According to Porges [ 17 ], the HPA-axis joins the sympathetic part of the ANS within the mobilization system, which becomes active when neuroception of imminent threat occurs, the social engagement system 'dissolves', and the organism has to be prepared for a fight or flight. The HPA-axis expresses itself by secretion of the hormone cortisol, which can be gauged from increased concentrations in blood and saliva. Cortisol facilitates the release of energy but also stimulates the immune system. It acts on receptors in the brain, in a way that is adaptive as a response to acute stress, but might become maladaptive when stress is chronic [ 32 ].
Cortisol plays a role maintaining a diurnal pattern, which for humans means that cortisol levels are high after awakening and low at night. Chronic stress may disrupt the normative diurnal pattern of cortisol, and for this reason has received a fair amount of attention as an indicator of stress and self-regulation among children in foster care. Indeed, it has been found that foster children were more likely than controls to display an abnormally flattened diurnal cortisol pattern, due to very low morning levels or stable high levels [ 33 , 34 ].
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In the study of Bruce et al. Based on animal and some human research, low morning cortisol levels may be the result of exposure to chronic stress resulting from abuse or neglect [ 35 ]. But not all foster children may have had a similar experience. Bruce and her colleagues also identified foster children who had primarily been exposed to emotional abuse. These children showed atypical high levels of morning cortisol. This may be explained by the more acute, episodic stress associated with emotional abuse [ 36 ].
These findings underline the need for more research to tease out whether patterns of physiological functioning of foster children are due to the out of home placement as a disruption of attachment or to aberrant experiences that precede out of home placement. In both cases, however, foster children are to be considered a group at risk for atypical psychophysiological development.
Fortunately, however, in independent investigations, Dozier and her colleagues as well as Fisher and his colleagues have provided experimental evidence suggesting that cortisol patterns may be changed towards more adaptive patterns using interventions with foster parents. Dozier developed the Attachment and Biobehavioral Catch-up ABC program for new foster parents through the first months of placement, to help them in 4 to 5 home visits to promote secure attachment through nurturing care and in 5 to 6 home visits to regulate behaviour and physiology.
The randomized trial showed heightened cortisol levels in a lab setting among the foster children in the control treatment compared to foster children in the ABC-condition [ 37 ].
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Fisher and his colleagues evaluated the effect of Multidimensional Treatment Foster Care for preschoolers MTFC-P , an intensive therapeutic foster care program for high risk foster children [ 38 ]. This program involves intensive training for foster parents in behaviour management, support from a multidisciplinary team throughout placement, telephone-based monitoring and guidance of foster parents, and therapeutic play group activities for the children. It was found that over time, children in the intervention group maintained a diurnal cortisol pattern more typical of their comparison-group of nonmaltreated children with low-income families, whereas the diurnal pattern in children in the regular foster care condition increasingly became abnormally flattened.
Fisher and Stoolmiller [ 23 ] showed that these effects appeared to be partially mediated by the reduction of stress in foster caregivers within the MTFC-P condition. Together, the first psychophysiological studies on foster care shed more light on the role that foster parents may play in changing the developmental pathways of neglected and maltreated children. Foster parents are not only important for supporting behavioural regulation but also for affect regulation, an important principle that can be traced back to the observations that James and Joyce Robertson made on the basis of their films of the children they fostered during short separations from their parents [ 39 ].
Symptoms of disinhibited attachment have to be taken serious as possible signs that separations and reunions with foster parents may indeed have a qualitatively different meaning for some foster children, perhaps because the relationship with foster parents plays a less central role in the regulation of affect. This possible interpretation is consistent with Porges' idea that children with attachment disorder are more prone to activate the mobilization system than to activate their social engagement system to deal with challenges under conditions of relative safety [ 17 ].
However, interventions to support foster parents, even foster parents of hard-to-place children, show promise for improving psychophysiological regulation in children. This may help to prevent negative outcomes of foster care along a broad array of domains [ 12 ]. Some children with a history of severe disruption or deprivation of attachment develop disorders of attachment. Several descriptions and criteria for disorders of attachment exist for young children, but consensus is emerging that there is a small group of children who fail to develop specific attachment relationships or show behaviours antithetical to maintaining specific attachments, due to the pathogenic environment in which they grow up [ 4 , 40 - 44 ].
