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

1. 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. 2 A Child�s Experience in Foster Care Video by Michael Trout, Director The Infant-Parent Institute Champaign, Ill Used with permission.

3. 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. 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 �I�m 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. 5 Dynamics of Foster Care � Child - 3 Common defenses against anxiety engendered by placement -displacement -identification with the aggressor -projection -regression

6. 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. 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 child�s life, e.g., child will forget who �real� mom is Threatened by opportunities afforded the child by foster family Fantasies about foster parent

8. 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. 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 don�t get too attached� Pacing of expectations Burn- out and respite

10. 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. 11 ENHANCE - 2 Howard Weinberger, MD Martin Irwin, MD Diane Erne

12. 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. 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. 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. 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 < 5 Mental Health eval for kids > 2.5

16. 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. 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. 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 child�s 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. 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. 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. 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. 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 child�s reactions, acquaint foster parent and caseworker with child�s defenses reassurance, support of foster parent�s efforts Assess foster parent response to feedback � do they �get it�?

23. 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. 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. 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 child�s emotional and behavioral needs are met

26. 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 child�s life AND because development generally proceeds in this manner

27. 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. 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. 29 Foster Parent as Therapist Discussions -1 Understand the dynamics of the child�s life Understand grief, separation, loss The need to communicate hope to the child Effects of implicit or explicit put-downs of child�s 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. 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. 31 Foster Parent as Therapist Discussions - 3 How to closely monitor child and communicate findings to ENHANCE and the caseworker Age-appropriateness of child�s behavior Severity and frequency of behavior Antecedent events or triggers Does behavior change with reasonable parental intervention

32. 32 Referrals for More Intensive or Specialized Treatment At any point in the child�s 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 discipline�s trainees) at SUNY Child Psychiatry Clinic My involvement decreases once kids are seen by ongoing providers