Welcome to Session 4! Meeting Developmental Needs: Loss

Welcome to Session 4!

Meeting Developmental Needs:

Loss

Remember the Core Competencies of PRIDE:

1. Protecting and Nurturing Children

2. Meeting Children’s Developmental Needs and Addressing Developmental Delays

3. Supporting Relationships Between Children and Their Families

4. Connecting Children to Safe, Nurturing Relationships Intended to Last a Lifetime

5. Working as a Member of a Professional Team

Supplemental Handouts for This Session

• Copy of PRIDE Connection Exercise on Loss

The Child Health Program

• Partnership between the UMDNJ School of Nursing (Francois-Xavier Bagnoud Center) and DCF/DYFS, established in 2008

• The purpose of the Child Health Program (CHP) is to support DCF/DYFS to ensure that the medical/dental/mental health needs of children in out-of-home placement are met

• The CHP develops child-specific health care plans• The CHP adheres to recommendations of the American

Academy of Pediatrics (AAP)


“Health Care Management is the responsibility the of the child welfare agency, but it is a function that requires

medical expertise.” 1

• Numerous studies indicate that children and adolescents in foster care have multiple physical, emotional and developmental needs

• Health Care Management is provided by the CHP to overcome barriers to ensure that children & adolescents receive high-quality, comprehensive and coordinated health care

1 Fostering Health: 2nd Edition, Task Force on Health Care for Children in Foster Care, AAP, 2005

• Responsible for managing the health care needs of children in out-of-home placement through Health Care Case Management

• Ongoing interaction with DYFS staff regarding health and medical needs of children in placement

• Provide nursing summary and Individualized Health Care Plan for children


Components of Health Care Services

• The American Academy of Pediatrics indicates there are four primary components to health care services: 1. An initial health screening (pre-placement exam) within 24

hours of placement

2. A comprehensive medical and dental assessment (CHEC or CME) within 30 days of placement

3. A developmental and mental health evaluation (part of CHEC)

4. Ongoing primary care and monitoring with the child’s Medical Home

• Continuity of care for children in out-of-home placement is paramount!

• Pre-placement or re-placement physicals are completed within 24 hours of placement/re-placement

• Physicals are to be completed by CHU nurse, Urgent Care Center or Medical Home

• DYFS policy prohibits pre-placement and re-placement physicals in hospital emergency rooms unless deemed necessary by the Local Office Manager

Initial Health Screening

• Comprehensive Health Examination for Children (CHEC) includes a mental health assessment (detailed interview and evaluation)

• Comprehensive Medical Examination (CME) includes a mental health screening (just a few general questions)

• CHU Staff Assistant will coordinate and schedule – must be completed within 30 days of placement

Comprehensive Medical Exam

• If during CHEC/CME needs are identified, CHU will follow up to assure that appropriate follow-up is obtained

• Children under age 3 should have an evaluation by the Early Intervention Program (EIP)

Developmental & Mental Health Evaluation

• Medical Home refers to child’s primary care physician• Medicaid HMO must be selected• Continue with prior Medical Home when feasible

(continuity of care)• Early Periodic Screening, Diagnosis and Treatment

(EPSDT) exams at specified intervals as per Bright Futures/AAP

• Immunizations per Centers for Disease Control (CDC)• Routine dental exam and care every 6 months, starting

at age 3*.

Ongoing Primary Care and Monitoring with Medical Home

How It Works: The Child Health Unit

• Group of child health care staff (nurses and assistants), dedicated to serving DYFS children in a given area: – Ensure that children receive their immunizations, dental and

medical appointments according to the American Academy of Pediatrics and Bright FuturesTM

– Access immunizations records– Obtain medical records and medical information– Assist Resource Parents with advocating for a child’s health

care needs– Manage the health care needs of children in out of home

placement

How It Works: The Child Health Unit

• Group of child health care staff (nurses and assistants), dedicated to serving DYFS children in a given area: – Health care resources, support, and education for Resource

Families– A “bridge” to the healthcare community– Communicates with those involved in care of child, keeping

them informed of child’s health status and participating in key case conferences concerning the child

– May attend regional placement conferences, family team meetings, court hearings, etc.

The Child Health Unit

Ensuring That A Child’s Health Care Needs Are Met

• Physical Health Needs– Children receive Early and Periodic Screening Diagnostic and

Treatment (EPSDT) examinations in accordance with the periodicity schedule

– Children receive timely immunizations – Children receive appropriate follow-up care to address their

health needs (includes follow-up of the recommendations of health care providers)


Ensuring That A Child’s Health Care Needs Are Met

• Mental Health Needs– Children receive mental health assessments– Child Health Unit will work with DYFS to ensure referrals that

service are in place

• Dental Health Needs– Children 3 years and older receive semi-annual dental

examinations- unless indicated otherwise. New recommendations began screening at age 1.


