Young foster children and their carers: An approach to assessing relationships

Abstract

Objective:

This article outlines an approach to assessing the quality of relationships between young foster children and their carers. These children are at high risk of disorganised attachment relationships and of developmental psychopathology given their relational experiences prior to and in care. During a semi-structured play interaction the emphasis is on identifying behaviours of clinical interest. This can be complex given the likelihood of atypical or unexpected behaviours expressed within relationships.

Method:

The paper draws on literature on the clinical application of attachment theory to the assessment of relationships and on the authors’ experience of developing and delivering an assessment and intervention service for children aged 0 to 5-years-old within a mental health service for children in foster care. Clinical material is used to illustrate and develop the issues.

Conclusion:

The case for including a semi-structured observational procedure as part of a comprehensive assessment of foster children and their carers is outlined. This is argued to have more clinical utility than formal approaches to attachment classification. The benefits of including a semi-structured and relational approach to clinical assessment of foster children are outlined along with the need to be cautious in the use of attachment related terminology when formal assessments have not been undertaken.

Keywords

Young children in care foster children and carers relational assessment semi-structured play assessment attachment relationships

Background

This paper is informed by the authors’ work in the Alternate Care Clinic (ACC), a mental health service for children aged 0–18 who are in kinship or foster care in western Sydney, Australia, with government or non-government agencies. The ACC includes a service for 0 to 5 year olds in care. The literature review and development of a semi-structured approach to assessment and formulation was prompted by recent expansion of the service to include the Gumnut Clinic specifically addressing the needs of children from birth up to 5 years of age in foster care, and contribution by the author (SM) and other ACC team members to a 12-month project to provide comprehensive health assessments for young children aged 0 to 5 years old in Out of Home Care in the state of New South Wales. The details of the overall approach to assessment used in the service the service is discussed elsewhere (Chambers et al, 2010; Chambers, 2012).

Young children in care are at high risk of disorganised attachment relationships and of developmental psychopathology (Dozier, Stoval, Albus, & Bates, 2001), and this is related to their relational experiences prior to and whilst in care, and frequent disrupted attachments. This paper considers one aspect of the overall psychosocial assessment of young children in care, a semi-structured approach to observation of the carer and child’s relationship.

A comprehensive assessment also needs to include information from multiple sources (e.g. primary carer and other family members, caseworker, preschool) and of multiple kinds (history and documentation, individual and family interviews, observation – both in the clinic and at times at home and at school), standardised psychometric measures (e.g. Strengths and Difficulties Questionnaire, Child Behaviour Check List and Parenting Stress Index – Short Form) and, when indicated, neuro-psychometric evaluation. Ideally information gathering also includes what can be called a ‘workers meeting’ where all the adults with responsibility for the child’s life and well-being communicate about and clarify their roles and responsibilities in relation to the child.

Introduction

A clinically relevant approach to observing, understanding and describing how attachment and other significant nurturing behaviours are organised within a particular relationship is a crucial part of identifying strengths and vulnerabilities within the care-giving context. This is a core component of determining and meeting the needs of the vulnerable and complex population of young children in care.

The existing valid and reliable procedures that assess attachment relationships used primarily for the purposes of research are time consuming and require extensive knowledge and specialised training (Crittenden, Claussen, & Kozlowska, 2007). There is considerable evidence that disorganised attachment is a serious risk factor for later maladjustment (e.g. Carlson, 1998; Lyons-Ruth, 1996) and that foster children are at substantial and increased risk of developing disorganised attachment patterns (Dozier et al., 2001). A universally accepted diagnostic protocol for assessing attachment quality in clinical settings, or agreement about classification and diagnosis of disorders of Attachment, does not exist (Crittenden et al., 2007; Newman & Mares, 2007). When assessing young children who are placed in foster care, there are other factors which confound the relational assessment, such as the length of time in the current placement, the child’s prior experience of care and attachment disruption including removal from biological parents, any history of exposure to perinatal risk (e.g. intra uterine substance exposure) and abuse or neglect prior to entering care.

Structured observational procedures offer methods of gathering information about the dyad (Crowell, 2003; Miron, Lewis, & Zeanah, 2009) that are compatible with the constraints of the clinical setting (Aspland & Gardner, 2003). Such observations are recommended as part of a comprehensive assessment of the child and family, which may also include questionnaires, interviews with caregivers and other significant persons (e.g. teachers) in different settings (Boris & Zeanah, 2005; Chaffin et al., 2006). There are several approaches to observation of the parent and infant dyad but as Aspland and Gardner (2003) emphasise, it is of foremost importance to identify those behaviours that are relevant for the population, based on theory and driven by the clinical questions that need addressing. A cautious approach is required when assessing young children in foster care given the complexity of the problems and impairments that they present with. This can lead to formulations and diagnoses that are conflicting, as well as the risk of over assessment, diagnosis and prescribing (Boris & Zeanah, 2005). The challenges inherent in the work increase the need for specialised training and assessment for clinicians working with this population (Berlin, Ziv, Amaya-Jackson, & Greenberg, 2005; Boris & Zeanah, 2005; Chaffin et al., 2006; Tarren-Sweeney, 2008).