The most well known distinction is between subtypes of reactive attachment disorder, also called disorders of nonattachment [ 41 ]. One subtype describes children with emotionally withdrawn behaviour who strongly inhibit attachment behaviour in situations which are expected to elicit seeking or accepting contact with a familiar caregiver. The other subtype describes children with indiscriminate proximity seeking to familiar or unfamiliar persons, showing a disinhibition of contact seeking behaviour.
Although DSM-IV describes these subtypes as distinct and mutually exclusive, considerable overlap in symptoms of these subtypes has been found among institutionalized Romanian children [ 45 ]. Disinhibited attachment was found in a substantial minority of children adopted in the UK out of Romanian orphanages, was associated with severe mental health problems, and showed strong persistence within the period between 6 and 11 years of age [ 4 ].
Less is known about the course of the inhibited attachment subtype. These disorders of nonattachment are to be distinguished from forms of insecure or disorganized attachment, as well as disorder within specific attachment relationships attachment disorder with self-endangering, with inhibition, or with compulsive compliance [ 41 ] or temporary reactions to disruptions of attachment [ 42 ]. In addition to the plethora of possible forms in which attachment may be disordered, considerable debate exists about the appropriate therapeutic response for these children. Based on the available theoretical and empirical evidence, as well as clinical consensus, Boris and Zeanah outlined recommendations [ 40 ].
After ascertaining safety for the child, the preferred avenue for treatment is working with the children's parents or regular caregivers, based on methods that have been proven effective in promoting security of attachment among parents and children at risk for insecure attachment [ 46 ].
Interventions may be said to be effective for children with disordered attachment, if children show that they become able to use the prospective attachment figure as a source of comfort and a secure base for exploration and learning. In Hofer's [ 6 ] terms, the intervention should establish or re-establish regulatory processes embedded within child-caregiver relationships, and in particular regulation of emotional distress. In terms of Porges' polyvagal theory, intervention is successful when children become more able to use the social engagement system to deal with challenges in the presence of a familiar caregiver or attachment figure.
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In order to test these outcomes, psychophysiological measures may be an important complement to behaviour observation, in order to provide a window to changes in emotion regulation and the social engagement system. Although psychophysiological measures are still being used sparsely in measuring changes in emotions during psychotherapy [ 47 ], successful examples do exist where cortisol sampling and cardiography are used to obtain objective indicators of treatment outcome because these data are provided 'blind' to the treatment condition as well as insight into the psychotherapeutical process [ 48 - 50 ].
We used psychophysiological measures to test the effects of a psychotherapeutical approach that was specifically designed for non-autistic children with disrupted attachment histories, severe behaviour problems, and moderate to severe intellectual and visual disabilities [ 51 - 53 ]. There are a small group of children who grow up with a combination of serious risk factors as well as severe learning difficulties. Due to intensive care needs or vulnerability in the family, not all families are able to adequately care for their child themselves.
Unfortunately, these children are often also difficult to place in foster families. As a result, some of these children grow up in group homes. Not only do these children experience instability of placement, but in group homes, they are confronted with multiple caregivers. Due to their intellectual limitations, it may be difficult for these children to develop selective attachment relationships with these caregivers. Left to their own, underdeveloped skills for dealing with stress, maladaptive forms of coping may develop. This may be one of the reasons why aggression to self, to others, as well as extremely withdrawn behaviour may be so heightened among children with intellectual disabilities [ 54 ].
The problem is that these challenging behaviours require a high level of caution, tolerance, and experience on the part of caregivers who may attempt to connect to these children in a way which may develop into an attachment relationship. The first phase of treatment is that an experienced and trained psychotherapist attempts to build an attachment relationship with the child. The therapist makes verbal and tactile contact and invites the client to engage in interaction. The interactions typically involve imitation and play. The therapist is sensitive to signs of resistance or discomfort, and never coerces the child into contact.
