Mary Dozier - US grants

The proposed research takes a first step toward tailoring treatment to the needs of young adult chronically mentally ill clients. Client differences in interpersonal functioning which interact with the interpersonal intensity of treatment will be examined. In particular, interpersonally intense treatment, e.g., case management, is expected to be optimal for individuals who are comfortable and secure in relationships, but not for those who are either preoccupied with relationships or dismissing of relationships. In this longitudinal study, 120 young adult chronically mentally ill adults will be randomly assigned to case management or to "standard care." Social support networks, general quality of life, use of treatment, time in psychiatric hospitals, and physical and psychiatric symptomatology will be assessed at six month intervals for three years. Individuals secure in relationships are expected to show more positive outcomes when in case management than in standard care, as evidenced by better use of treatment, less time hospitalized, etc. Individuals dismissing of relationships are expected to show the opposite pattern, becoming more symptomatic and using treatment more poorly, in case management. Individuals preoccupied with relationships are expected to show different types of problems in the two treatments. After three years, group and individual data will be used to reassign subjects who are inappropriately assigned to appropriate treatment. Following reassignment, subjects appropriately assigned are expected to show significant gains in functioning.

This research is a randomized clinical trial of specialized training for foster parents. Foster parents provide primary mental health services to foster children who have multiple problems including histories of abuse, neglect, and parental drug abuse. As a result of problematic caregiving histories, foster children often develop patterns of interacting which make it difficult for them to develop trusting relationships with their foster, adoptive, or biological parents. The effects of these interaction patterns can be quite damaging, contributing to children's failure to rely effectively on caregivers, and behavioral and emotional problems. The proposed study assesses the effectiveness of an intervention program developed to help caregivers understand and change the strategies children use for coping with problematic caregiving histories. Foster parents of infants will be randomly assigned to an experimental group, in which caregivers receive specialized training, or to a control group. Caregivers will receive the interventions at the time of placement and replacement, and when children are 12, 18, 24, and 30 months of age. Caregivers receiving the specialized training are expected to be more sensitive to their children's needs, and their relationships with their infants are expected to be more secure and effective compared to caregivers in the control group. Infants in the experimental group are expected to show fewer behavioral, emotional, and social problems than infants in the control group. Specific aims are to: 1) experimentally evaluate the effectiveness of a specialized intervention program for foster infants' caregivers; 2) examine particular characteristics of children and parents that may affect treatment outcomes; and 3) assess naturalistically the effects of timing and frequency of foster care placements, on children's adjustment to subsequent caregivers.

Long term research goals involve tailoring treatment to the individual needs of children in foster care. To this end, the specific aims of this proposed research program are to define subgroup distinctions among children who enter the foster care system, develop services appropriate to the specific needs of different subgroups, and assess the effectiveness of the services. Recent advances in neuroscience and developmental psychology will be brought to bear on the assessment of child functioning, with assessments of biobehavioral functioning and of specific behavioral transactions critical to defining subgroups and assessing intervention effects. The proposed program of research attempts to refine our understanding of foster children s specific functioning deficits. Children enter foster care at different ages, and with different caregiving histories; subsequently they have surrogate caregivers who differ in sensitivity. Current research indicates that even for infants, age at placement and sensitivity of the surrogate caregivers matter. Subgroups of children, differentiated roughly by age and caregiver sensitivity, are expected to be identified that have different needs and require different types and dosages of treatment. Services are expected to be most effective if they target the specific functional deficit of a foster parent/child dyad. Therefore, services will be developed and refined that are tailored to the particular needs of these dyads. A pilot project will assess the effectiveness of tailoring services to specifically identified needs of foster infants and their surrogate parents.

DESCRIPTION (provided by applicant): Young children who experience early maltreatment often adapt behaviorally and physiologically in ways that are challenging to their caregivers. Children's coping strategies make it especially difficult for already vulnerable parents to provide adequate caregiving. Their parents need help in developing skills such that they can provide adequate care. In addition, they often need help managing a host of other challenges, including mental health problems, substance abuse, and other basic needs. This study will test the effectiveness of an intervention for birth parents of maltreated children in the context of supportive community services. This intervention targets several key needs identified as critical. First, parents are helped to re-interpret children's behavioral signals. Second, parents are taught to "over-ride" their own propensities to respond in inconsistent or rejecting ways to children. Third, parents are helped to behave in ways that are not frightening to their children. Finally, parents are helped to provide an interpersonally responsive environment, which helps children develop regulatory capabilities. Parents will be randomly assigned to receive the experimental intervention or receive an alternative treatment. Parents in both groups will receive support services that help them access mental health and substance abuse treatment, and other services as needed. Outcomes will include assessments of parenting behaviors, as well as assessments of child behavioral, emotional, and neuroendocrine functioning. In post-intervention assessments, parents receiving the experimental intervention are expected to be more nurturing, sensitive, and less frightening to children than control group parents. Children of experimental group parents are expected to show better behavioral and biobehavioral regulation than children of control group parents.