Various observational methods, primarily those that have been identified to be of value in clinical settings, are reviewed as they relate to eliciting relevant behaviours in carer and child. This brief overview encourages the reader to research the relevance (e.g. age range) and cultural appropriateness, reliability and validity of these observational procedures in detail as well as other pragmatic considerations relevant to their organisation (e.g. population serviced, time and resources).

Attachment and attachment behaviours

Definition

The aim of defining attachment behaviours is to promote consistency, clarity and clinical applicability when translating attachment ideas to applied settings. Bowlby (1969/1982) described the “attachment behavioural system” as a goal corrected partnership composed of attachment behaviours that are motivational and organised within the individual in response to external and internal cues (Cassidy & Shaver, 2008). When writing about the ethological observations that informed his developing theory, Bowlby (1969/1982) identifies attachment behaviours as biologically driven and:

characterised by two main features. The first is maintaining proximity and restoring it when it has been impaired; the second is the specificity of the [individual]…Thus both parent and young usually behave towards each other in ways very different from the ways they behave towards all other (s)… (p. 181)

Ainsworth, Blehar, Waters, and Wall (1978) described behaviours aimed at seeking proximity with the caregiver (e.g. crying, approaching, seeking contact). The infant has learnt which behaviours are most useful and effective in achieving proximity and therefore of safety, and these are activated in varying situations and circumstances (Sroufe & Waters, 1977). Bowlby, Ainsworth and subsequent researchers emphasise the necessary “dynamic equilibrium” between attachment and exploratory behaviours. Hence, attachment behaviours are designed to promote infant-adult proximity, interaction and infant safety, and therefore serve the attachment relationship. They may also be used non-exclusively for other needs such as exploration and learning (Boris & Zeanah, 2005; Carlson & Sroufe, 1995, Bowlby, 1969/1982).

Infants begin to show a preference for particular others very early in life and have identifiable patterns of attachment to their caregivers by around 12 months of age. These patterns are identifiable as organised (secure or insecure avoidant and insecure resistant), or insecure/disorganised (Ainsworth et al., 1978; Main & Solomon, 1986). Infants and young children exposed to maltreatment or other relational disruption or traumas are at much higher risk of developing a disorganised attachment and this is associated with a high risk of developmental psychopathology. Main and Solomon (1986) describe infants as becoming behaviourally disorganised in the face of threat or unresolvable anxiety. Crittenden (2006) has proposed an alternative understanding and approach to classification, particularly of children who do not easily fit the organised secure and insecure categories. This approach, the Dynamic Maturational Model (DMM), understands maltreated infants as being strategically organised, (rather than disorganised) in ways that reduce the probability of continuing maltreatment (Crittenden et al., 2007). This is discussed further below.

Identifying what constitutes “attachment behaviour” in fostered children is relevant and challenging because foster children are expected to form an attachment to entirely new caregivers whilst simultaneously resolving and repairing attachments to their biological parents (Zeanah, Berlin, & Boris, 2011). They almost all have a history of relational disruption and attachment terminology may be used in ways that are inaccurate or unhelpful clinically in understanding and addressing the child’s complex needs (Berlin et al., 2005).

A meaningful approach to parent-child observations includes a focus on the organisation of attachment related behaviours within the relationship, their timing and the effectiveness of their expression (Cassidy & Shaver, 2008) and the functional and adaptive role of these behaviours in enhancing a child’s sense of “felt security” within the relationship (Sroufe & Waters, 1977). Underlying questions for the clinician include: “What is it like to be the infant/child in this relationship with this caregiver, at this time?” (McIntosh, 2008; Zeanah et al., 1997). It also includes exploration and thoughtfulness about what it is like to be this caregiver, in this relationship with this child, at this time. This is particularly relevant as the child brings into and enacts within the current relationship aspects of the history of their earlier care in behaviours that may be confusing or distressing for the current carer. Whilst brief clinical observations are limited in their capacity to explore these questions in depth, as part of a more comprehensive assessment they provide considerable information and a framework for clinical thinking when conducting parent and child or carer and child observations.

The Dynamic Maturational Model (DMM)

The DMM of Attachment understands attachment behaviours as organised and biologically determined (Crittenden, 2006). Attachment behaviours are seen as adaptive and organised functional strategies (Crittenden, 2006; Kozlowska & Hanney, 2002) that are self-protective in nature and have the potential to be modified with subsequent experience (Farnfield, Hautamaki, Norbech, & Sahhar, 2010). These behaviours have developed in interaction with an attachment figure or figures and may aim, for example, through exaggerated displays of negative affect, to increase the probability of eliciting unpredictable parent attention. Such behaviour might also lead to a diagnosis of Oppositional Defiant Disorder or other externalising psychopathology in the child, in the absence of the behaviour being understood within a relational context. Defining attachment behaviours, even those that appear “disorganised”, as strategic, adaptive, functional and self-protective, emphasises the central issue of safety in relation to raising children and being a child. Crittenden’s approach is sensitive to the early experience of children in foster care in the context of their probable exposure to a greater degree of endangering conditions as well as other factors such as separation, illness, trauma and loss (Kozlowska & Hanney, 2002).

