. On the one hand, he or she is the child’s attachment figure and the only potential source of safety in an uncharted threatening world. On the other hand, the abusive parent is the stressor who can suddenly and unexpectedly threaten the child with physical or psychological violence. The child is placed in an irresolvable paradoxical situation in which the only possible base from which to explore the world is at the same time the source of unpredictable abusive threat. (p. 314)

Long-Range Outcomes

Unfortunately, longitudinal studies show serious adverse outcomes for infants and young children with insecure and disorganized attachment as they develop into later childhood and adulthood (Bernard et al. in press; Weinfield et al. 2008). Disorganized attachment in infancy significantly predicts dissociative symptoms in adolescence and young adulthood (Lyons-Ruth et al. 2006; Ogowa et al. 1997) and places children at higher risk for dysfunctional externalizing behaviors (Lyons-Ruth et al. 1997). Numerous studies show correlations between disorganization in infancy and controlling/disorganized behavior in preschool and elementary school, affecting peer relationships and parent–child interactions (see Lyons-Ruth and Jacobvitz 2008). Two longitudinal studies have followed infants to young adulthood, allowing comparisons of attachment classifications between the infant Strange Situation (Ainsworth et al. 1978) and the Adult Attachment Interview (AAI) (George et al. 1984). One study found that 86 % of disorganized infants were more likely than secure infants to be classified as insecure on the AAI at age 19 (Main et al. 2005). Similarly, disorganized infants were more likely to be classified as unresolved on the AAI at age 26 (Sroufe et al. 2005).

There is additional evidence that children with insecure or disorganized attachment show elevated levels of the stress hormone cortisol, compared to securely attached children (Lyons-Ruth and Jacobvitz 2008), which “can cause long-term damage to certain brain regions” (Putnam 2005, p. 88). Neuroimaging research on the effect of trauma on children and adolescents has found that persons diagnosed with post-traumatic stress disorder (PTSD) had smaller brains due to atrophy, especially in the corpus callosum, the area of the brain that connects the two hemispheres (Putnam 2005). Findings indicate that brain atrophy and the degree and duration of the abuse are positively correlated. This is a particularly significant finding because antisocial behaviors are associated with abnormalities in the corpus callosum (Putnam 2005). In sum, children who develop disorganized attachment in response to their abuse and neglect appear to be at high risk for brain damage, physiological dysregulation, and consequent psychopathology.

In response to the serious developmental sequelae of child abuse and neglect , Putnam (2005) says, “Our recognition of the profound and often lifelong effects of early environmental stressors dictates that we develop programs at the public health scale to prevent these experiences from occurring to infants and children” (p. 93). Others share his view as evidenced by the attachment researchers who have turned their attention to the development of clinical interventions designed to prevent child abuse, treat traumatized children, and promote healthy parenting. The following discussion summarizes five programs that professionals have created and empirically evaluated in recent years.

Attachment-Based Treatment with Child Welfare Involved Families

The creation, implementation, and testing of treatment models for children and adults with attachment insecurity has become a major focus of attachment researchers over the past 20 years (Berlin 2005; Cassidy and Shaver 2008). A small, but growing, number of interventions are labeled as “evidence-based” or “promising” for use with traumatized children and their families, based on the number and level of empirical research studies that have demonstrated the effectiveness of the intervention (Igelman et al. 2008, p. 37). Evidence based practice (EBP), which originated in the field of medicine, refers to the process of “… integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al. 1996, p. 71). In the field of child welfare the concept of EBP, in contrast to a process, refers to a practice model or intervention empirically linked to positive change among clients (Luongo 2007).

Researchers tested some of the models discussed in this chapter with children and families affiliated with the child welfare system , yet few interventions specifically address the needs of foster children , and public child welfare agencies have not fully implemented these approaches. The following is a brief review of models recommended by the National Child Traumatic Stress Network (NCTSN 2011) or by scholars who focus on interventions for traumatized children and families associated with child welfare (Berlin et al. 2008; Dozier and Rutter 2008; Igelman et al. 2008). Although not an exhaustive review of all current interventions, these five models represent creative approaches that hold promise for children and families referred to child welfare agencies.

