Needs of Children in Foster Care

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Mildred Arlene Garrett
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1 Needs of Children in Foster Care Meeting the Complex Needs of Children in Foster Care Karen Rogers PhD, Suzanne Roberts MD, Jennifer Rafeedie PsyD, Cristina Dawes LMFT Karen Rogers PhD, Suzanne Roberts MD, Jennifer Rafeedie PsyD, Cristina Dawes LMFT

Jennifer Rafeedie PsyD, Cristina Dawes LMFT Karen Rogers PhD,

2 No Financial Relationships The presenters have No Financial Relationships associated with this presentation. 2

3 Objectives Participants will become familiar with: The special needs of children in foster care. The value of trauma-informed care. Strategies to engage caregivers, collaborate with the courts and child protective services, and link children to needed services. 3

4 Foster Care Children: A Special Needs Population Maternal and Child Health Bureau Definition of Children with Special Health Care Needs: Those with increased risk for a chronic physical, developmental, behavioral condition and who require health and related services beyond that required for children generally.. 4

increased risk for a chronic physical, developmental, behavioral condition and

5 Foster Care Children: A Special Needs Population Prevalence Chronic medical conditions % Mental health problems - 80% Developmental problems - 60% Educational problems - 45% 5

conditions - 35-80% Mental health problems -

6 Foster Care Children and Mental Health Mental health is the most significant health concern for children in foster care. Jee and Szilagyi. Comprehensive Health Care for Children in Foster Care, Up To Date,

7 Impact of Trauma on Developing Child Exposed to Abuse, Neglect, Violence: Concept of TOXIC STRESS ACE study 1998, Fellitti et al. Relationship of Childhood Abuse and Household Dysfunction on Leading Causes of Death in Adults, AmJPrevMed, 14 (4), 245. AAP 2008, Stirling et al. Understanding the Behavioral and Emotional Consequences of Child Abuse, PEDIATRICS, 122 (3), 667. AAP Technical Report 2011, Policy Statement 2012, Garner and Shonkoff, Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health, PEDIATRICS, 129,e224. 7

Understanding the Behavioral and Emotional Consequences of Child Abuse, PEDIATRICS, 122 (3), 667.

8 Lack of training Challenges for Physicians Lack of comfort Lack of interest in dealing with issues perceived to be related to mental health Lack of resources Lack of reimbursement for extra time 8

9 The Foster Care Hub at CHLA Katie A. vs. Bonta: a settlement with Los Angeles County Katie A vs. Bonta a class action lawsuit filed in 2002 by the Western Center on Law and Poverty and other public interest organizations on behalf of a group of foster care children for unlawfully denying them intensive mental health services, behavioral support, and case management. CHLA Hub Team Began in 2006 It is a collaboration between DCFS and Department of Mental Health. Interprofessional/interdisciplinary collaboration to screen and evaluate medical and mental health status and needs. 9

of foster care children for unlawfully denying them intensive mental health services, behavioral support, and case management.

10 The Foster Care Hub at CHLA The Evaluation Process A review of records An interview A mental status exam A physical exam A report to DCFS Linkage 10

11 Barriers 11

12 Systemic Issues Why Do the Needs of Foster Care Children Go Unmet? Inter- and Intra-agency Issues Goals, mandates, and processes differ it helps to understand the goals, mandates, and processes of collaborators Common to all providers Work overload impacting timeliness, responsiveness Bureaucracy - the hoops that slow down the system Court dates, legal Ethical and Legal Considerations Consents who can consent to the treatment needs of the child? To whom can you provide information? Status of Case Urgency 12

of collaborators Common to all providers Work overload impacting timeliness, responsiveness Bureaucracy - the hoops that slow

13 Why Do the Needs of Foster Care Children Go Unmet? Family Caregiver Issues Resistance guarded or angry attitude Denial minimization Logistics Geography Time Communication Issues Countertransference Avoidance Adversarial Approach empathy problem, defensiveness 13

Denial minimization Logistics Geography Time Communication Issues

14 Why Do the Needs of Foster Care Children Go Unmet? Confusion About the Mental Health Diagnosis Contributes to the Problem Traumatized children are often misdiagnosed as having ADHD, Bipolar Disorder, or Oppositional Defiant Disorder when in fact their symptoms of hyperactivity, impulsivity, emotional dysregulation, and defiance are explainable by the impact of the trauma. A diagnosis of Posttraumatic Stress Disorder may be more appropriate and lead to more appropriate treatment. Dual diagnosis is also possible, but impact of trauma should be given emphasis in the diagnosis and treatment planning process. 14

Oppositional Defiant Disorder when in fact their symptoms of hyperactivity, impulsivity, emotional dysregulation, and defiance are explainable by the

15 Mental Health Treatment for Traumatized/Chronically Stressed Children Mental Health Treatment for Traumatized/Chronically Stressed Children. With effective treatment, a child exposed to traumas can recover. Hoping the child will forget what happened if no one talks about it is NOT an effective treatment. It is necessary to address the trauma to clean out the wound and enable healing. 15

With effective treatment, a child exposed to traumas can recover.

16 Common Components of Effective Treatments Psycho-education about trauma, abuse, and children and families' traumatic stress reactions and experiences Parenting skills and behavior management Enhancing the child s (and caregivers ) emotional regulation and anxiety management skills Exposure to the traumatic memories in a safe, developmentally appropriate context Addressing grief and loss Promoting adaptive developmental progression Promoting safety skills Relapse prevention *from National Child Traumatic Stress Network 16

anxiety management skills Exposure to the traumatic memories in a safe, developmentally appropriate context Addressing grief and

17 A Partial List of Evidence-Based Trauma Treatments for Children Child Parent Psychotherapy (0-6) Trauma Focused Cognitive Behavior Therapy (4-adult) Parent Child Interaction Therapy (2-8) Cognitive Behavioral Intervention for Trauma in Schools (10-15) Structured Psychotherapy for Adolescents Responding to Chronic Stress (12-19) Adolescent Dialectical Behavior Therapy (12-19) Seeking Safety (older adolescent-adult) 17

Intervention for Trauma in Schools (10-15) Structured Psychotherapy for Adolescents Responding to

18 Case Examples Andy - 7 years 5 months, prenatal exposure to drugs, severe behavioral and academic challenges with a history of seizures, placed with a non-relative foster family. Nate - 4 years 4 months, alleged physical abuse and neglect, aggression towards peers and adults, severe medical problem with skin and mild asthma, placed with a foster/adoptive family. Annie - 1 year 10 months, severe neglect with suspected prenatal exposure to drugs, global developmental and speech delays with low birth weight, placed with biological mother s foster family. 18

Nate - 4 years 4 months, alleged physical abuse and neglect, aggression towards peers and adults, severe medical problem with skin and mild

19 Questions 19

2) Recurrent emotional abuse. 3) Contact sexual abuse. 4) An alcohol and/or drug abuser in the household. 5) An incarcerated household member

2) Recurrent emotional abuse. 3) Contact sexual abuse. 4) An alcohol and/or drug abuser in the household. 5) An incarcerated household member Co Occurring Disorders and the on Children: Effectively Working with Families Affected by Substance Abuse and Mental Illness Definition (Co-Occurring also called Dual Dx) A professional diagnosis of addictive/substance