Studies suggest that the DMM theory has validity (Gunnar, Morison, Chisholm, & Schuder, 2001; Leventhal, Jacobsen, Miller, & Quintana, 2004; Muller-Nix, Forcada-Guex, Pierrehumbert, Jaunin, Borghini, & Ansermet, 2004), and is clinically useful in understanding and assessment of maltreated preschool children and infants in foster care (Farnfield et al., 2010; Stacks, 2010).

It is beyond the scope of this paper to further develop the argument for one approach or another for the classification of Attachment behaviours. For our purpose, the DMM is useful in informing attempts to understand the child and caregiver contributions to any observed interaction in this complex and high-risk population. The nature and function of behaviours within the interaction is the focus of observations rather than assessment of attachment classification per se. Therefore the purpose of a relational observation is not classification but identification of the child’s strategies for engaging care or maintaining a sense of safety, or the absence of those strategies, as well as the caregiver’s repertoire of responses and the extent to which these fit with and meet the child’s needs.

Parenting and foster care

Parenting requires a capacity to judge and respond to the child’s changing competencies in ways that support their development and this includes providing appropriate protection and comfort for distress, but also supporting exploration and curiosity and sharing pleasure and excitement (Cassidy & Shaver, 2008; Crittenden, 2008). Clinical studies of infants and children in foster care have confirmed that the caregiver’s behaviour with and cognitions about the child (George & Solomon, 1999; Grienenberger, Kelly & Slade, 2005), and their capacity to provide sensitive and protective care (De Wolff & van IJzendoorn, 1997; van IJzendoorn, 1995; Dozier et al., 2001) are significant factors that influence security in the parent–child relationship. Dozier et al. (2001) found that infants aged between 12 and 24 months were able to organise their attachment behaviours with their foster parents and were able to form secure attachments when these caregivers were assessed to be “autonomous”, that is coherent in their discourse about and valuing of attachment. Hence the foster parent and the caregiving environment they provide are both potentially key therapeutic or healing influences for the child and/or a potential source of ongoing relational risk (Berlin et al., 2005).

There is also considerable evidence about the contribution of the infant to the attachment relationship and Bernard and Dozier (2011) propose that the foster child has an active role in shaping relationship dynamics. Unlike biological children, foster children are likely to have experiences of care with their biological parents and often multiple other caregivers as the result of several placement disruptions. Establishing new attachment relationships is thus influenced by both the quality of the child’s past relational experiences and subsequent disruptions, plus a host of other traumatic impacts on their developing sense of self, their capacity for emotional regulation and self-regulating behaviours (e.g. eating and sleeping), for interpersonal relatedness (Dozier, Dozier, & Manni, 2002; Kaufman & Henrich, 2000; Vig, Chinitz, & Shulman, 2005) and their developmental stage. Developmental delays including speech and language (Stock & Fisher, 2006), cognitive development (Harwick & Hochstadt, 2001) and gross and fine motor skills (Orlin, 1999) also occur frequently in the fostered population (Chambers et al., 2010; Nathanson & Tzioumi, 2007; Tarren-Sweeney, & Hazell, 2006). These can also confound both the child’s capacity for communication and the carer’s expectations about and responses to the child.

Stovall-McClough and Dozier (2004) have found that during the first months of placement, there are variations in children’s attachment behaviours that may have a significant impact on the way in which carers respond to their needs. Even carers who could be expected to provide nurturing care given their own history (i.e. with an autonomous state of mind) have been observed to respond in ways that are rejecting or non-nurturing towards children who displayed avoidant and resistant behaviours during the early phase of the placement (Stern, 2002; Bernier, Ackerman, & Stovall-McClough, 2004).

An infant’s ability to regulate their own arousal is learnt in relationship with a caregiver who provides timely, predictable, comforting responses to their distress signals (Crittenden, 2008; Schore, 1994). For infants and young children who have had dangerous or maltreating parents, the task for the foster parent is difficult, as the infant or child’s behaviour may appear contradictory, apprehensive and/or frankly rejecting or avoidant (Smyke & Breidenstine, 2009). This may make the child less rewarding to care for. Depending on the child’s age and prior experience, considerable time and effort may be required for the child to have the experience of comfort and protection with an available caregiver. For example babies and young children who have been maltreated (e.g. received unpredictable comfort), have been observed to display mixed negative affect when the caregiver approaches, such as fearful facial expressions and freezing of movement that can be confusing (Crittenden, 2008; Main & Solomon, 1990).