Attachment and Biobehavioral Catch-up

Attachment and Biobehavioral Catch-up (ABC) is a well-known, attachment-based intervention (Dozier et al. 2005, 2006, 2009), originally designed for foster parents and the infants and toddlers for whom they provide care, with the goal of “guiding parents to help their children regulate emotions, respond effectively to the children’s distress, and understand the children’s signals” (Dozier and Rutter 2008, p. 712). This program consists of ten weekly one-hour home visits by master’s level social workers trained to help foster parents provide nonthreatening nurturing. In this program, foster parents learn to follow the lead of the child, to place the child’s needs over their own non-nurturing instincts, and to recognize how their personal histories sometimes interfere with the special challenges many foster children have in regulating negative emotions (Berlin et al. 2008). Foster parents essentially “learn to re-interpret children’s alienating behaviors” (Dozier et al. 2009, p. 327). In preliminary findings, foster parents who received the training reported fewer behavioral problems for older foster children , and a majority of the children had lower levels of the stress hormone, cortisol, following intervention (Dozier et al. 2006). Comparative evaluations found that children whose foster parents received the ABC intervention were considerably less avoidant in their attachment than those who received an educational intervention (Dozier et al. 2009) .

Researchers have modified ABC for use with birth parents and continue to test the manualized intervention in randomized trials. Dozier et al. (2005) have reported, “birth parents embraced the intervention enthusiastically” because they learned ways “to override their own propensities to be rejecting of their children” (p. 190). In a recent study of 120 biological parents involved with CPS in a large, urban, mid-Atlantic city, outcomes support the efficacy of the ABC intervention (Bernard et al. 2012). Prior to intervention, the researchers assessed the attachment patterns of the children with the Strange Situation Procedure (Ainsworth et al. 1978) and then randomly assigned birth parents to the intervention and control groups. Compared to children whose birth parents received the control intervention focused on parent education and children’s cognitive and linguistic development, children whose parents received the ABC intervention had significantly higher rates of attachment security (52 % compared to 33 %) and lower rates of attachment disorganization (32 % compared to 57 %) after the treatment. Reportedly, this study’s results suggest that ABC “is effective in promoting organized and secure attachment outcomes among a group of young children who are at risk for neglect ,” yet “more nuanced questions of how and for whom the intervention works remain to be addressed” (Bernard et al. 2012). Nevertheless, the ABC intervention is significant because it is a short-term treatment model with both foster parents and birth parents involved in the public child welfare system .

Circle of Security

Another treatment model that has gained attention in child welfare is Circle of Security (COS), a 20-week group intervention based on attachment theory and object relations (Cooper et al. 2005; Marvin et al. 2002; Marvin and Whelan 2003). Researchers originally implemented COS with birth parents of toddlers recruited from Head Start and Early Head Start. According to the protocol, a parent interview and a videotaped Strange Situation (Ainsworth et al. 1978) yield the parent and child assessment prior to the first parent group. During the group process, parents learn to read their child’s attachment cues and miscues by viewing edited video clips of their own attachment–caregiving interactions observed in the Strange Situation (Ainsworth et al. 1978) and by watching the edited tapes of other parents. In an initial pre-post study of the manualized COS training, 80 % of the children were insecure prior to the intervention. After the intervention, 46 % were insecure and 54 % were secure (Berlin et al. 2008). To date, researchers have not tested the efficacy of the COS model with a randomized control group, but it is one of the few attachment-based interventions implemented by social workers in a public child welfare agency (Blome et al. 2010; Page and Cain 2009). In addition, it is in use as a dyadic intervention and has been an auxiliary treatment in a number of parent–infant intervention programs related to jail diversion (Berlin et al. 2008). Whether in a group or dyadic intervention format, the video-feedback in COS offers parents the opportunity to reflect more easily on their interactions and to see a video demonstration of their child’s attachment needs.