Gradually the therapists attempts to extend the chains of mutual responsiveness, introduces variations and games, and uses soothing responses to facilitate the regulation of the client's affective reactions, which may occur on reunion or at leave-taking, but which may also occur when the joint activities generate affective arousal. The therapist will be watching for evidence of object permanence and person permanence, because this is important for building up a representation of the therapist.
As soon as the therapist perceives evidence to this effect searching, recognition , the therapist will build on this by introducing games and activities peek-a-boo in which person permanence is further trained. The therapist will also stimulate and reward the expression of wishes and desires, in order to strengthen the representation of a responsive attachment figure. The first phase consists of three sessions a week, across a period of six months or longer in order for the client to learn about the therapist and recognize her, and build up expectations about her responsiveness. After this phase of building a therapeutic attachment relationship, the second phase uses this relationship as a secure context in which the child might be able to learn new adaptive behaviour to replace the maladaptive problem behaviour.
This is done by analyzing the conditions which continue to give rise to challenging behaviour, defining appropriate replacement behaviours, and using positive social reinforcement for training these behaviours. Within the final phase, the psychotherapist works with the regular caregivers to expand the attachment network of the child.
Gradually, the relationship with the psychotherapist moves to the background. A controlled multiple case study was conducted with six children between age 10 and 17 years old with a long history of disrupted attachment and IQs between 20 and 35 Clients were blind or visually impaired according to WHO criteria. Clients were assigned for this intensive form of psychotherapy if a documented history showed extensive disruptions of attachment early neglect, early institutional placement, placement shifts , challenging behaviour was severe, medical causes for the behaviour were ruled out, and behavioural interventions with the caregivers or others had failed.
Most children lived quite isolated lives in their group home, because the professional caregivers were hesitant to remain in the vicinity. Only one child received part-time care from his adoptive parents. The first question was whether these children would begin to seek proximity to the therapist in times of stress.
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A second question was whether having to learn new behaviour in challenging situations would be more successful with ITAB, as compared to regular behaviour modification, and whether clients would show less stress reactivity, in particular in the mobilization system. Sessions with the experimental ITAB therapist alternated with a session with a control therapist on the same day. During phase 1, the control therapist was only positively involved towards the client but did not take the initiative to build a relationship. The length of phase 1 was for the study manipulated to vary, in order to create a multiple baseline design.
During phase 2, this therapist applied the same behaviour modification protocol as the ITAB therapist for learning new, more adaptive behaviour in the challenging situation. Each session was videotaped, and coded in random order by trained observers blind to phase and condition. During the sessions, ambulatory recording was done of PEP, to measure reactivity in the sympathetic part of the ANS and an index of the mobilization system, and RSA, a parasympathetic indicator and reflective of the social engagement system.
Appropriate controls were used for artefacts due to locomotion [ 51 ]. Using the RSA and PEP data, we identified, within each of the sessions within phase 1, episodes of heightened sympathetic or parasympathetic arousal and coded the duration and frequency of proximity seeking to the therapist ITAB or control. A significant difference was found, meaning that proximity seeking to the ITAB therapist increased during periods of heightened arousal, whereas it remained stably low for the control therapist.
This indicated that even after a long history of deprivation, children may cease to inhibit their attachment behaviour and may start approaching responsive people in their environment in times of stress. However, these findings are inconclusive, because stress was not experimentally induced [ 20 ], which meant that the peak periods of ANS reactivity may have been caused by stress but also by attention, excitement, or even metabolic processes. In the second phase of psychotherapy, however, situations were identified which were presumably challenging or frustrating because they elicited problem behaviour such as biting, scratching, spitting.
Session with the ITAB therapist were expected to provide a better context for learning alternative, adaptive behaviours to replace these problem behaviours, than sessions with the control therapist, because these children might not perceive the situation as safe with the control therapist. Within Porges' [ 17 ] model, this would lead to reactivity in the mobilization system. Indeed we found that children learned to use adaptive behaviours more frequently in the sessions with the ITAB therapist [ 53 ].
