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

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

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

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

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