Shannon Bekman, WellPower, Denver, Colorado
Valerie Bellas, UCSF Benioff Children’s Hospital, Oakland, California
Grief does not spare infants and young children. Attachment disruption through the loss of a primary caregiver is devastating to a young child’s foundational experience of safety without the developmental capacity to understand any aspect of their loved one’s absence. In this case story, the authors explore the diagnosis of complicated grief in infants and young children through their assessment with a toddler who abruptly changed placements from his long-term foster caregiver without any transitional support to the care of his loving, yet unfamiliar, grandparents who were alarmed by his behaviors and worried greatly for him.
Corey, 18 months old, wakes up to see the sun coming through the windows. There is a moment of resting and anticipation of Mama coming to his bedside. His toes are ready for tickles! Where is she? She never takes this long. WHERE IS SHE? I am scared and alone. I want my Mama! Help me, Mama! Come! Corey is crying out now, frantic for her to come quick; her absence is interminable, and he is desperate for the embrace of his mama.
Cecilia Morales, Corey’s former foster mother who Corey has called “Mama” since he first could talk, is sitting at her kitchen table across town. She is sipping her coffee and tears are running down her face. She can feel her heart breaking. They just took him. I barely packed a bag. She breathes in for a moment, feeling a small wave of relief, I am glad he is with family. He belongs with family. She wipes her tears and notices a photograph of Corey with her dog, Fluffy, licking Corey’s nose, on the counter nearby. She gulps. I should have sent that photo with him. It makes him belly laugh chuckle.
I hope he is waking up with a smile today. I wish I could have told his grandparents how he likes his toes tickled in the morning, and how he giggles and says, “Tick, Mama, tick, tick, tick!” to get her to start their daily ritual as the sun peeks through the windows. Oh no! I should have told them that the only way I can get on his socks is to play peek-a-boo while I slide them on without him noticing. Do they know that he gets dry skin and that unscented gentle soap is all that can keep him from getting those awful dry patches?
Cecilia is beside herself thinking of all the things that might have eased Corey’s way that they just didn’t ask about or have time for her to share. I wish I could just be there for a minute and let him know that it is going to be okay, that he can trust his grandparents and they love him very much. How could the child welfare worker not understand that he is just a baby and can’t understand what is happening? I never want to go through this again. It is not right. I’m done being a foster parent.
Fast forward 2 months. The sun comes through the window rousing 20-month-old Corey awake. He barely stirs. I have been looking, looking, looking for you Mama every morning since I last saw you. Where are you, Mama? You’ve left me. I don’t think you’re coming back. I don’t know what I did to make you leave me. Corey is despondent and has given up on the hope that his foster mother is returning. Corey’s grandfather comes in to see his grandson. He reaches for Corey, and Corey arches away. He tells Corey about the day he has planned for the two of them. He brings over Corey’s socks to begin to get him dressed. He braces for the struggle that happens every morning when he has to grab Corey’s feet to get the socks on as he pulls away from his grandfather’s hands. Corey screams and yells and collapses on the floor, pushing his grandfather away and hitting his head on the floor. His grandfather pauses, feeling at the end of his rope. Corey is not okay. I don’t know what do. I have to talk to the child welfare worker about this; something is wrong.
Corey Is Referred for Assessment
Our infant mental health program is located in a community mental health center in Denver, Colorado. We frequently collaborate on cases with our local child welfare department and often receive referrals for young children who have experienced abuse, neglect, and other forms of trauma. A child welfare case worker outreached our program explaining that a toddler on her caseload, Corey, had been in foster care for the past 13 months and was recently moved to live with
his grandparents after the courts had made the decision to terminate Corey’s biological parents’ rights. Sheila, the case worker, shared that in the 2 months that he has been living with his grandparents, Corey has become “really aggressive.” When I asked her to describe the aggression, she explained that he will throw himself on the floor, bang his head on the ground, and more recently has begun wanting to be left alone in his crib and not be touched by anyone. She reported he will scream if anyone comes near him, and the grandparents can’t coax him to get up and play.
