Presentation on theme: "Meeting Developmental Needs: Loss"— Presentation transcript:
1Meeting Developmental Needs: Loss Welcome to Session 4!Meeting Developmental Needs:Loss
2Remember the Core Competencies of PRIDE: Protecting and Nurturing ChildrenMeeting Children’s Developmental Needs and Addressing Developmental DelaysSupporting Relationships Between Children and Their FamiliesConnecting Children to Safe, Nurturing Relationships Intended to Last a LifetimeWorking as a Member of a Professional Team
3Supplemental Handouts for This Session Copy of PRIDE Connection Exercise on Loss
4The Child Health Program Partnership between the UMDNJ School of Nursing (Francois-Xavier Bagnoud Center) and DCF/DYFS, established in 2008The 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 metThe CHP develops child-specific health care plansThe CHP adheres to recommendations of the American Academy of Pediatrics (AAP)
5The Child Health Program “Health Care Management is the responsibility the of the child welfare agency, but it is a function that requires medical expertise.” 1Numerous studies indicate that children and adolescents in foster care have multiple physical, emotional and developmental needsHealth Care Management is provided by the CHP to overcome barriers to ensure that children & adolescents receive high-quality, comprehensive and coordinated health care1 Fostering Health: 2nd Edition, Task Force on Health Care for Children in Foster Care, AAP, 2005
6The Child Health Program Responsible for managing the health care needs of children in out-of-home placement through Health Care Case ManagementOngoing interaction with DYFS staff regarding health and medical needs of children in placementProvide nursing summary and Individualized Health Care Plan for children
7Components of Health Care Services The American Academy of Pediatrics indicates there are four primary components to health care services:An initial health screening (pre-placement exam) within 24 hours of placementA comprehensive medical and dental assessment (CHEC or CME) within 30 days of placementA developmental and mental health evaluation (part of CHEC)Ongoing primary care and monitoring with the child’s Medical HomeContinuity of care for children in out-of-home placement is paramount!
8Initial Health Screening Pre-placement or re-placement physicals are completed within 24 hours of placement/re-placementPhysicals are to be completed by CHU nurse, Urgent Care Center or Medical HomeDYFS policy prohibits pre-placement and re-placement physicals in hospital emergency rooms unless deemed necessary by the Local Office Manager
9Comprehensive Medical Exam 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
10Developmental & Mental Health Evaluation If during CHEC/CME needs are identified, CHU will follow up to assure that appropriate follow-up is obtainedChildren under age 3 should have an evaluation by the Early Intervention Program (EIP)
11Ongoing Primary Care and Monitoring with Medical Home Medical Home refers to child’s primary care physicianMedicaid HMO must be selectedContinue with prior Medical Home when feasible (continuity of care)Early Periodic Screening, Diagnosis and Treatment (EPSDT) exams at specified intervals as per Bright Futures/AAPImmunizations per Centers for Disease Control (CDC)Routine dental exam and care every 6 months, starting at age 3*.
12How 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 FuturesTMAccess immunizations recordsObtain medical records and medical informationAssist Resource Parents with advocating for a child’s health care needsManage the health care needs of children in out of home placement
13How 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 FamiliesA “bridge” to the healthcare communityCommunicates with those involved in care of child, keeping them informed of child’s health status and participating in key case conferences concerning the childMay attend regional placement conferences, family team meetings, court hearings, etc.
14Ensuring That A Child’s Health Care Needs Are Met The Child Health UnitEnsuring That A Child’s Health Care Needs Are MetPhysical Health NeedsChildren receive Early and Periodic Screening Diagnostic and Treatment (EPSDT) examinations in accordance with the periodicity scheduleChildren receive timely immunizationsChildren receive appropriate follow-up care to address their health needs (includes follow-up of the recommendations of health care providers)
15Ensuring That A Child’s Health Care Needs Are Met The Child Health UnitEnsuring That A Child’s Health Care Needs Are MetMental Health NeedsChildren receive mental health assessmentsChild Health Unit will work with DYFS to ensure referrals that service are in placeDental Health NeedsChildren 3 years and older receive semi-annual dental examinations- unless indicated otherwise. New recommendations began screening at age 1.
16The Child Health Unit 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.
17The Child Health Unit 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.
18The Child Health Unit 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.
19Child 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 approvalCPR Certification is recommended for all Resource Parents and caregivers.