Child–Parent Psychotherapy

In contrast to the previous brief treatment models, Child–Parent Psychotherapy (CPP) offers a 50-session model of treatment based on attachment, psychodynamic, developmental, cognitive, behavioral, and trauma theories (Lieberman and Van Horn 2008; Lieberman et al. 2005; Lieberman 2003, 2004). It focuses on how domestic violence affects the parent–child relationship. Recommended by NCTSN (2011) as a promising evidence based intervention, this dyadic treatment is reminiscent of Selma Fraiberg’s classic work with mothers and young infants (Fraiberg 1980). Like Fraiberg’s (1980) psychoanalytic approach, CPP helps parents address “old ‘ghosts’ that have invaded the nursery” (p. 61) and are negatively influencing present-day parenting. Lieberman et al. (2005) state that CPP is based on the premise that “the attachment system is the main organizer of children’s responses to danger and safety in the first years of life,” and “early mental health problems should be addressed in the context of the child’s primary attachment relationships” (p. 1241). Following a manualized treatment protocol, the weekly joint child–parent CPP sessions, interspersed with individual parent sessions as needed, help the parent and child create a narrative about the traumatic events in their lives. The treatment “focuses on improving the quality of the child-mother relationship and engages the mother as the child’s ally in coping with the trauma” (Lieberman et al. 2005, p. 1243). Graduate level practitioners trained in the CPP protocol implement the approach as a home or office based intervention (Berlin et al. 2008).

One of the benefits of CPP is that professionals have effectively used the approach with a wide range of ethnic/racial groups, including Latino and African–American families, as well as recent immigrants in urban settings. Findings from randomized trials support the model’s efficacy with trauma-exposed at-risk children (Cicchetti et al. 2006; Lieberman et al. 2005; Weiner et al. 2009). It is one of the treatments of choice of the national team of consultants from Zero to Three: National Center for Infants, Toddlers , and Families, who work with the judicial system, CPS, and mental health on behalf of young children. A creator of CPP and weekly consultant to CPS in San Francisco’s public child welfare system, Lieberman states that the model “… is an excellent treatment approach for infants and young children in foster care ” (personal communication, July 10, 2011). She reports, “… approximately 40 % of the families receiving CPP in our program are either referred by CPS or involved in the dependency system” (personal communication, July 10, 2011).

Minding the Baby

Of similar length to CPP, Minding the Baby (MTB) is a long-term home visiting program designed for high-risk, first time mothers (Slade 2006; Slade et al. 2005). The interveners in the pilot study—dyads of clinical social workers and pediatric nurse-practitioners—visit the mother weekly beginning in the third trimester of pregnancy and biweekly throughout the first year of the infant’s life. In this model, the dyad aims to provide a secure base for the mother . In the pilot test, 36 % of the mothers had experienced abuse as children and 55 % had a history of depression (Slade et al. 2005). Notably, these are similar demographic characteristics of families affiliated with child welfare . This intervention aims to increase the mother’s reflective functioning, that is, to increase her capacity to be attuned to the mind of the baby. Preliminary analysis of the intervention’s outcome suggested that the mother’s reflective functioning increased significantly over the course of the baby’s first 18 months, and 76 % of the infants were secure at 12 months (Berlin et al. 2008). Significantly, the child welfare agency received no reports of abuse or neglect on behalf of the children participating in the study. According to Slade, “… we are not an intervention geared in any direct way toward families with [child welfare ] involvement, although we are, of course, touched by the system in many ways” (personal communication, April 10, 2011). Slade et al. (2005) recommend their approach for parents with “significant psychiatric and trauma history” because these parents “are the ones who most need and are most likely to benefit from the kind of intensive, integrated intervention MTB has to offer” (p. 172).

Chances for Children

Chances for Children (Mayers et al. 2008), a school-based project initiated in the New York City public schools, addresses the needs of another population served by child welfare agencies—teen mothers . With on-site daycare facilities for children whose adolescent mothers are students, this intervention takes a multi-dimensional approach through the provision of parent therapy, child play therapy, parent–child therapy, parent groups, and support from daycare staff . The theories of Fraiberg (1980) , Lieberman and Pawl (1993), and Fonagy and Gyorgy (2002) informed the treatment model, as well as the parent–child interaction focus of Beebe (2003) and McDonough (2000). Although the intervention is “primarily a clinical program, not a research program” (Mayers et al. 2008, p. 326), outcome measures suggest that it improved the responsiveness and affective attunement of the mothers to their children and increased the interest of children in their mothers. Publications about the program do not specify how many of these teens were receiving services from the public child welfare system in New York while they participated in Chances for Children .