Sheila has worked with our program before, and she is developing a keen appreciation for just how much very young children can be affected by their caregiving environment and the trauma that is frequently present in dependency and neglect cases. Sheila shared that the grandparents “are excellent parents” and she has no concern about this new placement. When I asked her how long the aggression has been occurring, Sheila shared that Corey had not been aggressive at all in his previous foster placement and indeed had done exceedingly well. Sheila’s confusion at this new onset of symptoms is apparent, so I gently asked her to tell me what the transition plan had been when Corey was moved from his initial foster placement to the grandparents’ home 2 months ago. She reported that Corey’s grandparents had a 2-hour visit at the department and the following week Corey was moved.
I was alarmed at such an abrupt move, but I slowed myself down and asked more questions. I asked Sheila about Corey’s pre-existing relationship with his grandparents, and she reported that Corey did not really know them prior to the move. She alluded to some “family drama” that had put distance between Corey’s biological parents and Corey’s paternal grandparents that led them to stay away.
I voiced to Sheila my sadness and empathy for his distress and asked her to tell me about what first led to Corey being taken into foster care. Sheila explained that Corey’s parents had a history of intimate partner violence and when Corey was 5 months old his mother and father had gotten into a violent altercation. Corey was being held by his mother when his father forcibly grabbed him from his mother’s arms and threw him into a recliner. The neighbors had called the police when they heard all the shouting. Corey was taken to the hospital and subsequently placed in foster care. Sheila said she would send over paperwork from the department with more of his history. I let Sheila know that I was happy she called me and said that we could definitely help Corey.
Later that day, I receive an encrypted email from Sheila with Corey’s child welfare records. I opened the email and read the report from the initial child welfare investigation along with several other documents. The reports detailed the intimate partner violence Corey was witness to. Results from a full skeletal examination revealed that Corey did not sustain any physical injuries from the incident; however, he was reported to be underweight with some concern for non-organic failure to thrive.
The notes also provided me with a timeline of Corey’s placements: Corey lived with his biological parents from birth until he was 5 months old. He was removed from his mother and father at that time and placed into a non-kinship foster care placement with Ms. Cecilia Morales, where he lived for 13 months—until he was 18 months old. Later records detailed how his biological parents were reportedly not engaging with their child welfare case plan and, after 13 months in care, the state changed the case plan from reunification to termination of parental rights, and will be moving forward toward adoption.
I scrolled through more of the paperwork to find the results of an Ages and Stages developmental screening showing that Corey was meeting all of his developmental milestones at the 18-month pediatric well-child check he attended with his foster mother, just prior to the change in placement. His foster mother did not report any behavioral concerns at that visit. Indeed, notes in his record show that Corey thrived in his foster mother’s care. He had grown in size and weight and was fully back on the growth curve. He crawled at 8 months old, began walking at 11.5 months, and was communicating with his foster mother with about 15 words at 18 months. A wave of sadness and anger passed over me. He was thriving developmentally in his foster placement! Why did he have to be moved so abruptly? Why was there not a thoughtful transition plan! He didn’t know his grandparents at all when they moved him! They broke his heart, and this could have been avoided! I took some deep breaths to steady myself. It is unclear to me why Corey was not initially placed with his grandparents who were now willing to provide a permanent home for him. I make a note to ask Corey’s grandparents when I meet them.
The First Session
A few days later, I met with Corey and his paternal grandparents, Mr. Kevin Murphy and Mrs. Regina Murphy. I greeted the family in the waiting room and found Corey wearing jeans, a dinosaur T-shirt, and crisp, white, new sneakers. Although there were various toys and books in the waiting room, Corey was seated in an adult chair, looking sullen with his feet dangling over the edge of the seat.
I introduced myself to Mr. and Mrs. Murphy first and then Corey, who was appropriately standoffish with me. Mr. Murphy helped Corey down from the chair and I walked them down the hallway to the office. Upon entering my office, Corey initially stood still, looking pensive. After some initial hesitancy and with prompting from his grandparents and myself, Corey slowly explored the toys in my office. He first picked up the farm animals—a pink pig and a smiling cow—and I watched as he loaded the animals into and off a tractor trailer. His expression was flat with few smiles observed. Instead, he seemed serious, sullen, and watchful of his caregivers’ movements in the room. He spoke minimally. However, when he did need support, he called his grandfather over with a hand wave and showed him that he needed help to open a sticky door to the toy ambulance.
