Identifying and Meeting the Mental Health Needs of Children Entering Foster Care

1
Identifying and Meeting the Mental Health Needs
of Children Entering Foster Care

• Ron Saletsky, Ph.D.
• Associate Professor
• Upstate Medical University
• Psychologist, ENHANCE

2
A Childs Experience in Foster Care

• Video by Michael Trout, Director
• The Infant-Parent Institute
• Champaign, Ill
• Used with permission.

3
Dynamics of Foster care - Child - 1

• Life Out of Balance
• Separation/Loss, incomplete grief reactions
• Move from the familiar to the unfamiliar
• Effects of pre-placement environment
• Self-blame for placement
• Questions about foster parent motivations

4
Dynamics of Foster Care Child - 2

• Child has little to no influence on major players
  and decisions made about his/her life e.g., where
  and with whom placed, frequency and intensity of
  visitation with birth family, caseworker, law
  guardian, judge, etc.
• Cumulative effects of each placement failure
  that can ultimately lead to a self perception
  that Im bad and not able to be cared for or
  loved
• Two or more tiers of value in foster home
  birth children, pre-adoptive track, long-term
  foster children

5
Dynamics of Foster Care Child - 3

• Common defenses against anxiety engendered by
  placement
• -displacement
• -identification with the aggressor
• -projection
• -regression

6
Dynamics of Foster Care Birth Parent - 1

• Strengths
• Psychopathology
• Relationship history
• Success as a parent
• Anger at the system for breaking up the family
• Compromised ability to trust

7
Dynamics of Foster Care Birth Parent - 2

• Identifies with victim role and perceives child
  as victim of the system, including the foster
  family
• Perceives self as having very little power or
  influence on child, as such may attempt to
  sabotage placement
• Threatened by foster parents position in childs
  life, e.g., child will forget who real mom is
• Threatened by opportunities afforded the child by
  foster family
• Fantasies about foster parent

8
Dynamics of Foster Care Foster Parent - 1

• Motivation (foster care as a way to parent a
  child at a juncture in their life or as a way to
  adopt children)
• Parenting history both their own and fostering
• Fantasies about birth parent
• Partnering with birth parent
• Adequate support from the system
• Integrating the child into an established family

9
Dynamics of Foster Care Foster Parent - 2

• Number of high-needs children in the home
• Empathy toward birth parent
• Empathy toward child deep understanding that
  child is part of another family that is important
  
• Acceptance of birth family
• Seeing each child as unique
• Care for the child, but dont get too attached
• Pacing of expectations
• Burn- out and respite

10
ENHANCE - 1

• Excellence iN Health cAre for Abused and
  Neglected ChildrEn
• Since 11/91, multidisciplinary primary care
  clinic providing pediatric services to children
  in foster care in Onondaga County
• Joint venture of SUNY Upstate Depts. of
  Pediatrics and Child Psychiatry and Onondaga
  County DSS

11
ENHANCE - 2

• Howard Weinberger, MD
• Martin Irwin, MD
• Diane Erne

12
ENHANCE - 3

• Steven Blatt, MD, Director
• Victoria Meguid, MD
• Ron Saletsky, PhD
• Terri Morse, PNP, Karen Dygert, PNP
• Toni Heer, RN, Laurie Rupracht, RN
• Fran Stasik, DSS Senior Caseworker Liason
• Jane Richards, Marcia Dattler - assistants

13
ENHANCE 4

• 3 half-day clinics/week Monday preview
• Acute medical visits throughout the week
• MDs always on call
• Clinic Visits
• Initial
• Comprehensive
• Well-Child
• Follow-ups
• Acute and Discharge

14
ENHANCE - 5

• Initial Visit within 1 week of placement
• Focus
• physical exam, blood work
• If there are acute behavioral/emotional concerns,
  meet with psychologist

15
ENHANCE - 6

• Comprehensive Visit 1 month after Initial visit
• Focus
• physical exam, vision/hearing screening,
  HIV-testing if risk factors identified
• Developmental screening for kids lt 5
• Mental Health eval for kids gt 2.5

16
ENAHNCE - 7

• Well-Child Visits per AAP recs, but no less
  than every 6 months
• Focus
• medical per AAP
• comprehensive developmental testing
• Check-in with psychologist

17
ENHANCE - 8

• Follow-up Visits, Acute Visits as needed
• Focus
• Acute care/ follow-up of illness
• Emotional/behavioral follow-up
• Foster parent support/counseling