Communication is KEY!• In-Person Contact:

– The Child Health Nurse will contact Resource Parents and make a home visit within 2-3 weeks of placement and visit about every 2-4 months depending on the child’s healthcare needs.

• Phone Contact:– Resource Parents are expected to contact their child health

nurse to inform them of any changes in health care status of the children in their care, doctor visits, new medications, etc.


• In the Beginning …– Ensure pre-placement and re-placement physicals for children in

placement are completed within 24 hours of initial placement or a change in placement.

– The child health nurse will complete a DYFS form that is the child’s Health Passport. This is mailed or given to the Resource Parent.

– The nurse may be calling you to discuss significant health care issues before receipt of the Health Passport.


• Ongoing care…– A child health care plan is developed by the Child Health Nurse

which will include their nursing plan and recommendations from health care providers and other community sources as well (e.g. School).

– The Health Care Plan is a living document and so it changes as the health care of your child changes. The Child Health Unit staff and Resource Parents will be communicating often.

Child Health: YOUR Responsibilities

• Maintenance of a “Medical Log” by the Resource Parent is expected and will be reviewed by the nurse at visits. The Medical Log should include all health care visits (well & sick), medications, illnesses, injuries, appetite.

• According to DYFS policy, if a child has a fever of 100.4°F, you must contact your child’s primary doctor.

• The Resource Parent must maintain a copy of the child’s immunization record.

• Psychotropic medications require DYFS approval• CPR Certification is recommended for all Resource

Parents and caregivers.


Questions?

Activity – Guided Imagery

The Removal

Definitions

• Separation is the change that occurs when there is a break up in a relationship

• Loss is the effect on people when something important is withdrawn

• Grief is the process that helps people work together through the pain of separation and loss

Challenges of Dealing with Loss

• Separation, loss and grief are painful experiences to think and talk about

• It makes us uncomfortable to be with children and adults who are sad and angry

• The grief of others can remind us of our own losses and trigger painful memories

• Our own painful experiences can either help or hinder the way we respond to other’s losses

• We often feel unsure how to help others people deal with their pain

• Dealing with painful losses can take a long time, sometimes forever

Categories and Types of Losses

• Loss of physical/mental health

• Loss of significant people

• Loss of self esteem or sense of well- being

Expected Losses

• Usually shared by all human beings• Usually a lot of support for expected losses• Usually considered “normal” and we therefore

feel normal in our need to grieve• There may be regrets, but typically no great

sense of blame or shame• Usually prepared by life for these to occur

Name Some Examples of Expected Losses

• Death of a parent or older family member• Moving to a new home, leaving friends and

community behind• Moving to a new job or retiring• Children growing up and leaving home• Loss of senses or abilities as a result of aging• Loss of certain privileges and freedoms as we

mature from children to adults

Unexpected Losses

• Usually unprepared to cope• Usually not shared equally by all humans• Sometimes there is little understanding or

support from society about the need to grieve• Often a sense of personal shame or blame• Often not regarded as “normal losses” and this

sense of being different complicates the grieving process

Name Some Examples of Unexpected Losses

• Loss of a child• Sudden loss of a job• Financial losses• Serious Illness or injury• Car accidents, fire, natural disasters• Infertility• Theft of property• Divorce

Why Do We Need To Know These Categories?

• Important to understand that the majority of significant experiences in life can involve a loss of some kind

• Some losses are not as apparent as others• The most frequent loss people suffer is loss of

self-esteem• All people who experience loss respond to it with

feelings and behaviors

Name Some Losses that Birth Families May Encounter When Children Enter Foster Care

• Loss of the child/children• Loss of home (housing assistance may be

discontinued when there are no children)• Loss of health (drug addiction, HIV, depression)• Loss of spouse/significant other• Loss of self-esteem (society looks down on

offenders of child abuse and neglect)• Loss of control/self direction (must negotiate the

return of their children with DYFS/Courts)

Name Some Losses that Resource Families May Encounter

• Loss of family stability• Loss to own children in assuming role of resource family (having to

share time with other children)• Loss of self-esteem (children who do not respond or are difficult to

manage)• Possible loss of status in the community (perception of anything

having to do with DYFS is negative)• Loss of important people (other team members when a child returns

home)• Loss to own children and extended family when a child returns

home• Loss of autonomy in parenting (need “permission” from DYFS)• Loss of privacy• Loss of health (exposure to children being placed, mental stress)

Name Some Losses that Adoptive Families May Encounter

• Loss of the family experience as they “expected” it to be if they were unable to have their own (birth) children

• Loss of exclusive parenting role in children’s lives (children are likely to be curious about their birth family)

• Loss of control in their family development (need to work with other team members to identify a child that is “right” for them)

Pathway Through the Grieving Process

• Resource families need to understand how people grieve their losses

• Grief is a healthy process that we must go through to heal the painful feelings of loss

• The “Pathway Through the Grieving Process” is described on PRIDEBook Page 136.