Another critical function for adaptation within an evolutionary framework is supporting the infant in the exploration and mastery of their environment (Carlson & Sroufe, 1995). These repeated attachment experiences in relationship with caregivers have been referred to as the secure base phenomenon (Ainsworth et al., 1978). This has been elaborated with the Circle of Security Intervention to specifically describe the parents or carers as both the secure base (to explore from) and the safe haven (to return to) (Cooper, Hoffman, Powell, & Marvin, 2005). Sharing the child’s enjoyment and mastery as well as acknowledging their anxiety or distress, moving close to the child, holding, touching the child are observed as examples of the caregiver’s capacity to provide secure base support and be a safe haven (Cooper et al., 2005; Crowell, 2003). For foster children with an abuse history, these otherwise appropriate and nurturing behaviours may provoke anxiety or threat and trigger or evoke behaviours that are perplexing or distressing for the carer.

Observations of parent–child interactions and relationships

Given the complex dynamic equilibrium between the attachment and exploratory systems (Berlin et al., 2005) there is a need for the parent to balance support and comfort with the child’s need for exploration and this requires sensitivity and intuition. Central to this is the capacity of the caregiver to provide experiences for the infant or young child that are related to both attachment and exploration so they are able to feel safe to move between these modes (Berlin et al., 2005). Structured and semi-structured assessment procedures which include a play interaction, a challenging task and a brief separation and reunion, provide opportunities to observe and focus on these processes.

The Strange Situation Procedure (SSP) (Ainsworth et. al., 1978) has been used as the ‘gold standard’ for assessing attachment classification and eliciting observations of secure base behaviour in infancy by inducing stress associated with a brief separation and reunion between the infant and their caregiver within a laboratory setting. Later adaptations of the initial procedure are used to identify attachment patterns in older children and adults (Zeanah, 2008). Variations of the core separation and reunion episode of the SSP are used in other observational procedures, for example the Parent-Child Early Relational Assessment (PCERA) (Clark, Paulson, & Conlin, 1993) and the Crowell procedure (Crowell, Feldman, & Ginsberg, 1988). The parent’s capacity to prepare the child for the separation and to comfort them on reunion is observed. For example, appropriately reassuring the child that the caregiver will return is seen as positive secure base support in preparing the child for the transition to separation (Crowell, 2003). Other observational methods provide different techniques for observing a caregiver’s capacity to soothe the infant following a stressful experience. In the Face-to-Face Still-Face (FFSF) procedure (Tronick et al., 1978) the caregiver is instructed to keep an expressionless or still face following an episode when they are engaged with and responsive to the infant. The caregiver’s capacity to soothe the infant after the period of withdrawal is noted, as are the infant’s attempts to elicit a parental response and their settling afterwards.

The infant and young child uses gesture and vocalisation and contact seeking and play in order to signal their needs to the carer. This may be independent of the carer’s interest and capacity to identify and respond to these cues. Behavioural signals emitted by the infant or child which are conceived as conflicting or confusing by a carer have been described as a miscue, for example, when the child may need comfort or nurturance from the carer but their behaviours appear contradictory, that is avoidant or resistant (Cooper et al., 2005).The Nursing Childhood Assessment Satellite Training (NCAST; Barnard, 1978) teaching and feeding scales and Parent Child Early Relational Assessment (PCERA) (Clark, Paulson, & Conlin, 1993) observe the child’s ability to generate clear cues and respond to their caregiver during a regular feeding time. The PCERA, SSP and the Crowell procedure also involve observations of the child’s capacity for self-regulation (Miron et al., 2009).

Crittenden (2006) suggests that there are three main challenges for infants that include: a) the capacity to learn the signals that impact on caregiver’s behaviours, b) regulating a moderate level of arousal and c) sharing of affective states such as attunement with others. Understanding the infant’s capacity to achieve these goals with an attachment figure in the context of their vulnerabilities is of interest in observational assessments. When observing fostered children it is important to recall that they are learning or have had to learn the rules, patterns and strategies that work within a new caregiving relationship. Also, an appreciation of the child’s strengths, such as their ability to display competence in attention, persistence and interest, for example, and to attract and maintain protective interactions with a caregiver should be noted as they function to support the child in adapting to their current environment (Crittenden, Landini, & Claussen, 2001), and influence the caregiver’s own sense of competence and of the child as rewarding.

Crittenden has developed an observational measure as an assessment of this dyadic synchrony for use with infants and toddlers called the CARE-Index that utilises a play-based method (Farnfield et al., 2010). The interaction is assessed rather than individual characteristics of the adult or the child such that a child’s behaviour (e.g. looking away from the mother, squirming) is coded when viewed from the perspective of the caregiver (Farnfield et al., 2010).

A dynamic and harmonious process of communication and adjustment occurs between an attuned parent and the young child who has the ability to send clear and comprehensible signals (Crittenden, 2008). An infant or young child’s displays of inhibition and negative affect can be understood as adaptive when they have had experience with caregivers who have been unpredictable, failed to respond to their distress, or responded in punitive or incongruent ways (Crittenden, 2008). Provocative behaviours such as oppositional, uncooperative, withdrawn or aggressive displays during observations are also of interest since these behaviours may elicit rejection or anger from caregivers (Berlin et al., 2005).