Program Highlights

In these five models, attuned practitioners strive to establish a secure base for parents to explore and reflect on their relationships with their children . Using home visits, in-school visits, or group process, these models aim to increase parental sensitivity and reflective functioning . Specifically, they seek to increase the parent’s capacity to understand how the child is viewing him/herself and others. Through interactions with the practitioners, parents begin to understand their children’s attachment needs. This process then enables the parent to address unresolved conflicts and meet the needs of his/her child. Through empathic connections, parents receive training to understand the child’s attachment cues, which give clarification about the child’s underlying emotional needs. It is important to underscore that these five models are comprehensive, multi-theoretical, and require skilled professionals trained in the treatment protocol to intervene with families. With the exception of ABC, the models are neither specifically for child welfare families nor are they an exhaustive summary of all attachment-based interventions for children and families. Potentially, these five creative approaches can meet the kinds of needs that are present in families involved with the child welfare system .

Child Welfare Services

Although the attachment-based treatment models discussed seem appropriate for children and families serviced by child welfare, there are federal policies and organizational issues that may impede their implementation. One major challenge to implementation is that the mission of child welfare is different from the focus of such comprehensive attachment-based interventions.

The Adoption and Safe Families Act of 1997—P.L. 105-89 (ASFA)—established child safety as the first concern guiding all child welfare services. Although the law asserts the right of children to the essentials needed for healthy development, including a sense of belonging, continuity of care, nurturing relationships, and access to opportunities (Lutz 2003), protection from abuse and neglect remains its primary focus. In addition to safety, the law mandates that child welfare agencies ensure permanency and stability in the child’s living arrangements and preserve family relationships and connections. Legislation, beginning with the Adoption Assistance and Child Welfare Act of 1980—P.L. 96-272, puts the focus on preventing placement, through family centered practice and establishing permanency for children (Lutz 2003).

To achieve permanency, child welfare agency staff must determine if the child can remain in the home, with services as necessary, or if safety concerns require placement in foster care with relatives or unrelated adults. While workers receive training to discern clues about the parent–child relationship—for example, the child’s reaction to the parent and the parent’s sensitivity to the child’s emotional needs—physical safety is often the most visible factor noted during an investigation. In other words, though abuse and neglect affects the parent–child attachment relationship (Baer and Martinez 2006), enhancing attachment is not the primary concern in the investigation and immediate provision of services. Safety, permanency, and well-being are the primary federally mandated goals for the child welfare system .

Permanency Planning

To meet these goals, caseworkers establish a permanency plan, which should include an assessment of the attachment of the child and parent. The child welfare worker must conduct the analysis on an ongoing basis by staying in regular contact with the child and the family. The organizational structure of child welfare, however, may thwart the ability of workers to spend time with families and understand the intricacies of the parent–child relationship. In child welfare systems, caseloads are often large, with one survey indicating that only 11 % of foster care caseloads meet the Child Welfare League of America national standards (Children’s Defense Fund and Children’s Rights 2007). Additionally, child welfare workers stay on the job an average of less than 2 years, and 90 % of states report difficulty hiring and retaining qualified staff (Children’s Defense Fund and Children’s Rights 2007). Staff with social work degrees are most likely to continue working in child welfare and to achieve permanency outcomes in the least time (Barbee 2005; Ellett et al. 2009; Jones 2002, Jones and Okamura 2000), yet “less than 30 % of child welfare workers have professional social work degrees (BSW or MSW)” (Social Work Policy Institute 2011, para. 4).

This job instability is critical because worker constancy can make a functional difference for children and families. A seminal study of child outcomes found that children who had experienced one worker achieved permanency in 74.5 % of the cases; two workers dropped the permanency rate to 17.5 %, and with a succession of three workers, the permanence rate was a mere 5.2 % (Flower et al. 2005). Further research associated caseworker turnover with an increased number of placements, longer stays in foster care , and fewer services offered to families (Children’s Defense Fund and Children’s Rights 2007). These troubling statistics have implications for the application of attachment-informed practices within public child welfare agencies. Without continuity of professionally educated workers, it is difficult to establish the level of connection with parents and children needed to assess and enhance attachment security. With increased frequency of placements—complicated by high staff turnover—children are at greater risk for disordered attachments (Strijker et al. 2008).