22DefinitionsSeparation is the change that occurs when there is a break up in a relationshipLoss is the effect on people when something important is withdrawnGrief is the process that helps people work together through the pain of separation and loss
23Challenges of Dealing with Loss Separation, loss and grief are painful experiences to think and talk aboutIt makes us uncomfortable to be with children and adults who are sad and angryThe grief of others can remind us of our own losses and trigger painful memoriesOur own painful experiences can either help or hinder the way we respond to other’s lossesWe often feel unsure how to help others people deal with their painDealing with painful losses can take a long time, sometimes forever
24Categories and Types of Losses Loss of physical/mental healthLoss of significant peopleLoss of self esteem or sense of well- being
25Expected LossesUsually shared by all human beingsUsually a lot of support for expected lossesUsually considered “normal” and we therefore feel normal in our need to grieveThere may be regrets, but typically no great sense of blame or shameUsually prepared by life for these to occur
26Name Some Examples of Expected Losses Death of a parent or older family memberMoving to a new home, leaving friends and community behindMoving to a new job or retiringChildren growing up and leaving homeLoss of senses or abilities as a result of agingLoss of certain privileges and freedoms as we mature from children to adults
27Unexpected LossesUsually unprepared to copeUsually not shared equally by all humansSometimes there is little understanding or support from society about the need to grieveOften a sense of personal shame or blameOften not regarded as “normal losses” and this sense of being different complicates the grieving process
28Name Some Examples of Unexpected Losses Loss of a childSudden loss of a jobFinancial lossesSerious Illness or injuryCar accidents, fire, natural disastersInfertilityTheft of propertyDivorce
29Why Do We Need To Know These Categories? Important to understand that the majority of significant experiences in life can involve a loss of some kindSome losses are not as apparent as othersThe most frequent loss people suffer is loss of self-esteemAll people who experience loss respond to it with feelings and behaviors
30Name Some Losses that Birth Families May Encounter When Children Enter Foster Care Loss of the child/childrenLoss of home (housing assistance may be discontinued when there are no children)Loss of health (drug addiction, HIV, depression)Loss of spouse/significant otherLoss 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)
31Name Some Losses that Resource Families May Encounter Loss of family stabilityLoss 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 homeLoss of autonomy in parenting (need “permission” from DYFS)Loss of privacyLoss of health (exposure to children being placed, mental stress)
32Name 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) childrenLoss 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)
33Pathway Through the Grieving Process Resource families need to understand how people grieve their lossesGrief is a healthy process that we must go through to heal the painful feelings of lossThe “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)
34Pathway Through the Grieving Process LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossThis 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.
35Shock Denial and Protest LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossWe try to stop the loss from occurring or deny that the loss has occurred.
36Flat emotions, no evidence of being upset What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossFlat emotions, no evidence of being upsetDenial that they have been removed by showing no reaction to the separationContinually asking to go homeRefusal to eat, sleeping problems, being susceptible to injuries or developing illnesses (real or imagined)
37Denying that there is anything is wrong in their family What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossDenying that there is anything is wrong in their familyLiving in a fantasy world that their parents will show up any minute to reclaim themEager to please and show compliant behaviors, pretending that nothing really bad or scary has happened
38How to Handle Shock/Denial Responses LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossRecognize that the absence of outward expression of feelings doesn’t mean that there is no feelingProvide information to the child about the situation in a reassuring and age-appropriate or developmentally-appropriate mannerEnsure a comfortable and comforting environmentReassure the child that he or she is safeProvide close supervision to prevent injuries and to ensure child’s physical needs are being met
39BargainingLossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossFeeling that there must be some type of atonement where they may make a deal and the situation will go away.
40Child may have conversations with self What Behaviors Might Be Expected of Children Responding to Grief by Bargaining?LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossChild may have conversations with selfUse of inappropriate behaviors as a way of getting “kicked out” or sent to where the child wants to beMay try to be “perfect” as way of making the situation “perfect”May have feelings of guilt and self blame
41How to Handle Bargaining Responses LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossProvide opportunities to talk and express feelingsGive permission to express sad, guilty, angry and blaming feelingsHelp them understand returning home depends primarily on family’s behavior, not theirsProvide consistent and supportive reminders that they are safeGive factual and nonjudgmental information about what happened and the reason for it
42Anger Shows itself in two different ways: Acting Out - “Outward Anger” LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossShows itself in two different ways:Acting Out - “Outward Anger”Depression - “Inward Anger”
43Acting Out Expressing angry, hostile behaviors LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossExpressing angry, hostile behaviorsRealization that the loss has occurred and it cannot be undoneChildren may find it easier to express these feelings toward resource families rather than toward their birth families
44How to Handle Acting Out Responses LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossGive permission to feel angry, while giving them ways to express this in a healthy and non harmful mannerGive them daily, consistent and structured support in managing their angry feelingsConnect them to counseling or therapyTeach good behavior management strategiesOpenly support child’s relationship with birth families and siblings
45DepressionLossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossCan be less visible to resource families, teachers and social workersEqually important to manage these feelings
46How to Identify Depression Responses LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossMay have excessive fearLack of interest or ability to engage in the normally expected activitiesClingy behaviorsLack of feelings in response to happy or sad experiencesAnxious behaviorsWithdrawn from peers or adultsSuicidal gestures or ideationSubstance abuse and sexual promiscuityPoor school performancePoor hygiene and physical appearance
47How to Handle Depression Responses LossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossReassurance that the child is valuable, important and lovablePermission for the child to feel sad and reassurance that over time things will feel betterTime to be left alone without expectations of joining the family lifeEncouragement for even small accomplishmentsClose structured supervisionComfort, reassurance of safety and sense of hopefulnessAvailability and nurturing child without pushing child to talkOpportunity for the child to cling, while providing reassurance for independent actionsCollaboration with mental health professionalsCollaboration with substance abuse professionals
48UnderstandingLossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossChildren 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 happenedThey begin to express why they felt ashamed, guilty, mad, sad or glad
49CopingLossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossThis is moving beyond understanding, allowing more energy to accomplish the tasks of life and providing a sense of hope for the futureMay begin to demonstrate new behaviors and feel a sense of having changed or grown
50What is a Loss ManagerLossHealth Self-Esteem SignificantPersonsShock/Denial/ProtestBargainingAngerActing Out Depression(Outward Anger) (Inward Anger)UnderstandingCopingManaging LossWhen one is successful in completing the pathway through the grieving process, they are able to offer their awareness and skills to help others grieveChildren need Loss Managers to help them on the pathway through the grieving process
51Factors that Influence How Loss is Experienced Nature of the LossAge at the time of the LossDegree of AttachmentAbility to Understand WhyAmount of Emotional StrengthCultural InfluencesCircumstances Causing the LossNumber of Previous Separations and LossesHelp given Prior to, During, and After the Loss
52Why 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 lossesThinking about how we have been helped to grieve may help us help others with their grievingCultural influences and “rules” about grieving may lead us to expect others to grieve in the same way we grieveSeeing how we have been able to manage losses in our past may give us confidence in helping someone elseChildren experiencing losses may “trigger” sad memories and feelings related to losses in our own past
53Losses Specific to Adopted Children Finality of the separation from their birth familyLoss of their foster familyLoss of friends, neighbors, teachers, coaches and others they knewLoss of the hope that they might return to their birth family
54Grieving is an Ongoing Process! Children may proceed through the grieving process and come to an understanding of their loss and develop healthy ways to copeDuring adolescence or adulthood, they may need to grieve the loss again, this time, with greater cognitive and emotional capabilities
55Using a Loss History Chart PRIDEBook Page 137 shows a template for a Loss History ChartHelpful tool to help foster/adoptive parents understand losses a child has experiencedYou will complete your own Loss History Charts as “homework”
56Loss History Chart Overview of child’s history Information to help understand how well they have grieved old lossesInformation on what early developmental stages may have been affected by the lossesInformation to prepare us for what we might expect the child to experience with current lossesInformation about past behaviors that may help with handling current behaviors and predict future behaviorsBetter understanding of emotional age and problems with attachmentAssess if past losses may have prevented child from achieving expected physical, intellectual, social, emotional and moral developmentAssists us in planning for the child
57The Importance of Teamwork Resource families need to work with other members of the professional team to help children manage their lossesManaging loss is an ongoing process as the feelings of old losses are triggered by life experiences
58CLOSURE Review Key Points, PRIDEBook Pages 141-147 Review You Need to Know!, PRIDEBook PagesRead A Birth Parent’s Perspective, PRIDEBook p. 152Complete the PRIDE Connection exercise on PRIDEBook Pages (copy in packet)Read Making A Difference!, PRIDEBook PageSession 5: Strengthening Family Relationships
59Group Exercise: “Nathan” Remember Nathan from the “Making a Difference” videoPRIDEBook Page 122 contains a vignette that provides more detail about NathanConsider the losses Nathan has experienced, how the team can help him, and what supports he may need
60Group Exercise: “Nathan” 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 familySchool (quit school to care for his father)Childhood (had to care for his father)Self-esteem
61Group Exercise: “Nathan” How might the team help Nathan now with his past and present losses?Give him time to grieve and healNurturing, structure and consistency at homeGentle encouragementAcknowledgement of successes and effortsHelp him to understand the nature of alcoholism and its impact on the familyRefer him to counseling
62Group Exercise: “Nathan” What supports may Nathan continue to need in the future?Continued contact with the resource familyCounseling for Nathan to deal with separation, his father to continue his sobriety, and for the family to help them healGuidance for Nathan when he graduates high school (college, training, life skills)
63ActivityPicture a loved one in your mindThink about how important this person is to you and how they impact your lifeWrite down this person’s name on a piece of paper and concentrate on how important they are to youFold the paper in half and set it in front of you, keeping your eyes closed and focusing on this personNow … Open your eyes
64What Kevin’s Loss History Teaches Us Being a Loss Manager for Kevin will be a challenging jobSeeing 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 personallyCan help the foster family set realistic expectations for Kevin