Traumatised children, including those in foster care, have been found to regularly miscue caregivers about their needs. This miscuing can be described and explained in different ways, (Cooper, Hoffman, Powell, & Marvin, 2005; Crittenden, 2008), but when infants and children miscue, caregivers are likely to respond in ways that do not meet the child’s needs, and which may include withdrawal, impatience or irritability (Stovall-McClough & Dozier, 2004). Relationship repair in these circumstances is crucial if distorted, ineffectual and dissatisfying patterns of interaction are to be minimised. This may be observed in attempts by the parent to re-connect with the child (e.g. hugs, comforting words, or remaining available and calm near to the child, despite a tantrum). Another component is the child’s capacity to accept comfort and nurturance from the caregiver following a stressful interaction, high negative affect or during an episode of challenging behaviour. According to Tronick and Weinberg (1997) ruptures or interactive errors during caregiver–infant interactions are normal and frequent, and reputation is critical and also regular in satisfying parent-infant interactions.

During the reunion following a brief separation, the mutuality and reciprocity between the dyad are also observed since ideally this contact is positive and reassuring for both, indicated by eye contact, hugging, holding hands, smiles and positive verbal exchanges (Crowell, 2003).

Components of the semi-structured assessment

A semi-structured interactional assessment, for research or clinical purposes, can take a number of forms but review of the literature identifies several common components and activities, which provide opportunities for observation of the dyad in a range of circumstances and highlight and challenge aspects of the relationship. These usually include a period of play, an opportunity for enjoyment, a request to tidy up, a challenging activity or task and a brief separation and reunion. These are discussed below with particular attention to the information obtained about the relationship between parent and child. Semi-structured observations are also a rich source of information about the child’s physical, cognitive, language and social development as well as parental health and psychopathology. These dimensions of the assessment are not considered further here.

The assessment must be developmentally informed; the child’s age and developmental level need to be taken into account in choosing appropriate toys, activities and other resources for the assessment. A younger child has fewer ways to both express and mask their feelings and attachment related needs and their language and play repertoire will be limited when compared to an older child. A healthy and secure infant is likely to seek physical contact, turn towards their parent for cues and resist separation when in distress, while an older child has the ability to also use language, cognition and play activities, or to turn to the clinician for support in managing the separation (Crowell, 2003). That said, attachment behaviours are recognisable in most infants and young children to an observer with training and experience and their miscuing, masking and distortion in children with traumatic and disrupted relational histories is also evident if clinicians have a strong grounding in observation of parents and young children.

A new setting

For most parents and children, the playroom and assessment process will be new and unfamiliar. This presents the adult and child with a mild stress intended to evoke attachment related behaviours and how they manage this novel setting together and as individuals is informative. For example in terms of the balance between proximity and exploration, does the child cling to the carer or show immediate interest in exploration, and how engaged with or disinterested are they in the stranger/clinician? How does the carer support and encourage the child in this new setting, and what kind of reassurance and encouragement do they provide?

The play interaction

Many observational procedures include a period of free play, and some include the instruction to the carer to follow the child’s lead, giving a chance to observe the child’s initiative and the carer’s capacity to limit their intrusiveness. It is of interest whether the carer can listen to and follow the clinician’s requests and instructions in relation to playing with the child and following the child’s lead, whether they know how to play and how physically available and engaged they are, for example do they sit on the floor or up on a chair, and if health or agility issues limit their participation, how do they compensate for this?

Synchronicity between the child’s contribution and that of the caregiver during interactions is referred to as the “attachment dance” (James, 1994). The complementary, rhythmic engagement involving contingent responsivity and affect synchrony between the caregiver and infant contribute to the infant’s healthy affective development (Schore, 2001). Feldman, Greenbaum and Yirmiya (1999) define synchronicity as the fit between the caregiver and infant or child’s activities that encourages mutual and positive play, and this follows a pattern whereby the parent at times follows the infant or child’s lead and at other times scaffolds, teaches and directs. Schore (2001) proposes that play states are crucial in providing opportunities to promote interactive augmentation of positive affect, as well as learning and cultural induction (Fonagy, Gergely, & Target, 2007). There are child-led play procedures in behavioural observations such as the Crowell and PCERA called free play segments, and in addition the Crowell includes play with bubbles (Miron et al., 2009).

In a study with children in care (Bernard & Dozier, 2011), foster parents who were highly committed to their fostered infants aged 9–28 months (measured using “This is my baby” interview) were found to express greater delight towards these infants using play assessment procedures. Caregiver delight is directly elicited and watched for during the free play and bubble segments of the Crowell and the play segments of the PCERA (Clark, Paulson, & Conlin, 1993). This is demonstrated by positive affect, praising, smiling and encouragement and affective matching. Joint attention, level of comfort with each other, mutuality and reciprocity, sense of partnership versus solitary play, are the behaviours of interest during these segments of play (Miron et al., 2009).