I noticed that Corey directed most of his bids for help toward his grandfather rather than his grandmother and made a mental note of this. As Corey settled into play, I shared with the Murphys that I received some documentation from child welfare, so knew a little of Corey’s history, but was eager to hear their perspective. When I asked what they thought was happening for Corey, Mr. Murphy said he believed that Corey was acting “mean” partly because he was never given the stability and structure that a young child needs and expressed disappointment in their son Brad, Corey’s father. Mr. Murphy expressed appreciation for the care that Ms. Morales provided Corey and some worry that she “spoiled him.” He also said that he thinks that Corey has a “hot Irish temper” like his father.
Approximately halfway through the session, when I wanted to inquire about more sensitive content, one of our clinical interns, Julissa, came in to accompany Corey to an adjoining space so that he would not overhear the adult conversation. At this time, Corey became noticeably alarmed, and, with his eyes wide, he dropped the truck he was holding and moved toward his grandfather, grabbed his grandfather’s index finger, and indicated he would not go without his grandfather. Knowing Corey’s history, this response was understandable. I supported Mr. Murphy to shepherd Corey into the adjoining room and helped him carry the trucks he had been playing with.
Julissa welcomed him in and sat down to play. I made sure to keep the door between the adjoining rooms open so that Corey could have line of sight of his grandfather throughout the remainder of our session. I then proceeded to ask Mr. and Mrs. Murphy about their decision to be a placement option for Corey at this time. The Murphys explained that when Corey was first taken into care at 5 months old, they were unwilling to be a placement option because they had felt that if they were taking care of Corey, Brad would have less reason to follow his case plan because he would think he could visit Corey whenever he wanted. However, when Brad failed to work his case plan and child welfare changed the case plan to termination of parental rights, the Murphys decided to “step up” and open their home to their grandson. I then asked about their concerns for Corey and asked for more detail about his current symptoms. Corey’s grandfather first described the aggression, noting that Corey experiences what he termed “rages” during which Corey cried inconsolably, kicked at his grandparents, threw himself to the floor, and sometimes banged his head on the ground. Mr. Murphy said to me, “He’s like a clone of his father...I’m afraid he’ll get more aggressive as he gets older, and he won’t have any friends at school.”
The grandparents also told me that Corey keeps asking for his “Mama,” which they understood to be his foster mother, Ms. Morales. Corey’s grandparents told me they have not said much at all to Corey about Ms. Morales because they did not think he would understand it and would soon forget her. I asked them about what is helpful to ease his suffering, and they reported that their efforts to soothe or distract him were in vain and they were not able to console him. They shared that although Corey often appeared sad and sullen throughout much of the day, he was most persistent in his cries for her at bedtime, and he could not fall asleep without his special “lovey”—a stuffed bunny rabbit that Ms. Morales had given him. Mr. and Mrs. Murphy described with some confusion that, despite Corey’s anger and apparent disinterest in them, in the last month Corey “loses it” when Mr. Murphy leaves the room. They described that Corey began crying intensely and ran in distress after Mr. Murphy when he tried to depart. These behaviors have limited the family’s activities and Mr. Murphy’s ability to get through his normal daily routine.
In addition to these concerns, they noted that Corey rarely played with the toys they thoughtfully made sure to acquire for him, and he sometimes just wanted to be left in his crib. Further, he would sometimes cry and protest when they tried to rouse him to participate in the fun activities they had planned for him. The Murphys reported this situation with frustration and annoyance that Corey did not appreciate how much they have “turned their lives upside down” to provide a home for him. Lastly, Mr. and Mrs. Murphy felt that Corey communicates less than they would expect for a child of 20 months and less than they expected given the developmental reports of how he communicated when in Ms. Morales’ care. When he was not expressing anger or sadness, they experienced him as quiet and withdrawn.
I validated their concerns about Corey’s significant change in behavior and offered hope that I thought I could be of help. I sent them home with several questionnaires to complete that would help me better understand Corey’s current struggles as well as his strengths. Mr. and Mrs. Murphy informed me that while Mr. Murphy is retired, Mrs. Murphy still works full time and often helps their adult daughter with their granddaughter and that Mr. Murphy will be the one most able to come to session with Corey. Mr. Murphy and I made a plan for our next session. I explained that it will be an observational session where I get a chance to see Mr. Murphy and Corey play and interact together.
