Mental Health NeedsAmong Foster Children

Presented By: Whitney Hardcastle, LMSW

Foster Care

A temporary arrangement in which adults provide for the care of a child or children whose birthparent, for a variety of reasons, is unable to care for them.

Can be informal or arranged through a court or social services agency.

The goal for a child in the foster care system is usually reunification with the birth family, but may be changed to adoption when this is seen as in the child's best interest.

Factors leading to placement

Parental Substance Abuse

Child Abuse and Neglect

Homelessness

Poverty

Family factors

Behavior problems

Domestic Violence

Statistics

Approximately 500,000 children are in the foster care system in the U.S.

Between 50%-75% of foster children have mental health issues

18%-22% of children in the general population have mental health issues

30%-40% of children in foster care receive Special Education services

63% of children stay in foster care less than 2 years, and average 3 placements

70% of foster children achieve reunification with their families

Statistics

Children under the age of 5 are twice as likely as those 5-17 to enter the foster care system

Younger children typically spend a longer amount of time in foster care than older children

Infants remain in foster care the longest amount of time with the median length of stay ranging from 11-42 months

Infants removed from their homes and placed in care are more likely than older children to experience further maltreatment and to be in out-of-home care longer

Question

Under what age are children more likely to enter the foster care system?

Issues Foster Children Face

Removal from biological parents requires a substantiation of maltreatment, not just an exposure

Many children long to return to their families, regardless of the history of maltreatment

Children with a history of maltreatment who additionally endure the trauma of separation from parents are susceptible to PTSD

Rates of PTSD in foster children are equivalent, if not higher than in veterans

Suggested that children exposed to child welfare with factors such as neglect and poverty, necessitated a greater need for mental health services

Issues Foster Children Face

Children in foster care are more likely to develop psychological, social, and developmental delays than those in the general population

Foster children have higher prevalence of conduct problems, language difficulty, attachment disorders, behavioral problems, and neurological impairments

Estimated that over half of children in foster care may experience at least one or more mental disorders and have clinically significant emotional or behavioral problems

Education

Foster children face many educational obstacles due to frequent moves and their risk for developmental delays

Have more difficulty than the general population graduating from high school

Rates of GEDs of children in foster care verses those in the general population were about 6 times greater

Lower rate of attending college

Trauma

Foster children have disproportionately high rates of trauma compared to youth in the general population

Young children lack an accurate understanding of the relationship between cause and effect

They believe that their thoughts, wishes, and fears have the power to become real and can make things happen

Lower ability to anticipate danger or to know how to keep themselves safe, making them particularly vulnerable to the effects of exposure to trauma

Young children are particularly at risk because their rapidly developing brains are vulnerable

Trauma

Children may blame themselves or their parents for not preventing a frightening event or for not being able to change the outcome

These misconceptions of reality compound the negative impact of traumatic effects on children’s development

Young children experience both behavioral and physiological symptoms associated with trauma

Cannot express in words whether they feel afraid, overwhelmed, or helpless

Trauma

Early childhood trauma has been associated with reduced size of the brain cortex which is responsible for memory, attention, perceptual awareness, thinking, language, and consciousness

These changes may affect IQ and the ability to regulate emotions

The child may become more fearful and may not feel as safe or protected

Trauma

Young children depend exclusively on parents/caregivers for survival and protection-both physical and emotional

When trauma impacts the parent/caregiver, the relationship between that person and the child may be strongly affected.

Without the support of a trusted parent/caregiver to help them regulate their strong emotions, children may experience overwhelming stress, with little ability to effectively communicate what they feel or need

Trauma

Children suffering from traumatic stress symptoms generally have difficulty regulating their behaviors and emotions

May be clingy and fearful of new situations

May be easily frightened

Difficult to console

Aggressive and Impulsive

Difficulty sleeping

Regression in developmental skills, functioning, and behavior

Question

Approximately what percentage of foster children have a mental illness?

Mental Health Needs

Children in foster care struggle to cope with the events that brought them into the system such as abuse, neglect, homelessness, exposure to domestic violence, and/or parental substance abuse

Foster children are experiencing unpredictable contact with family, multiple placements, and an inability to direct their own lives at a time when they need reassurance, understanding, and stability

Untreated mental health problems have been linked to higher rates of placement disruption and lower rates of reunification and adoption in child welfare involved youth

Unmet mental health needs can mean ongoing problems as they enter adulthood

Early Identification

Early identification is key in treatment

Early intervention affects adult health outcomes and quality of life

Early assessment for physical, developmental, and mental problems is necessary so appropriate interventions can begin early

Period assessments need to be completed

Family Involvement

Adequate mental health care for children in their biological homes can sometimes prevent placement in foster care

Families stressed by children with untreated serious mental health needs can be at increased risk for abuse and neglect

Social learning and behavior interventions can be implemented in the home and be beneficial for the entire family

Can be taught skills for developing and maintaining positive relationships

Can be allowed and encouraged to maintain family connections

Question

List some of the reasons children enter into foster care.