Parent–Child Visitation

Parent–child visitation is among the most important services when children are in substitute care. Research findings strongly link frequent visiting by parent(s) with permanency outcomes for children. In a study of state policies, the suggested visitation schedule for children and parents ranged from daily to monthly (Hess 2003b). Yet Kuehnle and Ellis (2002) ask:

Because physical proximity is the key goal of the attachment system for infants and toddlers , and availability is the goal for other children, how could children of any age possibly maintain an affectional or attachment bond with a parent he or she visits every 30 days? (p. 69)

Although family visiting is a core reunification service, planning and implementing visits is time-consuming and limited agency resources may undermine the success of the service (National Resource Center for Family Centered Practice and Permanency Planning 2008). A Georgia study found that only 12.7 % of mothers and 5.6 % of fathers visited with children in care at least once every 2 weeks during an 18-month period (Hess 2003a). Infrequent visits, influenced by scarce agency resources, further affect the parent–child attachment. Hess (1987) astutely observed:

Each visit of a child in placement with his or her parent begins with a reunion and ends with another separation, a separation that, in most cases, continues until the reunion that begins the next visit. It can be expected that parent-child attachment and the reactions to reunion and separation shape the interactions during each visit, as well as interactions over time. (p. 30)

In sum, the policy framework of child welfare services, the educational level and high turnover of staff, and the enormity of the workload test the capacities of child welfare agencies to protect and serve all children and families at risk of abuse and neglect . In addition, the nature of parent–child visitation for children in foster care complicates, rather than enhances, parent–child attachments. Furthermore, the decisions that child welfare workers make exist within an organizational structure subject to internal and external pressures that compound the implementation of attachment-based initiatives. The following explores these organizational complexities and their link to the implementation of intervention models.

Organizational Issues

Large, public agencies and their private, subcontractor partners carry out services to families at risk of child abuse and neglect. Of particular relevance to the discussion of implementing attachment-based programs is the reality that “the bureaucratic structure of public child welfare rewards more routinization and centralization, yet simultaneously seeks to fulfill missions through technologies that encourage greater worker discretion” (Yoo et al. 2007, p. 64). Consistency of practice is necessary in an organization that must monitor activities for federal and state reviewers, yet the problems brought by children and families engaged in the child welfare system call for sound worker judgment and flexibility. To provide consistency and best meet the needs of protecting vulnerable children from abuse and neglect , evidence based practice has become “the buzzword in child welfare today” (Blome and Steib 2004, p. 611).

Internal and External Influences on Implementation of Evidence-based Practice

Internal Factors

Despite the current emphasis on EBP, Blome and Steib (2004) point out that there is no uniform path to meet desired outcomes in child welfare . They report: “Unfortunately, no one evidence based program leads to faster reunification, more stable placements, or higher rates of recovery from addiction. Many programs and practices may affect these outcomes depending on a myriad of organizational and staffing issues” (Blome and Steib p. 611 2004,). The transition to an evidencebased approach to structuring services is a cultural shift, albeit one that is seen as inevitable by administrators in the field (Jack et al. 2010; Luongo 2007). Diffusion of an evidence based practice assumes, first, that the agency has knowledge of and access to empirically supported approaches and, second, that the agency has the ability and willingness to adopt the change (Rogers 2002).

Organizational culture and climate are two internal factors that influence attitudes towards the adoption of an innovative EBP model (Aarons and Sawitzky 2006). Organizational culture is the organization norms and expectations regarding how people behave and accomplish tasks within an agency (Glisson and James 2002). This includes the mission, goals, values, norms, leadership, communication flow, policies, and practices that shape all program activities (Luongo 2007) and the common history and experiences of the organization as a whole (Bryan et al. 2007). Organizational culture has many layers, with shared behavioral expectations in the outer, conscious layer and values and assumptions making up the inner, less conscious layer that members of an organization may not fully recognize (Rousseau 1990). For example, an agency may acknowledge the importance of attachment principles in family assessment, but not provide the supervision or training necessary to allow the practice to become part of the organizational way of working. On a conscious level, staff may receive encouragement to apply attachment principles in their work with children , but on a less conscious organizational level, supervisors or managers may not support the intervention. Both levels create a culture within a child welfare agency . Contrasting with organizational culture, organizational climate reflects the perceptions of individual workers of the psychological impact of the work environment on their wellbeing (Glisson 2002; Glisson and James 2002). In a study of organizational culture and attitudes toward EBP, researchers found that culture precedes and affects climate, therefore actions to improve organizational culture may lead to improvements in climate (Aarons and Sawitzky 2006). For example, if the organizational culture functionally supports implementation of an attachment-based intervention and workers can see substantive gains in the relationships of the parents and children they serve, the assessment of staff about the cost of the work on their wellbeing may improve.

