Mental and Behavioral Health – AAP.org

The emotional trauma of removal from all that is familiar and placement in foster care is emotionally traumatizing for all but the youngest infants. This is compounded by the ongoing separation, losses, and uncertainty that are endemic to foster care.

Trauma and ongoing losses adversely affect all aspects of well-being. It may be obvious that all children and teens entering the foster care system have families who are in crisis, either acutely or chronically. Those families often also have relationship problems or a trauma history that are not healthy for children. In fact, child protective services investigators indicate that 80% of primary caregivers of children at the time of the removal of their children have significantly impaired parenting skills. What is less obvious is that these children and teens also have a higher incidence of physical health problems, some of which are rooted in childhood trauma or exacerbated by ongoing losses and trauma. Prior childhood trauma can be exacerbated in foster care by:

It is important to remember that reunification of a child with siblings is usually a positive transition for a child or teen in foster care, but can also be traumatic if the prior relationship was of poor quality or abusive.

Children's and teens well-being is rooted in the well-being of their families. By definition, children and teens are in foster care because of significant family disruptions. Children and teens often enter foster care without a model for normal, healthy family relationships. They will need to learn some of the basic principles of being part of a healthy family: healthy communication, cooperation, problem-solving, respect for others and their property, etc. Foster parents need to provide the structures, routines, patience, flexibility, communication, role-modeling, consistency, and nurturance that enables children and teens to develop the skills they need to function as part of a healthy family. Foster care is intended to allow children to develop a sense of belonging in a new, healthy family environment while maintaining their connections to their family of origin, unless that is unsafe for the child or teen.

It is also important to recognize that almost all families, even those who have had their children and teens removed, have strengths. Despite their current situation, there might have been times when these families provided a very appropriate environment for their children or teens. Identifying those times and what worked, and what strengths the families possess, is important in helping families heal and achieving safe reunification with their children and teens.

Likewise, it is important to recognize that foster and kinship families have both strengths and needs. Building on strengths and helping families with their needs will support them so that they can provide good care for the children and teens who are in their care.

Ideally, mental health services for children and teens in foster care are provided by well-trained, experienced pediatric mental health professionals who provide care that is continuous over time and in the context of the micro-culture of foster care and the childs multiple families. Mental health professionals should be well-versed in practices that have evidence of efficacy with this population. Parents (foster or birth) or kin need to be engaged in the childs mental health, especially for younger children. Unfortunately, even when a community has pediatric mental health professionals, children and teens in foster care may not have access to them in a timely manner. Discontinuity in mental health care as a result of transitions in placement, lack of consent, or health insurance barriers are common. Some of these issues need to be solved at the systems level.

This is a controversial and challenging issue in foster care for many reasons. Complex childhood trauma experiences, ongoing separation and losses, and multiple transitions adversely impact a childs emotional well-being. The lack of health, mental health, developmental and educational history is often compounded by the lack of any single adult who has had ongoing close contact with the child over time. The health care professional may be reliant on parents (foster or birth) or kin to present an accurate and detailed history of the childs emotional and mental health, but the child may have only been in their care for a short time. There is also often a lack of clarity about who can sign consents for evaluation and treatment, and a dearth of appropriately experienced and trained pediatric mental health professionals to conduct evaluations. The child may also be evaluated and assessed during a critical transition, which may skew the results of the evaluation. Children in foster care also sometimes accumulate mental health diagnoses over time and may not even be accurate.

This is the context in which the decision of whether or not a child or teen in foster care would benefit from treatment with psychotropic medication. Unfortunately, coercion (both subtle and blatant) to take psychotropic medication occurs all the time. Thus, pediatric and psychiatric professionals should be very careful and judicious in the use of psychotropic medications. Children and teens should be part of the treatment plan at all times; however, the placement or receipt of services should not be based on compliance. There are several resources that discuss the use of psychotropics in children in foster care. A brief list of accepted guidelines includes:

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Mental and Behavioral Health - AAP.org