Foster children tend to be over-medicated. Surveys show that foster youth receive 5 times the number of psychotropic medications, frequently three or four simultaneously, as privately insured children.
What else, beside medications, can we offer foster children who are often struggling with psychiatric issues and difficult and unfamiliar family environments? Medications can be very helpful, but they are designed to suppress symptoms, not to cure. Informed, empathic relationships heal, whether in psychotherapy, with foster parents, or with other caring people in a child’s life.
In my own work with foster children, I use the following approach.
First, I do a comprehensive evaluation of these children. Beyond the usual information about behaviors and symptoms, I find it helpful to elicit a complete developmental, educational, medical, and family history. I am especially interested in a history of physical and sexual trauma (age of onset, duration, frequency, and nature of the trauma), separation from or loss of significant attachment figures, economic instability, and indicators of family dysfunction. Did they witness domestic violence, substance abuse, or sexual activity? Have they seen violence in their neighborhood? What circumstances brought the child into foster care? Is there a history of depression? Of suicidal thoughts or attempts? Have there been hospitalizations? Are there school difficulties? What is the nature of their peer relationships? And of course I obtain a complete medication history (and for older youth, a drug history). Who have been the most important adults in their lives? Are they currently in touch with family members? How often?
It is most common that they do not volunteer this information; so, if we want to know, we must ask them specifically. It is remarkable how often children can talk frankly about difficult issues if they are asked directly.
Example: An 11-year-old girl came through the emergency room after a sub-lethal suicide attempt. After she was triaged and stabilized, I interviewed her before discharge. When I asked about sexual abuse she hesitated for a second before saying, “No.” I inquired about the hesitation, and she began to weep, revealing that an uncle had molested her for several months when she was 9 years old and she had never told anyone about it. Her foster parent, who accompanied her, was instantly empathic and the foster family rallied around her.
Once I have a good sense of the child’s situation, I select from a variety of psychosocial interventions that are particularly helpful for foster children. There are two main categories: psychotherapies and community-based programs.
1. Psychotherapies Trauma-informed individual psychotherapy. Trauma-informed therapy (Weiner DA et al, Children and Youth Services Review 2009;31(11):1199–1205) entails the strategies such as recognizing the impact of trauma on your patient’s development and coping abilities, helping your patient develop a sense of empowerment by emphasizing that they are not at fault, and minimizing the possibility of re-traumatization, especially rejecting invitations to do the same subtly in the therapy. The core element of these therapies is working individually with a traumatized child to encourage them to express in words, play, or art what they have been expressing in actions.
Example: Mandy, a sexually-abused 16-year-old, wears increasingly provocative clothing and sits so as to accentuate and display her figure. Part of the task of therapy is to help her to identify what she seeks—love, caring, self-respect, and protection-—and how to obtain the same while avoiding shaming, scolding, or exhibiting arousal.
Trauma Systems Therapy (TST). See CCPR, June 2015 for an in-depth look at TST. As opposed to individual psychotherapy, TST involves a team that evaluates the child’s environment for triggers that may be not be recognized in individual therapy.
Targeted group therapy. There are many varieties of group therapy designed for specific populations. For example, Dialectical Behavior Therapy (DBT) is effective for those with borderline traits (cutting, substance abuse, repeated suicide attempts). Same-sex groups for sexually molested girls/boys are helpful because they help youth see that they are not alone in their difficult experiences, just as LGBT groups can assist with the stresses of alternative sexual orientation/gender identification.
Experiential and expressive therapies and programs. There are plenty of non-traditional therapies available. These include yoga, meditation, exercise, equine therapy, wilderness programs designed for foster youth, pet therapy, and art and music therapies. Any of these may provide a foster child with additional self-esteem and insight, augment their investment in themselves, and allow them positive experiences. Finding an area in which a child has an interest and helping them to develop their skills in it can be very useful. Frequently the county departments of mental health or social services will have a current directory of what is available.
2. Community-based services Foster parent training. Many counties have contracted with non-profit organizations to provide training for foster parents. Foster children have been traumatized by their removal from their families, as well as by the conditions that led to their removal. Their behaviors can be remarkably trying, and foster parents can gain skills and understanding through training that increase the likelihood of success for the child in that household. The last thing a foster child needs is placement failure with another rejection.
Example: 5-year-old David was previously identified as autistic. Surprisingly, and contrary to behaviors I would have expected in an autistic patient, I noticed that he dramatically demanded attention and attachment from his detached foster mother. Helping the mother to identify his need and to meet it led to a significant improvement in his disruptive behaviors.