Leadership is key to a positive organizational culture (Glisson 1989) and may be especially important to the implementation of the multi-dimensional attachment-based programs like the five models previously discussed. Transactional leadership builds on exchanges that occur between the leader and the follower in which the leader rewards the follower for meeting specific performance criteria (Aarons 2006). Because child welfare is a highly regulated endeavor, transactional leadership, with the focus on measureable goals and established benchmarks, is an expected approach. Transformational leadership that inspires staff and increases their intrinsic motivation through understanding the goals of the leader provides the greatest relationship with positive results (Aarons 2006). Paired together, transactional leadership and transformational leadership can promote a culture of enthusiasm, openness, and trust. For example, implementing a complex attachment-based approach requires sustained interest by managers and supervisors, as well as consistent tracking of the fidelity of the intervention. Teaming the transactional and transformational approaches is necessary to move an intervention from a pilot to an institutionalized approach to practice.

Leadership also occurs at the supervisory level, and in child welfare , supervisors may be responsible for maintaining consistent attention to practice fidelity. They are central to the successful implementation of new programs. For example, the implementation of the COS intervention in a public child welfare agency demonstrated supervisory commitment to an EBP approach (Blome et al. 2010; Page and Cain 2009). Timothy Page, the social work researcher who studied COS, stated that one mid-level supervisor was so impressed with COS—especially the model’s emphasis “on strengthening parents’ capacities for empathic responsiveness to their children”—that she “became the chief advocate for crossing the divide between appreciation of the program as good theory and application of the program in the agency service environment” (Blome et al. 2010 p. 437). She preferred the COS method of having parents observe their children via videotape, which she viewed as more effective than the common didactic methods of many parenting classes.

External Factors

Leaders championing organizational change must constantly assess the external forces that may assist or impede the change initiative (Fernandez and Rainey 2006). As child welfare is a highly politicized and scrutinized field (Blome and Steib 2007), the planning and implementation of change frequently occurs in full view of both supporters and detractors. The workers and managers in child welfare operate in a fishbowl of public inquiry. Media outlets may portray tragedies as the result of faulty decision-making or caseworker error (Smith and Donovan 2003). The decision-making environment is often reactive and crisis driven, resulting in the hasty development of policies and practices to address current, sometimes tragic, events (Jack et al. 2010). Additionally, an external political crisis may undermine an attachment-based program in the process of implementation.

Organizational change does not occur through a one-time staff orientation or a series of emails. “With each strategic change the organization decides to make comes an inherent risk, and that risk must be weighed against the potential return” (Allawi et al. 1991, p. 39). Yet, political trends may influence potential return. For example, some theorists point out that long-standing public organizations , like child welfare systems, may be in the stage of development where conservers take control of the organization and the pace of change decelerates (Fernandez and Pitts 2006). Other theorists find that public organizations change regularly due to frequent shifts in the political environment—a significant risk factor for the implementation and sustainability of a complex treatment program. As public system observers have noted, “… constant change makes it difficult to implement and sustain long-term change in the public sector” (Fernandez and Pitts 2006, p. 4).

Economic considerations also influence change. Fernandez and Pitts’ (2006) study of the conditions under which public managers pursue organizational change revealed two findings that relate to readiness for change. Public managers with more financial resources at their disposal are more likely to favor change in their organizations , and the more a manager interacts with relevant actors in the external environment, the more likely the manager will have a positive attitude to change. Such findings are relevant for academic researchers who evaluate attachment-based models of intervention within child welfare agencies. If researchers actively develop professional relationships with child welfare managers and if the agency receives financial resources through grants, the organization may be more open to implementing new interventions.