Furthermore, we found that in four out of the six children, the therapeutic relationship with the ITAB therapist prevented the activation of the mobilization system, because sympathetic reactivity increased during behaviour modification with the control therapist but remained stably low during behaviour modification with the ITAB therapist [ 51 ]. These findings suggest that for clients who before did not approach caregivers and appeared indifferent to human contact, the interaction with a specific person had become a support for the regulation of physiological reactivity in challenging situations.
Psychobiological theory may be an important complement to theories such as attachment theory to not only explain the consequences of the complex experiences surrounding disruptions of attachment, but also to identify mechanisms through which developmental change can be effected. The relationship between children and foster parents may contain the 'hidden regulators' that Hofer [ 6 ] proposed as typical for regular attachment relationships, as shown by the parasympathetic nervous system responses to separations and reunions [ 24 ] and by the effects of interventions aimed towards improving the interaction between children and foster parents or therapeutic workers [ 37 , 38 , 51 ] on physiological indices of affect regulation.
Relationships between children with disrupted attachment and their caregivers are therefore an important focus for research on their developmental pathways, as well as a focus for support and intervention in order to promote more adaptive developmental outcomes. For some children, however, the regulating function of their relationships with caregivers appears compromised.
Within Porges' theory, this would be the case when situations that would be safe enough for social engagement to be activated, elicit responses that facilitate mobilization of resources for fight or flight [ 7 , 17 ]. In his theory, processes on a subcortical level e. Mechanisms that facilitate recognition of visual and auditory patterns are probably involved in this so called neuroception of safety and danger [ 17 ].
Little is known about the kinds of experiences that may lead to aberrant neuroception. Neuroception of danger would predispose to reactivity of the sympathetic part of the ANS, called the mobilization system in polyvagal theory, and would weaken parasympathetic reactivity or vagal tone. The link found between sympathetic ANS reactivity and a history of neglect suggests one avenue for further research.
Another relevant finding was the low parasympathetic reactivity during reunion with foster parents by children showing symptoms of disinhibited disordered attachment [ 24 ]. Clinically, children with disorders of attachment appear to have pervasive disturbances in social relatedness and in particular using familiar caregivers as a source of comfort and safety [ 40 ], and these disturbances appear to be persistent [ 4 ].
Distortions in neuroception of safety and danger may be one explanation for this persistence, and therefore a potential target for intervention. Links between disorganized attachment relationships and sympathetic reactivity on reunion with the caregiver would in Porges' framework be highly consistent with the interpretation by attachment theorists that disorganized attachment patterns are the result of the opposing tendencies engendered by the fear system fight or flight and the attachment system seek contact [ 55 ]. These direct links have, however, not been found in the one study that examined this.
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An further important test of Porges' theory as well as the theories regarding disorganized attachment would therefore be to investigate the extent to which sympathetic ANS reactivity on reunion with caregivers mediates the link between frightening experiences with these caregivers and disorganized attachment behaviour. Furthermore, Porges' propositions that neuroception is based on systems for feature and movement detection, localized within the temporal cortex [ 17 ] require the extension of psychophysiological measures with imaging techniques [ 13 ].
Psychobiological perspective and research findings may also contribute to rational interventions for children with disrupted attachment histories. These interventions should not only be effective, but also safe unlike coercive treatments that are labelled by their proponents as 'attachment therapies' [ 56 ]. If support within children's own families is not effective or feasible and children have to be placed out of home, the developmental risks of foster care show that more is needed than a physically safe family.
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Skip to search form Skip to main content. This paper draws on the third phase of Growing Up in Foster Care, a longitudinal study of 52 children in planned, long-term foster care — View via Publisher. Alternate Sources. Save to Library. Create Alert. Share This Paper. Figures from this paper. She had just switched off.
I had to stay close to her and respond to even the slightest sound or facial movement and keep talking to her and touching her. It took time to replace those first weeks, but gradually she started to show different feelings and become more responsive. I needed just to be there and he needed to have the confidence that I would wait for him to come to me. On one occasion I gave him a small cushion to take with him so that he had something to hold onto, but also so that he would know he would be coming home.
She missed that out when she was little.