After the session I checked in with Julissa to see how her time with Corey went and what she observed. She looked tense and upset. I invited her into my office to talk. She shared with me that her family immigrated to the United States from El Salvador when she was 1 year old. Her eyes misted over as she reflected on how all of her connections to her extended family were cut off suddenly when she was just Corey’s age! Because her family was undocumented, they could not travel back to El Salvador to visit, and she missed out on so much. Julissa says that she can’t stop thinking about all the toddlers separated from their parents at the border, and how despairing they must feel. I listened to her carefully, making reflective space for her pain and anger, knowing that her experiences will serve as a compass for her work in the field.
The following week, Corey and his grandfather returned to the clinic to participate in a 45-minute observation which helped us further assess various aspects of the caregiver– child relationship. This observation consisted of a number of different activities including free play, clean up, blowing bubbles, and some problem-solving tasks. I observed from an adjoining room behind a one-way mirror. During the free play, Mr. Murphy and Corey displayed some positive interactions, with Mr. Murphy patiently helping Corey settle into exploration of the toys. Mr. Murphy showed Corey several different toys until Corey showed interest in the toolbox set. The two were observed to enjoy tinkering with the toy screwdriver and hammer, pretending to fix things in the room. However, clean up proved to be a source of conflict for the two with Corey’s grandfather expressing frustration that Corey only minimally participated in putting toys away. He muttered a commentary under his breath that Corey was stubborn, “just like his father.”
Bubbles provided a reprieve with moments of shared joy between the two with Corey squealing and smiling in response to his grandfather’s encouragement to pop the bubbles. It was the first genuine smile from Corey that I had witnessed. Their interaction became much more challenging as problem-solving tasks were introduced. Corey became frustrated, laid on the floor, and stomped his feet in frustration, while his grandfather commented, “You’re being a bad boy.” The remainder of the observation proceeded in a similar manner.
The following week, I asked Mr. Murphy to come without Corey so that I could complete a caregiver perception interview that would help me understand how Mr. Murphy thinks and feels about Corey. The interview was notable for Mr. Murphy’s disappointment that he did not have a relationship with Corey as a baby given the poor relationship he had with his son, Brad. Another prominent theme was fear that Corey would turn out like his father who had a diagnosis of bipolar disorder but would not engage in treatment. Mr. Murphy described Corey as “the spitting image of Brad,” noting similarities in their anger, aggression, and stubbornness. Overall, Mr. Murphy appeared to be preoccupied with a mix of disappointment in, anger at, and fear for his son, that appeared to overshadow his ability to maintain focus on his young grandson and sometimes impacted how he saw Corey. Simultaneously, there was also a notable lack of appreciation of Corey’s emotional experience, particularly the grief and loss of losing his foster mother.
Mr. Murphy also brought back the completed assessment measures. After scoring them, I saw clinical elevations in several scales related to stress, anxiety, and depression. The trauma assessment put Corey in the range where a “probable diagnosis” of trauma is likely. In addition to the assessments, Mr. Murphy also brought me the results of a recent Part C early intervention evaluation. This evaluation was completed just prior to beginning mental health services at our clinic when the Murphys expressed their concerns to Sheila. The evaluation showed Corey to be in the normal range in all areas of development except social–emotional, in which he demonstrated delays in emotional regulation abilities, which were noted to be similar to a 12-month-old.
I had another session with Mr. Murphy during which I learned more about his Irish Catholic upbringing and his own experience with grief and loss as a child. Mr. Murphy told a story about when his own father passed away suddenly when he was 6 years old. He did not remember anyone talking to him about his father’s death and said, “I was just a kid, and my mother had enough to deal with raising us. I think Corey will be just fine, too.” He went on to say Corey is too young to feel more than “maybe a little missing” of his former foster mother.