The number of children adopted into the United States internationally has increased dramatically over the last two decades, with many of these children experiencing institutional care prior to adoption. Problems associated with early institutional care include inattention, deficits in inhibitory control, and insecure attachments. Although rapid gains are seen in some areas, many problems persist. It is critical that interventions be developed that address the specific issues faced by these children and their parents. Attachment and Biobehavioral Catch-up for Children Adopted Internationally (ABC-I) is a 10 session parent training program designed to enhance children's ability to regulate attention, behavior, and physiology, and develop secure, organized attachments to their parents. The proposed study will examine the effectiveness of this intervention through a randomized control design. Initially 220 young children who have lived in institutional care prior to adoption will be enrolled in the study. They will be randomly assigned to the ABC-I intervention or to a control intervention. At least 180 children will be assessed in various contexts annually until they are 4-years- old. Children's ability to regulate attention, behavior, and physiology will be assessed throughout the study period. Children in the ABC-I intervention are expected to show fewer problems with inattention, better inhibitory control, more secure attachments, more normative patterns of hormone production, and lower incidence of diagnosed behavior disorders, than children in the control intervention.

DESCRIPTION (provided by applicant): The challenges for toddlers (2-3 year olds) in foster care straddle issues faced by infants and preschoolers. Similarly to infants in foster care, toddlers face significant challenges in forming new attachment relationships; similarly to preschoolers, they face challenges developing behavioral control. The attachment needs of these children are not addressed well by an exclusively social learning approach, and the needs for developing behavioral control are not addressed well by an exclusively attachment approach. This competing continuation R01 would assess the effectiveness of an intervention that targets these dual issues within the context of the child welfare system. Attachment and Biobehavioral Catch-up for Toddlers in Foster Care (ABC-T) was developed to help foster parents: provide nurturing care so that children develop secure, trusting relationships; and set reliable contingencies that enhance children's ability to regulate behavior and biology. This intervention's effectiveness will be assessed in a randomized clinical trial. Participants will include 220 young children between the ages of 24 and 36 months who are placed into foster care. Children will be randomly assigned to receive either the ABC-T intervention or a control intervention, Developmental Education for Families (DEF). Both interventions will consist of 10 sessions delivered in families' homes. Foster parents' behaviors and children's functioning will be assessed at pre- and post-intervention, and when children are 3-, 4-, and 5-years old through a variety of tasks. Foster parents receiving the ABC-T intervention are expected to provide more nurturing care and to set more reliable contingencies than foster parents receiving the DEF intervention. Children in the ABC-T intervention group are expected to show more secure attachments to caregivers than children in the DEF intervention, to show more normative production of cortisol, to show fewer behavior problems, and to show lower incidence of DSM IV-R disorders, including most especially Oppositional Defiant Disorder and Conduct Disorder, than children in the DEF intervention group.

DESCRIPTION (provided by applicant): Experiences of early neglect have pernicious effects on young children's developing brain and behavioral systems. An intervention for neglecting parents, Attachment and Biobehavioral Catch-up, was developed to help parents provide synchronous, nurturing, and non-frightening care to infants and toddlers. As expected, this intervention proved effective in a randomized clinical trial in enhancing attachment security, emotion expression, and physiological regulation among young children. In this competitive renewal, the effects of this intervention on children's functioning in key middle childhood tasks will be examined. First, children in middle childhood need to be able to control or regulate behavior, inhibiting a dominant response. Failure to develop inhibitory control results in problems functioning in both classroom and peer settings. Second, in middle childhood, children need to have the capacity to regulate emotions, controlling the expression of emotions such as frustration or disappointment where it is appropriate to do so. A third key task for middle childhood is developing positive relationships with peers, which affects well-being across domains. Finally, children need to adequately regulate physiology, which although not apparent to observers, has effects on health and well-being. These key domains, inhibitory control, emotion regulation, peer relations, and physiological regulation, are therefore the outcomes assessed in this study. The children followed in this competitive renewal will include 210 children, at least 140 of whom were originally enrolled in the randomized clinical trial testing th efficacy of the Attachment and Biobehavioral Catch-up Intervention, and 70 low-risk comparison children matched for age, ethnicity, and gender. Children will be assessed when they are 8, 9, and 10 years old because this is an age-range when regulatory capabilities have typically consolidated, and demands for self-regulation are high. Inhibitory control will be assessed through behavioral tasks and through event-related potentials (which measures brain activity). Emotion regulation will be assessed through tasks that require children to regulate or control the expression of affect under challenging conditions. Peer relations will be assessed through teacher report, and peer simulation and attributional bias tasks. Physiological regulation will be assessed through measurement of the hormone cortisol. Children whose parents received the Attachment and Biobehavioral Catch-up Intervention and low-risk comparison children are expected to show stronger inhibitory control, better emotion regulation, more appropriate and less aggressive behaviors with peers, and more normative cortisol production, when compared with children whose parents participated in the control intervention.