The ability of an organization “… to recognize the value of new, external information, assimilate it, and apply it … is critical to its innovative capabilities” (Cohen and Levinthal 1990, p. 128). Prior knowledge of a related area may facilitate assimilation of new knowledge. For example, in social work programs, the curriculum includes theory courses on human growth and development and, in many schools, courses on attachment . The extent to which child welfare agencies have staff with this foundational knowledge may enhance the implementation of an attachment-based program. Similarly, the level to which individuals are familiar with research terms and processes may influence their openness to implementing empirically informed practices. Jack et al. (2010) found that decision makers were more likely to use research evidence if they had research courses during graduate school, had work experience outside of child welfare, had access to databases which compile research findings, and possessed critical appraisal skills and a personal dedication to inquiry.

In addition to the knowledge of individual staff members, an organizations’ absorptive capacity depends on the transfer of knowledge across and among subunits of the agency (Cohen and Levinthal 1990). In child welfare, implementing an attachment-based program would require an appreciation of family connections, beginning with intake and assessment and continuing through placement and reunification decisions. Involving the continuum of service divisions within the organization requires a focused communication strategy that is consistent, integrated, and thorough to assure fidelity of implementation of the empirically based program.

Steps and Stages of Organizational Change

Preparing organizations for change involves a series of interconnected steps. While agencies may successfully adopt simple innovations without difficulty, attachment-based treatment models are complicated. Pertinent to the implementation of the programs discussed in this chapter, Simpson (2009) suggests that “as innovations and new procedures become more complex and comprehensive, … the process of change becomes progressively more challenging—especially in settings where staff communication, cohesion, trust, and tolerance for change are lacking” (p. 543). For these reasons, it is critical to plan and prepare for implementation and “to identify and address organizational deficiencies before facing decisions about innovations” (p. 543).

Various theorists have outlined steps in the organizational change process (Fernandez and Rainey 2006), such as the five stages of exploration, program installation, initial implementation, full operation, and sustainability (Fixen et al. 2005). The first stage, exploration, assesses the potential match between community requirements, evidence based practices and programs, and community resources in order to decide whether to proceed. Stakeholders exchange information to identify the need for an intervention, to assess the fit between the intervention program and community needs, and to prepare the staff and resources by mobilizing information and support (Fixen et al. 2005). The process of convincing individuals of the need for a change—such as the usefulness of implementing ABC into foster care training or referring children and parents to therapists trained in CPP—begins with a compelling vision for the new way of operating (Fernandez and Rainey 2006). “The most elegant and sophisticated of new practices will not be implemented if they are not embraced by potential users” (Kimberly and Cook 2008, p. 12).

Program installation, the second stage, is a set of activities in which administrators establish structural supports necessary to initiate the program. The agency hires or realigns staff to meet the qualifications required by the program and secures resources and technology, as needed. Initial implementation, the third stage, can be challenging as the compelling forces of fear, inertia, and investment in the status quo (Fixen et al. 2005) test confidence in the decision to adopt a program. Some initiatives fail at this point, the victim of internal and external influences. In part, the lack of success may stem from insufficient attention to the individual level of adoption , because personal innovativeness, attitudes towards the innovation, and peer usage affect the outcome (Frambach and Schillewaert 2002). The challenge to managerial leaders is to build internal support for change and reduce resistance through full participation in the change process (Fernandez and Rainey 2006). Fourth, full operation occurs when the agency gives the message that the innovation is the accepted way of business. It is no longer the new program within the organization. Currently, some child welfare agencies are pilot testing attachment-based approaches, such as ABC and CPP, but no known agency has moved into the organizational phase of full operation. The last stage, sustainability, occurs when the innovation survives the departure of well-trained staff, adjustments to funding streams, and changes in the political and social environment (Fixen et al. 2005). Organizational managers, staff, and external researchers need to pay careful attention to all five stages of organizational change for successful implementation and, ultimately, sustainability of attachment-based interventions.