As part of the assessment process, I wanted to speak to Ms. Morales to obtain her perspective on Corey and what has happened. After making sure it is okay with the Murphys, I called Ms. Morales. I introduced myself, described my role, and shared a little bit about how Corey was doing in hopes to enlist her help to ease Corey’s suffering. Ms. Morales was sobbing, sharing, “My heart is broken, I love him so much, but he needs to move on. And I think it’s best he has a clean break.” She said, “I’m sorry” and then hung up the phone. My heart sank knowing that she had been informed of something that was wholly untrue. A clean break was not what Corey needed. He needed a slow, developmentally sensitive transition that honors his attachment relationships.
The Diagnostic Picture
Taking all of the assessment information together, I was able to put together a picture of a toddler with an early life history notable for neglect and exposure to his parents’ intimate partner violence. From 5 to 18 months old, Corey rebounded with the support of a loving foster mother with whom he thrived developmentally. It is only in the last 2 months— when there has been an abrupt change in placement, with no transition plan to unfamiliar family, and the permanent loss of his only attachment figure—that Corey’s mental health was severely compromised. At 18 months, the peak of developmentally normative separation anxiety, his primary attachment figure was altogether taken away from him, and he faced a world without her that he cannot understand. He is now described as “aggressive,” and he showed frequent sadness, crying, separation anxiety, and a refusal to be picked up or comforted by his new caregivers.
Corey did not know his grandparents and continued to long for his foster mother. He actively protested against her intolerable absence, expressing intense anger and fear directed both at others and at himself. He rejected his grandparents’ care, as they were not the ones he was looking for, but he did not want them to leave because then he would be completely and utterly alone. Sometimes Corey gave up trying because Mama was just not coming back. In those terrible moments, he could feel his grandparents pulling away tensely, their own past experiences and worries interfering with fully embracing him.
Thus, we came to understand Corey’s grief, as well as its complications. When he faced the permanent loss of his foster mother, Corey was psychologically vulnerable due to the traumatic experiences of his early infancy. After he left her care, Corey’s capacity to heal from this primary loss was complicated by factors in his relationship with his grandparents and their unresolved feelings about their son, his unwillingness to get treatment for his mental illness, and how that relationship sometimes seeped into how they view Corey.
So what picture does this paint? Corey’s symptoms of persistently crying out for his foster mother, intense separation protest, depressed affect, lack of interest in play, self-harming behavior of head banging, loss of developmental milestones, and functional impairment following the permanent loss of his attachment figure are consistent with a diagnosis of complicated grief disorder of infancy/early childhood.
How Diagnosis Informed Treatment
After the assessment was complete, I thought about how I might share the diagnosis with Mr. Murphy. I knew that he might not think grief was a word that could be used for anything short of the experience of a death. I thought of how I might explain the idea of a permanent loss, and that Corey, because of his young age, could not know that Ms. Morales was still alive but not there. I also thought about how there had not been a planful transition from Ms. Morales’ home to the Murphys’ home, which had there been, could have avoided so much of this harm and psychological suffering. I explored all of these ideas and thought about Corey’s experience together with Mr. Murphy. I described to him how child–parent psychotherapy (Lieberman et al., 2003, 2015) could support Corey and his grandfather to understand what has happened and is happening for both of them and to think about all the feelings and behaviors that arise for Corey given his tremendous loss. Mr. Murphy agreed to start therapy and began to open his perspective to the possibility that Corey was not mean or spoiled, but perhaps in deep mourning over the loss of his beloved foster mother.
Reflections on the System
The science of early childhood and its underlying neurobiology affirms that the development of attachment is the primary developmental task of infancy and sets the stage for all subsequent developmental milestones. This knowledge base, established across decades of research and known deeply in the hearts of generations of families and communities who provide care to the babies they love, is unequivocal about the precious development needs of young children. With this in mind, it is more than clear the impact of a sudden move on a child made with only adult timelines in mind, instead of a transition that holds the young child’s needs as primary and develops bridges of care coordination from one loving relationship to the next. Corey’s experience of relationship disruption and subsequent complicated grief exemplifies missed opportunities and avoidable harm. Had a thoughtful developmentally informed transition plan (see Box 1) been implemented between his long-term foster caregiver and loving grandparents, Corey’s mental health and development likely would not have been compromised.