Family Finding. Family Finding is an approach that relies on locating supportive relatives of a foster child, who can then become engaged with the child’s life. The technique was developed by Kevin Campbell, who founded the National Institute for Permanent Family Connectedness. Here’s how it works: Trained master’s-level clinicians enter any and all information they can obtain about a child’s family into a specially designed Internet search database. They retrieve names and contact information and make initial inquiries to ascertain that the relatives are, in fact, blood relatives of the child. The relatives are contacted to assess their degree of interest in making contact with the child. The child is not informed of this until late in the process to avoid what could be catastrophic disappointment. If it goes well, supervised contact is arranged between the child and their interested family member. Remarkable numbers of family members, close and distant, are generally found.
An auntie in New York who reliably sends an email or a card to her nephew in California can make a crucial difference for a child isolated from family members, providing the promise of more intimate and enduring family connection. Sometimes Family Finding can lead to adoption; more often it can provide an ongoing source of support, love, and lasting family connection for the child. Most children need meaningful relationships with family in order to have hope for their future. Example: Bob was a severely sexually abused, neglected, and cognitively-impaired 15-year-old in a secure residential treatment center. After a year of no progress, we employed Family Finding, locating relatives in Texas, Oregon, and New York. Some visited him, he traveled to Oregon to visit another, and others sent him regular cards and emails. Bob became hopeful, much less assaultive, and an eager participant in his treatment program.
Wraparound services. Wraparound teams are special clinical support networks funded in systems of care under contract with county departments of social services and of mental health.The teams usually consist of a child care worker, a master’s-level clinician, a child psychiatrist, and a supervising social worker. You can enlist wraparound teams by calling the child’s court-appointed social worker. What, specifically, do these teams do? Here are a few examples: Make regular home visits supportive of both foster parents and the foster child; have after-school Big Brother/Big Sister-type relationships and activities; visit the school to problem-solve bullying, depression, learning disabilities, academic delays, and other issues related to school failure; and provide individual and family psychotherapy.
Therapeutic Behavioral Services (TBS). TBS is a time-limited, targeted behavior modification intervention. When available, it is generally provided by nonprofit organizations contracting with each county department of mental health. A clinician meets with the family (or school) and child, then identifies one or two problematic behaviors, such as tantrums at bedtime or difficulty with transitions in school. Working directly with the child, antecedents are elicited, modifications in routine or the environment are considered, and replacement behaviors are introduced and tested.
Court-appointed Special Advocates (CASA). CASAs are specially trained volunteers who are assigned to foster children. Their job is to advocate for them in court, in school, and elsewhere. They are available in most counties and are a free service. The unique features of CASA are: 1) They often will have a continuous, caring relationship with the child for years; 2) Their task is purely to advocate for the child, with no governmental, legal, or other conflicting agenda. To find a CASA in your area, simply look on their website (either local or national).
The Individual Education Plan (IEP) meeting. The majority of foster children have IEPs, which are mandated by most public school systems for children who have psychological issues impeding their ability to learn. The IEP meeting occurs when initiated by the child’s guardian or by the school, is reviewed annually, and usually includes the following participants: current teacher(s), school psychologist, special education staff, child, guardian/parent, CASA, and any other relevant providers, including members of a child’s wraparound team. Why should we take the time to actually attend these meetings? A child’s school success can be a key to improved self-esteem and, eventually, to a constructive life. School failure is a strong predictor of incarceration at a later age. We can discuss the child’s trauma history, perceptions of unsafety, attachment issues, low self-esteem, a need to re-create their trauma, etc., bringing empathy and a deeper understanding of the child to the meeting. My experience is that our presence is strongly sought and our voice well-heard.
Crisis Services. When children are in crisis, we are tempted to rely heavily on medications. But don’t neglect to consider the variety of crisis services in your area. For example, mobile crisis teams can be summoned to the home where they can assist in the de-escalation of a crisis and/or triage children for a higher level of care if needed. Crisis stabilization units (CSU) are fairly new, freestanding county facilities where a child can be safely contained for up to 24 hours. While there, they are assessed for hospitalization or for discharge with continued outpatient services.
As you can see, the options for psychosocial treatment are plentiful. Unfortunately, as detailed in a recent newspaper series on the California foster care system (see this month’s Q&A for an interview with the lead journalist on that series), these interventions aren’t being used as much as they should. Why? There are various reasons. These include a lack of funding, an absence of a unified directory of existing services, a lack of familiarity or fluency by the child psychiatrist with the broad range of possible interventions, a perceived lack of time to initiate them, and even a conviction by the child psychiatrist that their role is limited to prescribing medication. Hopefully, you will be able to add some of these tools to your kit and deploy them for your troubled foster patients.