• The entry point into this process can be any significant loss (health, significant person or self-esteem)

Pathway Through the Grieving ProcessLoss

Health Self-Esteem SignificantPersons

Shock/Denial/Protest

Bargaining

Anger

Acting Out Depression(Outward Anger) (Inward Anger)

Understanding

Coping

Managing Loss

This pathway illustrates responses to grief, not

necessarily stages of grief.

These responses may not occur in orderly

progression, as illustrated.

Many people may go back and forth from one

response to another …

… or they may exhibit several of these

responses at once.

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Shock Denial and Protest

• We try to stop the loss from occurring or deny that the loss has occurred.

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?

• Flat emotions, no evidence of being upset• Denial that they have been removed by

showing no reaction to the separation• Continually asking to go home• Refusal to eat, sleeping problems, being

susceptible to injuries or developing illnesses (real or imagined)

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?

• Denying that there is anything is wrong in their family

• Living in a fantasy world that their parents will show up any minute to reclaim them

• Eager to please and show compliant behaviors, pretending that nothing really bad or scary has happened

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

How to Handle Shock/Denial Responses

• Recognize that the absence of outward expression of feelings doesn’t mean that there is no feeling

• Provide information to the child about the situation in a reassuring and age-appropriate or developmentally-appropriate manner

• Ensure a comfortable and comforting environment

• Reassure the child that he or she is safe• Provide close supervision to prevent injuries and

to ensure child’s physical needs are being met

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Bargaining

• Feeling that there must be some type of atonement where they may make a deal and the situation will go away.

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

What Behaviors Might Be Expected of Children Responding to Grief by Bargaining?

• Child may have conversations with self• Use of inappropriate behaviors as a way of

getting “kicked out” or sent to where the child wants to be

• May try to be “perfect” as way of making the situation “perfect”

• May have feelings of guilt and self blame

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

How to Handle Bargaining Responses

• Provide opportunities to talk and express feelings

• Give permission to express sad, guilty, angry and blaming feelings

• Help them understand returning home depends primarily on family’s behavior, not theirs

• Provide consistent and supportive reminders that they are safe

• Give factual and nonjudgmental information about what happened and the reason for it

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Anger

• Shows itself in two different ways:

Acting Out - “Outward Anger”

Depression - “Inward Anger”

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Acting Out

• Expressing angry, hostile behaviors• Realization that the loss has occurred and it

cannot be undone• Children may find it easier to express these

feelings toward resource families rather than toward their birth families

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

How to Handle Acting Out Responses

• Give permission to feel angry, while giving them ways to express this in a healthy and non harmful manner

• Give them daily, consistent and structured support in managing their angry feelings

• Connect them to counseling or therapy• Teach good behavior management strategies • Openly support child’s relationship with birth

families and siblings

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Depression

• Can be less visible to resource families, teachers and social workers

• Equally important to manage these feelings

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

How to Identify Depression Responses• May have excessive fear• Lack of interest or ability to engage in the normally expected

activities• Clingy behaviors• Lack of feelings in response to happy or sad experiences• Anxious behaviors• Withdrawn from peers or adults• Suicidal gestures or ideation• Substance abuse and sexual promiscuity• Poor school performance• Poor hygiene and physical appearance

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

How to Handle Depression Responses• Reassurance that the child is valuable, important and lovable• Permission for the child to feel sad and reassurance that over

time things will feel better• Time to be left alone without expectations of joining the family

life• Encouragement for even small accomplishments • Close structured supervision• Comfort, reassurance of safety and sense of hopefulness• Availability and nurturing child without pushing child to talk• Opportunity for the child to cling, while providing reassurance

for independent actions• Collaboration with mental health professionals• Collaboration with substance abuse professionals

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Understanding

• Children are beginning to let go of their powerful feelings of grief and begin to understand in a more realistic way what has happened to them and why it happened

