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

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Dynamics of Foster care - Child - 1. Life Out of Balance ... Diane Erne. 12. ENHANCE - 3. Steven Blatt, MD, Director. Victoria Meguid, MD. Ron Saletsky, PhD ... – PowerPoint PPT presentation

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Title: 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
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