Box 1. A Developmentally Sensitive Transition Plan for Corey
The emotional harm Corey experienced secondary to the abrupt, traumatic removal from his foster mother could have been mitigated with a thoughtful, developmentally sensitive, planful transition. A planful transition means that those responsible for the child’s well-being (e.g., child welfare, foster parents, judge, attorneys, and kinship caregivers) work together to ensure that the child’s move from one caregiving situation to another is smooth and takes into account the child’s developmental level and current attachment relationships (Zeanah, 2022). Many times, systems try to rush or omit these transitions altogether, and while there is no formula or magic algorithm, here we provide the steps of a planful transition that we wish Corey, his foster mother, and his grandparents could have all experienced.
This plan highlights and honors the primacy of Corey’s attachment needs; respects his foster mother’s need to say goodbye and impart all of her firsthand knowledge of Corey’s personality, his likes, dislikes, and sensitivities; and warmly welcomes in his grandparents who, although eager to offer their love, are unknown to Corey at the start of the transition plan. Our explicit goal is to allow time and sufficient contact for Corey to develop an attachment relationship with his grandfather prior to the move rather than just disrupting his current attachment relationship with his foster mother. This transition plan occurs over the course of approximately 6–8 weeks and may be slowed down or sped up based on how Corey responds. A crucial part of any planful transition is to watch how the infant or young child copes with the changes, especially in terms of any disruptions to eating, sleeping, and mood. In addition to the following plan, in a more perfect universe, at the point of placement into foster care, a concurrent plan of adoption by kin (i.e., grandparents) would have been indicated and regular visits with Corey and his grandparents would have started shortly after his initial placement in care so that he would have been developing a relationship with them all along.
1. Phone call between Ms. Morales and the Murphys to introduce each other, for the Murphys to begin to hear about Corey, and for Ms. Morales to gain an understanding of to whom Corey will be going.
2. Begin 2–3x weekly home visits by Corey’s grandfather (and grandmother, if possible) in Ms. Morales’ home. This setting is chosen because it is the most familiar and comfortable setting for Corey. All caregivers are present with Corey for the 2-hour home visit. Corey is provided a developmentally appropriate narrative of who the grandparents are (e.g., “This is Grampy. He is here to play with you and to get to know you.”). They discuss that Corey will spend some time with his grandfather over the coming weeks.
3. Ms. Morales can explain routines and preferences (including naptime, bedtime, and bathtime care routines) and show Mr. Murphy Corey’s room during these home visits. Ms. Morales can also complete a caregiver form outlining routines, Corey’s preferred foods, detergents and soaps, special needs, comfort items, and other important details that will support Corey in the transition.
4. Community visits in a comfortable and familiar setting such as a playground or park near Ms. Morales’ house where Corey often goes to play with both Corey’s grandfather and Ms. Morales present. The length of these visits can gradually increase in time and frequency up to 3–4 hours. As Corey becomes more familiar and trusting of Mr. Murphy, Ms. Morales can step away for brief periods of time, pending Corey’s reaction.
5. Home visit in the Murphys’ home with Ms. Morales present. Ms. Morales stays for the whole visit. A series of these visits are scheduled until Corey seems comfortable.
6. Continued home visits in the Murphys’ home with a change in Ms. Morales’ presence. Ms. Morales is present at the start of the visit and then leaves for 30 minutes to an hour toward the end, gradually decreasing the time she is present and increasing the time she is not there until Corey is comfortable with a drop off and pick up by Ms. Morales for visits of 2–4 hours increasing to 4–6 hours.
7. Extended (all day) home visit at the Murphys’ and then return to Ms. Morales for sleep, adding days until Corey is spending at least 4 full days at his grandparents’ house. Corey is provided a developmentally appropriate narrative of his move to his grandparents, with visual support to help understand the days until his move (e.g., using a paper ring chain to represent number of days left) if this is helpful. He is shown his new bedroom and toys at his grandparents’ house.
8. Celebration of love with Ms. Morales. Ms. Morales is encouraged to make a memory book with photos and send special objects with Corey. Corey is to be present when Ms. Morales is packing favorite items.