The clean up

In the clean up episode of the Crowell the caregiver delivers the instruction to the child to pack away the toys following a period of play. This is intended to elicit resistance from young children (Miron et al., 2009) and to provide an opportunity to observe the caregiver’s communication of the instruction and the child’s compliance, as well as the capacity of the dyad to negotiate and co-operate during this activity, particularly communicating effectively and adjusting their actions during periods of transition between activities (Miron et al., 2009).

The challenging task – teaching and problem solving

The caregiver’s role in promoting the attachment-exploration balance is elicited in the teaching or problem solving tasks of the Crowell and the NCAST Teaching and Feeding Scales (NCAST) (Miron, et al., 2009). Teaching and problem solving evokes a level of stress and it requires the capacity of the caregiver to maintain availability and support (e.g. set limits and provide scaffolding and structure) whilst also providing opportunity and encouragement for the child to initiate activity and interactions, explore and learn independently. Using the NCAST procedure, the capacity of the caregiver to match their behaviour to the child’s developmental level when teaching is observed. In encouragement and support of the child’s ability, a caregiver’s expressions of delight reinforces to a child their worth and importance (Bernard & Dozier, 2011; Britner, Marvin, & Pianta, 2005) and is considered to play a role in the child’s capacity to regulate their emotions (Rosenblum, Dayton, & McDonough, 2006). The child’s readiness to use the caregiver for support, to work with them and their capacity for attention and perseverance as well as cognitive, language and fine motor competence can also be observed.

The separation and reunion

The separation component provides evidence of the caregiver’s ability to communicate clearly and to support the child to manage the separation, as well as the child’s strategies to engage the carer if distressed (Crowell, 2003). It is of significance if a child displays either exaggerated, indiscriminate or absent secure base behaviours during the separation reunion sequence, in the presence of a relatively unknown adult (the clinician). The reunion component elicits the child’s strategies in seeking comfort from their caregiver, the carer’s capacity to provide this and whether the response from the carer is effective in soothing the child. Compared to an infant or toddler, an older child is expected to have a broader repertoire of play and strategies for managing the separation, for example using words, engaging or distracting themselves with activities as well as turning to the clinician for support during a separation if the clinician is present.

Reflection

Once the parent and child have re-united, the carer is asked to reflect on the experience of the play assessment, to comment on whether anything stood out to them or was surprising and to consider how what has happened in the room might differ from what usually occurs at home. As well as providing information, this is an opportunity to gauge the caregiver’s capacity to reflect and to listen to how they speak about the child in the child’s presence.

Clinical examples

The approach of our service is to use a modification of the Crowell assessment which includes the following components: play as usual; follow the child’s lead; clean up; bubble play; puzzle task (choose an easy and a hard puzzle); brief separation with the clinician present; reunion and reflection. It can be completed in approximately 30 minutes and when consent is obtained the interaction is filmed to allow review. To date we have not used a formal coding system although various approaches have been developed and proposed (Crowell et al., 1988) and the filmed interaction enables subsequent coding, including for research purposes.

The assessment takes place in the clinic, and the room is set up with a consistent selection of toys chosen to match the developmental stage of the child. A clinician is present in the room throughout the assessment, including the separation. It is recognised that young foster children have often experienced multiple disruptions and separations and referral to the clinic is likely to occur at a time when the current placement is under stress. Leaving the infant or young child totally alone in a strange room even briefly is not considered appropriate and useful information can be obtained with the clinician present. Also families attending our service are often highly anxious, stressed and have had several attempts at previous intervention and support. Having the clinician in the room is intended to partially “normalize” a strange situation, reduce anxiety and to support the development of a therapeutic alliance. It can also be useful to observe the interactions of the carer and the child with the clinician and with each other in the presence of the clinician.

These brief examples are de-identified and compiled from multiple assessments. They illustrate the way in which a semi-structured approach evokes relevant behaviours and responses in foster parent and child as they transition between the tasks and to show how these observations can be used to inform clinical opinion. The observation provides a stimulus to thinking about particular aspects of the child and the adult’s behaviour, as well as the nature of their observed interaction and relationship in this setting.

Gurmeet

Gurmeet aged just over 6 months had been with his current carer, Leanne, since he was 8 weeks old. He was not yet crawling but could sit unsupported. She sat close behind him on the floor and after initially looking back at her anxiously he engaged with the toys and their interaction appeared enjoyable and synchronous. His movements were animated and vigorous at times and he vocalised frequently. When asked to leave the room she told him what she was going to do and moved a cushion behind him as she got up. When she left the room he did not protest, but spent a lot of time staring at the door, stopped vocalising and his movements and play became inhibited and restricted. When she came back in he looked at her, vocalised and lifted his arms.