DESCRIPTION (provided by applicant): Experiences of early neglect have pernicious effects on young children's developing brain and behavioral systems. An intervention for neglecting parents, Attachment and Biobehavioral Catch-up, was developed to help parents provide synchronous, nurturing, and non-frightening care to infants and toddlers. As expected, this intervention proved effective in a randomized clinical trial in enhancing attachment security, emotion expression, and physiological regulation among young children. In this competitive renewal, the effects of this intervention on children's functioning in key middle childhood tasks will be examined. First, children in middle childhood need to be able to control or regulate behavior, inhibiting a dominant response. Failure to develop inhibitory control results in problems functioning in both classroom and peer settings. Second, in middle childhood, children need to have the capacity to regulate emotions, controlling the expression of emotions such as frustration or disappointment where it is appropriate to do so. A third key task for middle childhood is developing positive relationships with peers, which affects well-being across domains. Finally, children need to adequately regulate physiology, which although not apparent to observers, has effects on health and well-being. These key domains, inhibitory control, emotion regulation, peer relations, and physiological regulation, are therefore the outcomes assessed in this study. The children followed in this competitive renewal will include 210 children, at least 140 of whom were originally enrolled in the randomized clinical trial testing th efficacy of the Attachment and Biobehavioral Catch-up Intervention, and 70 low-risk comparison children matched for age, ethnicity, and gender. Children will be assessed when they are 8, 9, and 10 years old because this is an age-range when regulatory capabilities have typically consolidated, and demands for self-regulation are high. Inhibitory control will be assessed through behavioral tasks and through event-related potentials (which measures brain activity). Emotion regulation will be assessed through tasks that require children to regulate or control the expression of affect under challenging conditions. Peer relations will be assessed through teacher report, and peer simulation and attributional bias tasks. Physiological regulation will be assessed through measurement of the hormone cortisol. Children whose parents received the Attachment and Biobehavioral Catch-up Intervention and low-risk comparison children are expected to show stronger inhibitory control, better emotion regulation, more appropriate and less aggressive behaviors with peers, and more normative cortisol production, when compared with children whose parents participated in the control intervention.

PROJECT SUMMARY/ ABSTRACT Young children who have experienced neglect or abuse are at increased risk for poor behavioral and biological outcomes. However, this risk can be buffered if their parents behave in sensitive ways. Attachment and Biobehavioral Catch-up (ABC), a home visiting intervention, targets parental sensitivity among parents of high-risk infants. Through efficacy trials, the ABC intervention has been shown to engage the intervention mechanism, parental sensitivity, and enhance parental neural activity. In addition, children whose parents receive the ABC intervention show better outcomes in attachment, cortisol production, and behavioral regulation than children whose parents receive a control intervention. Pilot work suggests that some parents respond to the intervention within several sessions, suggesting that an abbreviated intervention could be optimal for them. The next critical step is demonstrating that the ABC intervention engages the intervention mechanism when implemented by community clinicians in a community context, and examining whether some parents can benefit from an abbreviated version of the intervention. This effectiveness trial leverages an existing partnership between a community-based organization and child welfare system to examine whether the ABC intervention engages the treatment mechanism, parental sensitivity, when implemented by community clinicians, whether changes in parental sensitivity mediate intervention effects on child outcomes, and whether parental cumulative risk moderates the effectiveness of varied dosages of the intervention. A total of 360 parents and their young children involved in the New York City child welfare system will be included as participants. Parents will be randomized to a screen-and-refer intervention with an established evidence base (Safe Environment for Every Kid; SEEK), to SEEK plus a 3-session version of ABC (ABC 3), or to SEEK plus the standard 10-session ABC intervention (ABC 10). Intervention effectiveness will be examined as changes in parental sensitivity (the intervention mechanism) at both behavioral and neural levels, as well as changes in child outcomes. Changes in parental sensitivity are expected to mediate intervention effects on child outcomes. Individual differences in response to treatment dosage will be explored.