Family Involvement

Family members should be involved and participate in children’s mental health treatment

Includes treatment planning, implementation, and evaluation of services

Important for both parents and caregivers to understand the results of evaluations, the diagnoses, and full range of treatment options

In general, participation of family results in improved treatment outcomes

Without the involvement of families, it is difficult for service providers to ensure that gains achieved by the child are maintained and solidified

Family Involvement

Important for foster parents to be involved when children are already in their care

Specific and active support form the foster caregiver is needed to prompt and reinforce use of anxiety coping skills for children who potentially are faced with a new environment, uncertainty about their future, court involvement, and visits with family

Common Mental Disorders

Most Common mental health diagnoses:

Depressive Disorders

ODD

PTSD

Adjustment Disorders

Conduct Disorders

Depressive Disorders

Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder

Adversely affect mood, energy, interest, sleep, appetite, and overall functioning

Symptoms of depressive disorders are extreme and persistent and can interfere significantly with a young person’s ability to function at home, at school, and with peers

Major Depressive Disorder

Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks.

Mood represents a change from the person's baseline.

Impaired function: social, occupational, educational.

Specific symptoms, at least 5 of these 9, present nearly every day:

1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

2. Decreased interest or pleasure in most activities, most of each day

3. Significant weight change (5%) or change in appetite

4. Change in sleep: Insomnia or hypersomnia

5. Change in activity: Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt

8. Concentration: diminished ability to think or concentrate, or more indecisiveness

9. Suicidality: Thoughts of death or suicide, or has suicide plan

DSM-IV-TR

Dysthymic Disorder

Mild, but chronic, form of depression

A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years.

B. Presence, while depressed, of two (or more) of the following:

(1) Poor appetite or overeating

(2) Insomnia or hypersomnia

(3) low energy or fatigue

(4) low self-esteem

(5) poor concentration or difficulty making decisions

(6) feelings of hopelessness

C. During the 2-year period of the disturbance, the person has never been without symptoms in Criteria A and B for more than 2 months at a time

D. No Major Depressive Disorder has been present in the first 2 years of the disturbance

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as schizophrenia or Delusional Disorder

G. The symptoms are not due to the direct physiological effects of a substance or a general medical condition

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning DSM-IV-TR

Bipolar 1 Disorder

A condition in which a person has periods of depression and periods of being extremely happy, or being cross or irritable

A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Disorder

B. There has been previously at least one Manic Episode or Mixed Episode

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

D. The mood symptoms in Criteria A and B are not better accounted for by another mental disorder

E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance or a general medical condition

DSM-IV-TR

Bipolar Disorder

A. Presence (or history) of one or more Major Depressive Episodes

B. Presence (or history) of at least one Hypomanic Episode

C. There has never been a Manic Episode or a Mixed Episode

D. The mood symptoms in Criteria A and B are not better accounted for by another mental disorder

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

DSM-IV-TR

Anxiety Disorders

As a group are the most common mental illnesses that occur in children and adolescents regardless of foster care status

Prevalent among 13% of children and adolescents in the U.S.

Generalized Anxiety Disorder

A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities

B. The person finds it difficult to control the worry

C. The anxiety and worry are associated with three or more of the follow symptoms 1. restlessness or feeling keyed up or on edge

2. being easily fatigued

3. difficulty concentrating or mind going blank

4. irritability

5. muscle tension

6. sleep disturbance

D. The focus of the anxiety and worry is not confined to features of an Axis 1 disorder

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

F. The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder

DSM-IV-TR

Post Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Criterion A: stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)

1. Direct exposure.

2.Witnessing, in person.

3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.

4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non- professional exposure through electronic media, television, movies, or pictures.

PTSD

Criterion B: intrusion symptoms

The traumatic event is persistently re-experienced in the following way(s): (one required)

1.Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.

2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

3.Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.

4. Intense or prolonged distress after exposure to traumatic reminders.

5. Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event:(one required)

Trauma-related thoughts or feelings.

Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

PTSD

Criterion D: negative alterations in cognitions and mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)

Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).

Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").

Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).

Markedly diminished interest in (pre-traumatic) significant activities.

Feeling alienated from others (e.g., detachment or estrangement).

Constricted affect: persistent inability to experience positive emotions.

PTSD

Criterion E: alterations in arousal and reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

Irritable or aggressive behavior

Self-destructive or reckless behavior

Hypervigilance

Exaggerated startle response

Problems in concentration

Sleep disturbance

Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.

Criterion G: functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness.

