1. Among Foster Children Presented By: Whitney Hardcastle, LMSW
Mental Health Needs
Among Foster Children
Presented By: Whitney Hardcastle, LMSW

2. 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.

3. Factors leading to placement
Parental Substance Abuse
Child Abuse and Neglect
Homelessness
Poverty
Family factors
Behavior problems
Domestic Violence

4. 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

5. 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 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Question
Approximately what percentage of foster children have a mental illness?

16. 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

17. 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

18. 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

19. Question
List some of the reasons children enter into foster care.

20. 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

21. 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

22. Common Mental Disorders
Most Common mental health diagnoses:
Depressive Disorders
ODD
PTSD
Adjustment Disorders
Conduct Disorders

23. 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

24. 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

25. 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

26. Bipolar 1 Disorder
A condition in which a person has periods of depression and periods of being extremely happy, or being cross or irritable
Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Disorder
There has been previously at least one Manic Episode or Mixed Episode
The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
The mood symptoms in Criteria A and B are not better accounted for by another mental disorder
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

27. Bipolar Disorder
Presence (or history) of one or more Major Depressive Episodes
Presence (or history) of at least one Hypomanic Episode
There has never been a Manic Episode or a Mixed Episode
The mood symptoms in Criteria A and B are not better accounted for by another mental disorder
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
DSM-IV-TR

28. 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.

29. 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

30. 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.

31. 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).

32. 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.

33. 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.

34. 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

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

36. 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

37. 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

38. 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

39. Attachment Disruptions
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

40. 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

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

42. Interventions Trauma-Focused CBT Parent Child Interaction Therapy
Psychotherapy
Behavioral Intervention
Psychopharmacology
Most are more effective when a caregiver is present

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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 Retrieved from
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:
Parent-Child Interaction Therapy with At-Risk-Families. Child Welfare Information Gateway. (2013). Retrieved from:
Polihronakis, T. (2008). INFORMATION PACKET: “Mental Health Care Issues of Children and Youth in Foster Care”. Retrieved from:
Troutman, B., Ryan, S., & Cardi, M., “The Effects of Foster Care Placement on Young Children’s Mental Health”. Retrieved from:
The National Child Traumatic Stress Network. (2010). Early Childhood Trauma. Retrieved from:

61. 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:
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
Austin, L. (2004). Mental Health Needs of Youth in Foster Care: Challenges and Strategies. The Connection. Winter 2004, Vol. 20, No. 4. Retrieved from