PROJECT SUMMARY/ ABSTRACT Parents serve as co-regulators for their young children, helping them regulate behaviors, emotions, and physiology and supporting the development of healthy brain circuitry. Neglecting parents often fail to serve as co-regulators, which has implications for young children?s self-regulatory capabilities and brain development. As children become older, these difficulties with self-regulation may become more pronounced. Adolescence represents a period of particular vulnerability for the emergence of mental health problems because of increasing demands for regulation of emotions and behaviors, coupled with on-going development of neural circuits that support emotional and behavioral regulation. In this competing renewal, we propose to follow children into adolescence who initially participated in a randomized clinical trial design of Attachment and Biobehavioral Catch-up (ABC) as infants, allowing us to experimentally assess plasticity and modification of brain circuits and self-regulation as the result of an early intervention. The ABC intervention was designed to help parents learn to interact in responsive and sensitive ways, with the expectation that children would show enhanced ability to regulate behavior, emotions, and physiology. We assessed the efficacy of the ABC intervention among parents involved with Child Protective Services (CPS). Parents were randomized to ABC or to a control intervention. Children were followed at T1 (ages 1-4) and T2 (ages 8-10). At T1, more of the children in the ABC group developed secure and organized attachments than children in the DEF group, and children in ABC showed more normative production of cortisol, less expression of negative emotions, and stronger inhibitory control than children in DEF. ABC parents were more sensitive and showed more optimal neural activity than DEF parents. At T2, ABC children showed greater prefrontal cortex activation in response to photographs of fearful faces than DEF children, suggesting better regulation to threat at the level of brain activation. Also at T2, children in the ABC group reported more secure relationships with parents, and showed more normative cortisol production and more optimal autonomic nervous system functioning than DEF children. In adolescence, the ABC intervention is expected to result in enhanced brain circuitry and more optimal functioning relative to the control intervention. In the proposed study, we will assess behavioral and neurobiological development among 13-, 14- and 15-year-old adolescents whose parents were referred by CPS to a randomized clinical trial in infancy (n=120), and among low-risk adolescents followed since middle childhood (n=80). At each annual assessment, the primary constructs, inhibitory control, emotion regulation, physiological regulation, and attachment/affiliation, will be assessed at the level of brain activation and circuitry, and at the behavioral level.

Opioid use has increased dramatically in recent years, with rates especially high among women living in poverty. Maternal opioid use combined with poverty renders children highly vulnerable to a host of short- and long-term challenges developing self-regulatory capabilities. In infancy, challenges in self- regulation can be seen in problems in the regulation of attachment behaviors, autonomic nervous system activity, and production of steroid hormones. Sensitive parenting is especially important for such children. Without intervention, many children born to opioid dependent mothers are unlikely to receive sensitive parenting. Early intervention is needed that helps these mothers provide sensitive care despite the challenges of substance use. In this project, we will assess the efficacy of a home visiting program adapted for mothers with opioid dependence who are living in poverty. Mothers on medication assisted treatment for opioid dependence during their third trimester of pregnancy will be randomized to this adapted home visiting program, modified Attachment and Biobehavioral Catch-up (mABC: N=100), or to a control condition of the same duration and frequency (modified Developmental education for Families, or mDEF: N=100). We will assess whether the mABC intervention engages the purported treatment mechanism, maternal sensitivity. Second, we examine whether the intervention has positive effects on infants? regulation of cortisol production, autonomic nervous system activity, and attachment. Third, we examine whether maternal sensitivity mediates intervention effects on infant outcomes. An exploratory aim examines whether the intervention alters maternal neural activity related to the rewarding nature of babies versus drugs. Parental sensitivity will be assessed prenatally, and at infant ages of 1 week, and 3, 6, and 12 months of age, and maternal neural activity will be assessed prenatally and at infant age of 12 months. Infant cortisol will be assessed at 3, 6, and 12 months, autonomic nervous system regulation at 6 and 12 months of age, and attachment at 12 months. The mABC intervention is expected to affect child behavioral and biological outcomes with these effects mediated by maternal sensitivity.