ADHD

Affects an estimated 4% of children and adolescents in the U.S.

Developmentally inappropriate levels of attention, concentration, activity, distractibility and impulsivity.

Usually have impaired functioning in peer relationships and multiple settings including home and school

Question

As a group, what are the most common mental illnesses that occur among children in the U.S. regardless of foster care status?

Attachment Issues

A healthy attachment style can play a crucial role in the psychological effects of foster children.

Attachment styles are developed in childhood and continue to affect the ability to form intimate and healthy relationships as adults

Bowlby believed that the infant-caregiver relationship forms an internal working model that later influences interpersonal perceptions, attitudes, and expectations.

This invokes trust and a secure base for the child to develop

Attachment Issues

Foster children experience ambiguous loss as a result of the removal of significant family members from their internal family structure.

Family systems theory suggests that this ambiguous loss may leave them confused about who is in or out of their internal family system

To develop into a psychologically healthy human being, a child needs a relationship with an adult who is nurturing and protecting and who fosters trust and security

Attachment Disruptions

Placement outside of the home is typically associated with attachment disruptions in the children’s relationships

Disruptions and lack of permanence can lead to a difficulty for the child to develop the ability to form a secure attachment to a primary caregiver

The more changes in placements a child experiences, the more likely they are to exhibit oppositional behavior

These disruptions lead to an increase in the likelihood the child will develop Reactive Attachment Disorder

• Maintaining attachment relationships with parents is difficult for children in foster care

• It is common for family visits to be stressful or upsetting for the children, sometimes causing disruptions in their development

• Children may experience toileting problems, sleep disturbances, aggressive behavior, clinging, and crying prior to, during, and after the visits

Attachment Disruptions

Early Insecure Attachments

Care that meets the young Childs' needs, but is unresponsive to their attachment signals and emotional needs can lead to an insecure caregiver attachment

Early insecure attachment relationships places the child at an increased risk for emotional and interpersonal difficulties

Question

List some of the behaviors a child may display after returning from a family visit.

Interventions

Trauma-Focused CBT

Parent Child Interaction Therapy

Psychotherapy

Behavioral Intervention

Psychopharmacology

Most are more effective when a caregiver is present

TF-CBT

Essential Components:

Establishing and maintaining a therapeutic relationship with child and parent

Emotion regulation skills

Connecting thoughts, feelings, and behaviors associated with the trauma

Stress management skills

Parenting skills training

Personal safety skills training

Coping with future trauma reminders

TF-CBT

Short-term: Results expected in 12-16 weeks

Linked to improvements in PTSD, depression, anxiety, behavioral problems, and feelings of shame and mistrust

Positive effects for the children increase when the parent is involved

Family-level intervention, with caregivers receiving approximately half the active treatment time

Focuses on parenting, to equip caregivers with necessary skills to handle trauma-related and general behavior problems

TF-CBT

Designed to reduce negative emotional and behavioral responses following abuse, domestic violence, traumatic loss, and other traumatic events

Treatment based on learning and cognitive theories

Addresses distorted beliefs and attributions related to the abuse and provides a supportive environment in which children are encouraged to talk about their traumatic experience

Also helps parents who were not abusive to cope effectively with their own emotional distress and develop skills that support their children

Multisystemic Therapy

A home and community-based intervention that addresses conduct related mental health needs by intervening in all systems that impact youth

Important all systems the child is a part of work together

Family

School

Neighborhood

Built on the principle that a seriously troubled child’s behavioral problems are multidimensional and must be confronted using multiple strategies

Multisystemic Therapy

The behavior problems of a child typically stem from a combination of influences, including family factors, deviant peer groups, problems in school or the community, and individual characteristics

Counselor works closely with teachers, neighbors, extended family, peer groups, and parents

Good for antisocial behaviors or substance abusing behaviors

Goal is to develop independent skills among parents and youth to cope with family, peers, school, and neighborhood problems

Parent-Child Interaction Therapy

Family-centered treatment approach proven effective for abused and at-risk children ages 2-8 and their caregivers

Therapists coach parents while they interact with their children, teaching caregivers strategies that will promote positive behaviors in children who have disruptive or externalizing behavior problems

Addresses the negative parent-child interaction pattern that contributes to the disruptive behavior of young children

Parent-Child Interaction Therapy

Parents learn to bond with their children and develop more effective parenting styles that better meet their children’s needs

Parents learn to model and reinforce constructive ways of dealing with emotions

Children, in turn, respond to these healthier relationships and interactions

Dyadic Developmental Psychotherapy

Goal is to help the child’s relationship with their parents

Therapist has a conversation with the child about their experiences, feelings, and thoughts and explores all aspects of the child’s life; safe and traumatic; present and past

The therapist and parents’ intersubjective experience of the child helps the child get a different understanding

Therapist talks in a way that is like telling a story rather than giving a lecture

Dyadic Developmental Psychotherapy

Involves the child and parents working together with the therapist

Child gains relationship experience which helps them grow and heal emotionally

Family members develop healthy patterns of relating and communicating

Leads to less feelings of fear, shame, or need to control within the family

Question

True or False: Most therapy models proven successful with foster children involve the biological family or the foster parent.