Finally, it is important to underscore the importance of financial resources for training. A public child welfare agency may want to implement an attachment-based intervention but may lack the funds to hire professional staff and train them in the identified model. Programs often require staff with a minimum of a Masters of Social Work (MSW) degree and specific training in the protocol, but public child welfare agencies, in most states, do not have a full complement of caseworkers at the MSW level. Although many child welfare agencies have sophisticated training academies that offer pre-service and in-service training, additional support may be necessary to implement a program with the complexity of the attachment-based interventions discussed above. As Luongo (2007) has said, “training in child welfare , to be successful, must encompass a much broader view of training as facilitating ongoing development (of the individual and organization)” (p. 93). In other words, successful implementation requires significant financial resources for broad, yet protocol-specific training, in addition to mutual awareness among agency leaders and external researchers regarding organizational readiness and organizational stages of change.

Recommendations for Practitioners and Organizations

Of the five attachment-based models presented in this chapter, researchers and clinicians have implemented ABC, COS, and CPP as pilot projects in public child welfare agencies. To promote these models and similar attachment-based interventions in the future, professionals will need to engage in careful planning, frequent collaboration, and extensive training, in addition to securing sufficient funding. A summary of the organizational literature and research models discussed above lead to the following recommendations for clinical practitioners and child welfare organizations that attempt further implementations:

  1. 1.

    Clinical practitioners and child welfare professionals need to understand the terminology, differences, and context of various attachment patterns, rather than assume that all child behavioral symptoms are a result of an attachment disorder. Clinicians need to use classifications that describe attachment patterns judiciously and with understanding of the meaning of the terms. These classifications can stay with a child for years and may cause harm if the description is incorrect or shared with non-professionals. Clearly, a best practice approach is for professionals to maintain confidentiality about the child’s attachment patterns.

  2. 2.

    Practitioners and researchers need to conceptualize attachment disorders using a common framework and typology. Currently, there is inconsistency between practitioners and researchers regarding the meaning and etiology of disorganized attachment in children . Fidelity of definition is important for all professionals who try to create, implement, and evaluate models of intervention for children affected by maltreatment.

  3. 3.

    In keeping with the child welfare mandate to assure the well-being of children in the protective system, administrators must allocate funding to a wide-range of services, including attachment-based interventions. However, designers of attachment-based interventions should consider the organizational and funding realities that exist for public child welfare agencies. In a time of funding cuts, it is difficult for child welfare agencies to provide interventions that require long-term commitments of time and resources.

  4. 4.

    Attachment theory is complex and the clinical programs based on this theory call for professional staff trained in the model’s protocol. Public child welfare organizations need to hire professionals with the credentials to implement and oversee attachment-based interventions.

  5. 5.

    Because child welfare is a public sector program, government policies mandate that all children and families at risk receive a consistent level of service. Yet, the strengths and needs of each child and family demand an individualized approach, driven by a well-trained professional worker. It is important that private clinicians and academic researchers appreciate these conflicting demands on child welfare workers. Otherwise, workers may feel misunderstood and criticized, which may challenge the collaborative process essential to implementing an empirically based intervention.

  6. 6.

    The high turnover among workers and administrators impedes the implementation and institutionalization of practice change in child welfare agencies. Organizations need tactics, such as increased numbers of social workers , adequate professional supervision, improved continuing education, and smaller caseloads, to retain staff in order to maintain change processes.

  7. 7.

    Child welfare agencies need transformational leaders to promote collaboration and cooperation among stakeholders and support innovative approaches to serving children and families. In preparing to implement an innovative program, child welfare administrators, external academic researchers, and community clinicians must collaborate frequently and respect each other’s skills.

  8. 8.

    Children in the child welfare system have a right to expect that the professionals engaged in their lives will provide the most effective empirically based treatments available and will believe in their capacity to lead functional and productive lives. Similarly, professionals need to appreciate the hope and possibility of change that attachment-based modalities can offer the child and family.

Conclusion

Child welfare administrators and staff understand the need to serve children and families who have experienced the disruptive influences of abuse and neglect and the interruption of attachment relationships . To address concerns about trauma and separations, professionals must balance the appeal of attachment-based interventions with an understanding of the organizational factors that may support or impede the performance of the model. This chapter reviewed empirically validated models that address the attachment processes for at-risk children and families, including those in the child welfare system. However, all five models require highly skilled, trained professionals to serve families, as well as organizational commitment to fidelity and evaluation to assure the proper implementation of the model. To optimize the successful expansion of these models into the public child welfare arena, attention to organizational issues and environmental context is critical.