18
Mental Health Assessment - 1

• At Comprehensive appointment, child, foster
  parent, caseworker birth parent are invited
• to attend
• Challenges set the stage for collaborative,
  trusting working relationships define myself as
  separate from DSS often have little historical
  info about childs functioning
• Goal assess level of risk and need for ongoing
  mental health treatment
• How developmentally appropriate interviews of
  those present, standardized behavior checklists
  as appropriate

19
Mental Health Assessment 2

• Content
• Initial transition to care home, school, peers
  response to separation from the familiar
  anticipation of visits with birth family
  response to visits with birth family recovery
  time sleeping/eating patterns response to new
  routines and culture of foster home

20
Mental Health Assessment - 3

• Content cont.
• Major affects and their expression stability of
  mood coping style mental status exam of child
  play observation goodness-of-fit between child
  and foster parent psychological mindedness of
  foster parent caseworker-foster parent
  relationship foster parent-birth parent
  relationship

21
Mental Health Assessment - 4

• Content cont.
• Reality check with caseworker clarify reasons
  for placement potential time in foster care
  history of birth family difficulties caseworker
  perspective on how the placement is going
  name/involvement of law guardian history of
  services, level of intensity, names of
  agencies/providers already involved

22
Mental Health Assessment - 5

• Formulation strengths based
  deficits/pathology
• Feedback to foster parent, caseworker, birth
  parent
• Psycho-education regarding dynamics of foster
  care, normalizing of childs reactions, acquaint
  foster parent and caseworker with childs
  defenses
• reassurance, support of foster parents efforts
• Assess foster parent response to feedback do
  they get it?

23
Mental Health Assessment - 6

• Verbal feedback to ENHANCE team about child
• Written general feedback to DSS about appointment
  
• Feedback to mental health professionals involved
  with child

24
Mental Health Assessment - 7

• Referrals for ongoing treatment
• Significant suicidal ideation/intent or
  self-hurting behavior not responsive to
  limit-setting
• Significant sexual acting out not responsive to
  limit setting
• Sexually aggressive behavior
• Significant violent behavior toward other kids or
  toward animals
• Psychotic thought

25
Ongoing Consultation - 1

• I continue to see child, foster parent, birth
  parent and caseworker for ongoing assessment for
  as long as the child is in care
• Have them back as often as clinically indicated,
  to reassess and monitor needs and provide support
  and input, along with others involved, to
  maximize the chance of placement success and that
  the childs emotional and behavioral needs are
  met

26
Ongoing Consultation 2

• Over time, I expect that the trajectory of
  adaptive behaviors at home, at school, with peers
  to proceed gradually in the right direction.
• There will be regressions depending upon reality
  demands in the childs life AND because
  development generally proceeds in this manner

27
Ongoing Consultation - 3

• For children with normative adjustment reactions,
  which include sadness, anxiety, anger, sleep
  disturbance, appetite disturbance, normative
  regression, etc., I try to engage the foster
  parent in the role of therapeutic parent
• Empower the foster parent to use their skills

28
Foster Parent as Therapist

• A referral to a mental health professional is not
  my first choice if at all possible kids in
  foster care are confronted with meeting so many
  new people in such a short period of time.
• I try to capitalize on the wonderful skills that
  so many foster parents bring to the job
• For kids struggling with adjustment reactions,
  many foster parents have the skills and
  confidence to be the primary therapeutic agent to
  decrease symptoms and increase coping, with
  support from us at ENHANCE and others in their
  lives

29
Foster Parent as Therapist Discussions -1

• Understand the dynamics of the childs life
• Understand grief, separation, loss
• The need to communicate hope to the child
• Effects of implicit or explicit put-downs of
  childs birth family or over-emphasizing how
  great the foster home is compared to the birth
  home
• Need to not be seen as a barrier to the birth
  parent
• Empathic listening

30
Foster Parent as Therapist Discussions - 2

• Importance of age-appropriate activities
• Importance of advocating for child at school and
  how to
• Not being seen by child as being associated with
  placement decisions rather be seen as someone
  who is supportive whatever decisions are made,
  e.g., delays in return, change in visitation
  frequency or intensity, termination of rights,
  etc.

31
Foster Parent as Therapist Discussions - 3

• How to closely monitor child and communicate
  findings to ENHANCE and the caseworker
• Age-appropriateness of childs behavior
• Severity and frequency of behavior
• Antecedent events or triggers
• Does behavior change with reasonable parental
  intervention

32
Referrals for More Intensive or Specialized
Treatment

• At any point in the childs placement, should
  their symptoms become too severe or if foster
  parent needs more support than what can be
  provided by ENHANCE, referrals for services are
  made to appropriate providers (psychologists,
  social workers, child psychiatrists and each
  disciplines trainees) at SUNY Child Psychiatry
  Clinic
• My involvement decreases once kids are seen by
  ongoing providers