This interaction provided evidence both of the carer’s sensitive commitment to Gurmeet and his reliance on her for support. Although he tolerated the separation without overt distress, he was less able to play and engage and appeared to be using his resources to manage and contain himself during her absence. At his age of around 6 months, Gurmeet is too young for a formal attachment classification such as the SSP to have been undertaken and yet the semi-structured observation provides clear evidence about his capacities and the quality of their developing relationship.

Tamara and Ahmed

Tamara aged 18 months and Ahmed aged 3 years are siblings who attended with two carers, Jim and Jan, both in their late 50s who they had been placed with for 6 months. They had been removed from parental care after Tamara had a significant fall resulting in a subdural haemorrhage and concussion. On discharge from hospital she was reported to be developing normally. His mother had blamed Ahmed for the fall. The carers reported that Tamara was “easy, no trouble”, but that Ahmed was “naughty, aggressive and impossible”. Before the separation for the play assessment and in response to some sibling conflict over a toy Jim spoke loudly and sharply to Ahmed, scolding him, despite Tamara apparently being the instigator. Ahmed was clumsy on his feet and with his hands, stumbling about, knocking things over and easily distracted. He rarely approached his carers while Tamara frequently took toys over to show them and indicated when she needed assistance or support. Jim and Jan remained sitting on the sofa during the later play assessment and explained that they had arthritis that prevented them sitting on the floor.

During the assessment, interactions between Jan and Ahmed lacked any developed or collaborative play and there was little apparent enjoyment. Ahmed attempted to help clean up but was rebuked when he put a block into the basket intended for the cars. A struggle for control occurred during the bubble play and when the mixture was spilt, Jan scolded Ahmed looking in exasperation at the clinician and saying, “see what I mean, he is impossible”.

Without providing further detail it was evident that Ahmed was a distressed child who made attempts to comply or engage and that these were overlooked or rebuffed by the carers. They were struggling to meet his needs and perhaps could not recognise and adjust their expectations to his developmental level. There was little empathy for his distress and he was potentially scapegoated. Tamara on the other hand was regarded affectionately and was indulged. She appeared an easy and compliant child, although developmentally this seemed likely to change and the impact of her earlier head injury was unclear. The age of the carers may have added to their other difficulties in adequately responding to and meeting the needs of these two young children. This brief period of semi-structured assessment highlighted Ahmed’s attempts to cooperate and his carers struggle to respond adequately to him and the observations were used to inform the formulation and recommendations about these children’s needs and the placement which subsequently broke down.

Sam

Sam aged three and a half had recently been returned to the care of his grandmother after his mother resumed substance use and her partner was arrested after a violent assault. He previously had multiple short supervised placements with his grandmother and she had no complaints or concerns about his behaviour, but childcare reported he was often aggressive and non-compliant. Their play was superficially cooperative although he ignored many of her requests and comments and then when she asked him to clean up, he climbed up into a chair crossed his arms on his chest and said “I the man, you clean up”. Despite being a three and a half years old, his manner and tone were derogatory and threatening and her response was to back down and appease him. The role reversal and punitive aspects of the interaction were clear and may not have been so evident without the clear instruction to the carer that she ask him to tidy up.

Malia

Malia aged three and a half years had been taken into care after an unexplained fracture of her arm when she was 11 months old. She had then been placed with an older single carer who had not adequately met her developmental needs. At aged 2, Malia was placed along with her 6-month-old brother with the current carers. At this time she was delayed in a number of motor and social milestones and had significant language delay. Her carers reported they were currently concerned about her oppositional behaviour and indiscriminate sociability particularly with older women.

In the assessment Malia ran into the playroom and initially moved rapidly from one activity to another, frequently approaching the clinician (SM), leaning on her and talking to her. When directed back to Sue, her carer, she re-engaged and eventually managed to sustain her focus on setting up the doll’s house. During the play she sat, leaned and stood on the carer who did not object and appeared willing to accommodate all of Malia’s demands despite looking physically uncomfortable at times. Physical contact with Sue appeared to support Malia’s concentration and focus. She cleaned up when asked to and clearly enjoyed the bubble play, becoming excited and laughing a lot, but then struggled when it was time to change task and put the bubbles away. The carer’s strengths were evident in her capacity to support Malia’s attention and competence in the puzzle task. When Sue told Malia she was leaving and would be back soon Malia continued to work on the puzzle during the separation, asking the clinician for assistance but remaining focussed on the task. On reunion they resumed their interaction but Malia became disruptive and demanding when the clinician and the carer attempted to talk and reflect on the assessment. In this observation, the child demonstrated the capacity to use Sue as a support to improve her focus on structured tasks but also showed her difficulty and distress in sharing the carer’s attention after separation. The observation highlighted areas of strength and difficulty in their interactions and this was used to inform subsequent dyadic work as part of the intervention and support offered to the family.