• They begin to express why they felt ashamed, guilty, mad, sad or glad

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

Coping• This is moving beyond understanding, allowing more

energy to accomplish the tasks of life and providing a sense of hope for the future

• May begin to demonstrate new behaviors and feel a sense of having changed or grown

Loss



Bargaining

Anger


Understanding

Coping

Managing Loss

What is a Loss Manager

• When one is successful in completing the pathway through the grieving process, they are able to offer their awareness and skills to help others grieve

• Children need Loss Managers to help them on the pathway through the grieving process

Factors that Influence How Loss is Experienced

• Nature of the Loss• Age at the time of the Loss• Degree of Attachment• Ability to Understand Why• Amount of Emotional Strength• Cultural Influences• Circumstances Causing the Loss• Number of Previous Separations and Losses• Help given Prior to, During, and After the Loss

Why is it important for resource families to understand their own experiences with loss?

• If you are overwhelmed with your own losses, it will be difficult to help children manage their losses

• Thinking about how we have been helped to grieve may help us help others with their grieving

• Cultural influences and “rules” about grieving may lead us to expect others to grieve in the same way we grieve

• Seeing how we have been able to manage losses in our past may give us confidence in helping someone else

• Children experiencing losses may “trigger” sad memories and feelings related to losses in our own past

Losses Specific to Adopted Children

• Finality of the separation from their birth family• Loss of their foster family• Loss of friends, neighbors, teachers, coaches

and others they knew • Loss of the hope that they might return to their

birth family

Grieving is an Ongoing Process!

• Children may proceed through the grieving process and come to an understanding of their loss and develop healthy ways to cope

• During adolescence or adulthood, they may need to grieve the loss again, this time, with greater cognitive and emotional capabilities

Using a Loss History Chart

• PRIDEBook Page 137 shows a template for a Loss History Chart

• Helpful tool to help foster/adoptive parents understand losses a child has experienced

• You will complete your own Loss History Charts as “homework”

Loss History Chart• Overview of child’s history• Information to help understand how well they have grieved old

losses• Information on what early developmental stages may have been

affected by the losses• Information to prepare us for what we might expect the child to

experience with current losses• Information about past behaviors that may help with handling

current behaviors and predict future behaviors• Better understanding of emotional age and problems with

attachment• Assess if past losses may have prevented child from achieving

expected physical, intellectual, social, emotional and moral development

• Assists us in planning for the child

The Importance of Teamwork

• Resource families need to work with other members of the professional team to help children manage their losses

• Managing loss is an ongoing process as the feelings of old losses are triggered by life experiences

CLOSURE

• Review Key Points, PRIDEBook Pages 141-147• Review You Need to Know!, PRIDEBook Pages 148-151• Read A Birth Parent’s Perspective, PRIDEBook p. 152• Complete the PRIDE Connection exercise on

PRIDEBook Pages 153-154 (copy in packet)• Read Making A Difference!, PRIDEBook Page 155-156

• Session 5: Strengthening Family Relationships

Group Exercise: “Nathan”

• Remember Nathan from the “Making a Difference” video

• PRIDEBook Page 122 contains a vignette that provides more detail about Nathan

• Consider the losses Nathan has experienced, how the team can help him, and what supports he may need


• What losses has Nathan had to grieve? Of these losses, which will he need to continue to grieve and why?– His mother (killed in a random shooting)– His father (alcoholism led to placement)– Extended family– School (quit school to care for his father)– Childhood (had to care for his father)– Self-esteem


• How might the team help Nathan now with his past and present losses?– Give him time to grieve and heal– Nurturing, structure and consistency at home– Gentle encouragement– Acknowledgement of successes and efforts– Help him to understand the nature of

alcoholism and its impact on the family– Refer him to counseling


• What supports may Nathan continue to need in the future?– Continued contact with the resource family– Counseling for Nathan to deal with

separation, his father to continue his sobriety, and for the family to help them heal

– Guidance for Nathan when he graduates high school (college, training, life skills)

Activity

• Picture a loved one in your mind• Think about how important this person is to you

and how they impact your life• Write down this person’s name on a piece of

paper and concentrate on how important they are to you

• Fold the paper in half and set it in front of you, keeping your eyes closed and focusing on this person

• Now … Open your eyes

What Kevin’s Loss History Teaches Us

• Being a Loss Manager for Kevin will be a challenging job

• Seeing how Kevin’s behaviors changed over time and after many losses may help us predict future behaviors (running away, continued inappropriate behavior)

• May help Kevin’s foster family not to take his reactions personally

• Can help the foster family set realistic expectations for Kevin

Documents

Welcome to Session 4! Meeting Developmental Needs: Loss