Therapeutic Foster Care

Originally started to help children and youth in the juvenile justice system, but has grown to include foster care

Model actively includes foster parents in mental health treatment by having them provide the primary intervention in their homes.

Usually lasts 6-12 months and is often used as an alternative to residential treatment

Multidimensional Foster Care

Contrasts to regular foster care

Places children singly or with one other child in a very structured and professionally supported foster home for 6-9 months while engaging the family to which the child will return in weekly therapy and parent training

Barriers to Treatment

Multiple placements in foster homes

Leaving and re-entering the foster care system

Under reporting of mental health concerns by foster parents

Only about 25% of foster children receive mental health services

Older children are more likely than younger children to receive services

Lack of specific policies regarding mental health concerns for foster children

Fragmentation of responsibility and funding

Failure to provide foster parents with adequate information

Barriers to Treatment

Shortage of child and adolescent providers and long waits

Lack of training on issues specific to foster children to providers, foster care workers, and foster parents

Providers’ inability to recognize problem and make appropriate referral

Reliance of case workers on foster parents’ judgment of identifying mental health problems

Lack of coordination between child welfare staff and mental health providers

Barriers to Treatment

Failure of community providers to identify mental health needs

Failure of the system to conduct screening assessments

Limited collaboration between providers and biological parents

Mental health needs being overshadowed by physical medical needs, or disruptive behaviors such as substance abuse, anger, and opposition

Foster Care Alumni

Estimated 20,000 young people leave foster care each year.

Just over half earn a high school diploma

Estimated that a quarter become homeless

Overall, with the exception of PTSD recovery, alumni rates were similar to those of the general population

Foster Care Alumni

When aging out of foster care at 18, many children will find themselves with little, if any, financial, medical, or social support

Many will experience mental illness, criminality, and an inability to function productively and independently in society

Many will not know or remember their bio families and will not have close ties to their foster families

References

Bruskas, D. (2008). Children in Foster Care: A Vulnerable Population at Risk. Journal of Child and Adolescent Psychiatric Nursing, Volume 21, Number 2. pp. 70-77. Retrieved from www.alumniofcare.org/assets/files/jcap_134.pdf

Craven,P., Lee,R. (2006). Therapeutic Intervnetions for Foster Children: A Systematic Research Synthesis

Landsverk, J., Burns, B., Stambaugh, L., Reutz, J., (2006). Mental Health Care for Children and Adolescents

in Foster Care: Review of Research Literature. Retrieved from: http://www.casey.org/resources/publications/pdf/mentalhealthcarechildren.pdf

Parent-Child Interaction Therapy with At-Risk-Families. Child Welfare Information Gateway. (2013). Retrieved from: www.childwelfare.gov/pubs/f_interactbulletin?f_interactbulletin.pdf

Polihronakis, T. (2008). INFORMATION PACKET: “Mental Health Care Issues of Children and Youth in Foster Care”. Retrieved from: www.hunter.cuyn.edu

Troutman, B., Ryan, S., & Cardi, M., “The Effects of Foster Care Placement on Young Children’s Mental Health”. Retrieved from: www.healthcare.uiowa.edu

The National Child Traumatic Stress Network. (2010). Early Childhood Trauma. Retrieved from: www.nctsn.org/sites/default/files/assets/pdfs/nctsn_earlychildhoodtrauma_08-2010final.pdf

www.adopt.org

www.ddpnetwork.org

www.mstservices.com

www.youthvillages.org

References

Grayson, J. (2012). Mental Health Needs of Foster Children and Children at Risk of Removal. American Psychological Association Children, Youth, and Families Office. Retrieved from: www.apa.org/pi/families/resources/newsletter/2012/01/winter/pdf

Dorsey, S., Conover, K., Berliner, L. (2012). Trauma-Focused Cognitive Behavioral Therapy with Youth in Foster Care: The Impact of Caregiver Engagement.

Orlando, S. (2013). The Intersection of Foster Care and Mental Health. National Council on Disability. Retrieved from www.ncd.gov/newsroom/PolicyCorner/05062013

Austin, L. (2004). Mental Health Needs of Youth in Foster Care: Challenges and Strategies. The Connection. Winter 2004, Vol. 20, No. 4. Retrieved from www.lisettaustin.com/pdfs/CASA_MentalHealth.pdf