Joanne

Joanne aged almost 4 had been with her current carers for 12 months. Prior to that she and her siblings were exposed to severe domestic violence as well as neglect in the context of untreated maternal mental illness. During the play assessment she was very quiet and orderly in her play but creative as well, building an elaborate town and train track with her carer. She was immediately compliant with all requests and, appeared to enjoy the interaction while barely acknowledging the clinician (SM). When her foster mother briefly left the room she looked frequently and provocatively at the clinician and became very active, piling up cushions to climb on the furniture and up onto the window sill in potentially self endangering ways. When her carer returned she initially remained sitting up high but was then compliant with her request to get down and to tidy up. Once the carer returned she again ignored the clinician.

It is clear that Joanne behaved and/or organised herself very differently in the presence or absence of her current carer. Their relationship was an established one within which she was better able to play, concentrate and cooperate although she remained rather inhibited. During the separation from her carer, Joanne behaved in ways that could be described as provocative and which ensured she was she was not ignored or forgotten. This could be understood as evidence of anxiety and/or disorganisation, but it also functioned as an effective and apparently organised strategy to provoke and ensure the clinician’s attention and involvement. The semi-structured observation elicited a far wider range of behaviours from this child with this carer than would have otherwise been seen and clearly demonstrated her continuing vulnerability despite apparently “settling” in the placement.

Conclusion

A semi-structured approach to assessing the parent child relationship is a useful component of a comprehensive clinical assessment. An approach that provides opportunities for play and enjoyment, collaboration and compliance, a challenging activity that requires the child to seek and accept and the carer to provide support, as well as a brief separation and reunion, then reflection, can provide a glimpse of the nature and quality of the current relationship between the caregiver and the child. This is a useful part of a comprehensive assessment of the infant or young child’s functioning within their current placement and helps to identify strengths and vulnerabilities in the placement context. Ideally this information is used to inform interventions and decision making that will reduce the risk of the child being exposed to further disruption and/or inadequate care. These observations provide the assessor with considerable useful information that needs to be considered within the context of the overall assessment. It does not provide an attachment classification or specific diagnosis.

Assessing caregiving relationships formally in terms of attachment classification can be difficult in the clinical setting and is potentially less useful than approaches that provide an understanding of the meaning of the child’s behaviours and how they are organised, functional and adaptive within the current care-giving relationship. The caregiver’s capacity to provide security and support to the child is also illustrated. Understanding problems, strengths and vulnerabilities as they exist in the current relationship between caregiver and child and identifying what each contributes to the relationship is more useful than conceptualising strengths and difficulties as primarily existing within the individual child or carer (Zeanah et al., 2011). This acknowledges the importance of the current relation context for the young child’s current and future functioning and can inform and focus interventions.

The use of attachment related classifications and terminology (such as the terms insecure resistant or avoidant or disorganised) can imply or require a formal assessment, and can be misleading or confusing in the clinical setting. Research indicates that infants and young children in out of home care are at high risk of disorganised attachment behaviours and may also meet criteria for Reactive Attachment Disorder as defined within Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR) (American Psychiatric Association, 2000). This diagnosis is distinct from identifying or implying a formal attachment classification. Valid and reliable approaches that identify behavioural indicators of secure base behaviour in the child and secure base provision by the carer that have clinical utility, are not currently unavailable. While they are developed and researched (Berlin et al., 2005), a semi-structured assessment can provide useful and clinically relevant information.

This review has limited its focus to arguing for inclusion of a semi-structured approach to observation of the caregiver–infant or young child dyad and describing the attachment related and relational information obtained from this. Caregiving relationships are embedded within the complex systems of family, culture and society and a comprehensive assessment takes these contextual and systemic issues in to account.

Attention to parent–child interactions is essential to understanding the child’s presenting symptoms and problems and the strengths and vulnerabilities in the current caregiving context. An informed semi-structured approach to observing and assessing carer–child interactions can contribute to a comprehensive assessment of the mental health and developmental needs of young children in care. There is a need for further research to better inform training and support for clinicians who undertake assessment and intervention with this vulnerable and complex population of children and their carers (Berlin et al., 2005; Tarren-Sweeney, 2008).

Footnotes

Acknowledgements

The authors acknowledge the considerable support and encouragement provided by their colleagues at Redbank House in both the clinical approach and the ideas that inform this paper. Particular thanks go to Dr Margaret Goldfinch, Romina Tucker, Dr Megan Chambers and Dr Alison Saunders and to the children and families who continue to educate us.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biographies

Sarah Mares is an infant, child and family psychiatrist with established clinical and academic interest in infancy and early childhood and in prevention and intervention with highly disadvantaged populations, including families involved with child protection, Indigenous families in remote communities and refugee and asylum seeking families. She is an experienced clinician, consultant and educator and is currently Senior Research Fellow at the Centre for Child Development and Education, Menzies School of Health Research in Darwin, Australia.

Marianne Torres is a psychologist for NSW Department of Community Services and a Doctoral of Clinical Psychology student at The University of Wollongong, in NSW, Australia. She has worked with children and families within the child protection field, including non-government agency work and in a specialist clinic for children in foster care. Her interests are within the area of family therapy, systemic thinking, complex trauma and attachment

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