9. Move in with grandparents. Corey’s grandparents follow Ms. Morales’ routines until Corey is comfortable and then can add in new routines after he has adjusted. Ms. Morales is available by phone for support, and they can plan visits back with Ms. Morales after Corey settles in, and as indicated. The Murphys continue to help Corey hold Ms. Morales in mind with the picture book and support the integration of Corey and Ms. Morales’ time together into the narrative of his early life.
According to The Annie E Casey Foundation (2022), there were 29,105 infants less than 1 year old and 140,213 children 1–5 years old in foster care, with numbers of infants in foster care rising by 24% between 2011–2018. With so many lives in the balance and disproportionate representation of Black, Indigenous, and People of Color (BIPOC) families in the child welfare system, it is crucial to address the needs of young children as they are transitioning placements. There is no doubt that overwhelmed systems are challenged to provide time and reflective space for these thoughtful conversations to share, coordinate, and problem solve. These systems founded in and maintained by systemic racism move quickly toward inhumane treatment of BIPOC children and families, as well as targeted groups such as those with substance abuse disorders or severe mental illness. Despite these pervasive and powerful factors, there are practical approaches that have made great strides in centering the needs of infants and young children in the child welfare system and the importance of developmentally sensitive transitions (Jones Harden, 2007) including programs such as the Safe Babies Court Team approach (ZERO TO THREE, 2020).
DC:0–5TM: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood
ZERO TO THREE, 2016
The DC:0–5 manual provides a developmentally based system for diagnosing mental health and developmental disorders in infants and young children, and includes criteria for complicated grief disorder following the death or permanent loss of an attachment figure.
DC:0–5TM Casebook: A Guide to the Use of “DC:0–5TM: Diagnostic Classification of Mental Health and Developmental Disorders
of Infancy and Early Childhood” in Diagnostic Assessment and Treatment Planning
ZERO TO THREE, in press
A chapter on complicated grief disorder in the DC:0–5 Casebook provides an analysis of Corey’s case from an alternate perspective—one in which his foster mother dies due to COVID. The authors provide an in-depth review of the assessment process and differential diagnosis using the DC:0–5 criteria.
Shannon Bekman, PhD, IECMH-E®, is a licensed clinical psychologist at WellPower and the director of Right Start for Colorado, an infant and early childhood mental health (IECMH) initiative aimed at expanding Colorado’s IECMH workforce and clinical services. Dr. Bekman is also clinical instructor at University of Colorado School of Medicine with the Harris Program in Infant Mental Health, and a member of the ZERO TO THREE Academy of Fellows. She has published on the topics of assessment, diagnosis, and treatment of IECMH concerns.
Valerie Bellas, PhD, is a licensed clinical psychologist with UCSF Benioff Children’s Hospital, Oakland, California, and lead instructor for the Infant and Early Childhood Mental Health (IECMH) Post-Graduate Certificate Program at California State University, East Bay. She received her training at Clark University, Child Witness to Violence Project, and Tulane University Infant Team. Her work focuses on collaborative approaches to developmentally sensitive and culturally responsive IECMH service provision and workforce development.
Bekeman, S., & Bellas, V. (2022). Holding multiple perspectives: A toddler's journey with traumatic grief in the child welfare system. ZERO TO THREE Journal, 43(2), 5–11.
The Annie E. Casey Foundation, KIDS COUNT Data Center. (2022). Children in foster care by age group in the United States [Data set]. https://datacenter.kidscount.org
Jones Harden, B. (2007). Infants in the child welfare system: A developmental framework for policy and practice. ZERO TO THREE.
Lieberman, A. F., Compton, N. C., Van Horn, P., & Ghosh Ippen, C. (2003). Losing a parent to death in the early years: Guidelines for the treatment of traumatic bereavement in infancy and early childhood. ZERO TO THREE.
Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2015). Don’t hit my mommy! A manual for child–parent psychotherapy with young children exposed to violence and other trauma (2nd ed.). ZERO TO THREE.
Zeanah, C. (2022). Advocating for planful transitions for young children in foster care [Webinar]. Early Trauma Treatment Network. https://youtu.be/OwqgrMXAB78
ZERO TO THREE (2020). The Safe Babies Court Team approach: Core components and key activities. ZERO TO THREE.