Pediatric Annals

Special Issue Article 

Mental Health Issues in Foster Care

W. David Lohr, MD; V. Faye Jones, MD, PhD, MSPH

Abstract

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [Pediatr Ann. 2016;45(10):e342–e348.]

Abstract

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [Pediatr Ann. 2016;45(10):e342–e348.]

According to the Children's Bureau at the US Department of Health and Human Services, 415,129 children were in the foster care system a couple months past the mid-year point of 2014, which was an increase of 3.5% from the previous year at the same time.1 Many of these children have unique social and emotional backgrounds, placing them at a higher risk for mental and behavioral health problems compared to their peers who are not in the foster care system. In fact, studies have shown that up to 80% of children enter the foster care system with a significant mental health need.2–4

Reasons for Foster Care Placement

Typically, children are placed in foster care for reasons of impending threat to their safety. This may take the form of neglect and/or physical abuse or even a lack of an available caregiver for the child. Parental substance use abuse, extreme poverty, uncertain or unreliable living conditions, mental illness, and/or violence within the family may also be contributing factors for the child's involvement in the child welfare system.2,5 Many routinely experience trauma or hardships, with 85% of children living outside of their homes reported witnessing violence and 51% reported being a victim of violence in their lifetimes.6

Disorders Associated With Trauma

Each of these adverse conditions, either singularly or in combination, especially if frequent and unrelenting and not countered by a nurturing, responsive caregiver, affect the circuitry of the brain leading to disruptive physiologic responses or toxic stress.7 Children who have been exposed to high levels of stress through violence or aggression may suffer the effects of chronic heightened activity of the stress system—the hypothalamic-pituitary-adrenal axis. Chronic overactivation of this system by toxic stress, in turn, affects mental and behavioral health as well as physical well being and learning capacity. Therefore, it is not surprising that children who enter foster care have a high prevalence of mental and behavioral health needs.8,9

Children exposed to trauma and toxic stress at an early age manifest emotional and executive functioning deficits, which may lead to behavioral issues later in life.10 In fact, up to 61% of older youth in foster care have at least one diagnosed psychiatric disorder in their lifetime.11 However, specific diagnoses were more common with these children. Children with a lifetime experience of foster care are more likely to report externalizing and internalizing psychiatric symptoms than their peers with no history of foster care involvement. Adolescents in foster care are 4 times more likely to have attempted suicide and 5 times more likely to have a drug-dependency diagnosis within the preceding 12 months compared to their peers who had not been involved with the foster care system.12

Attention-Deficit/Hyperactivity Disorder

The most common mental health diagnoses for children in foster care include those related to attention-deficit disorder with or without associated hyperactivity, oppositional defiant, and conduct disorders. Vanderwerker et al.13 found youth in foster care to have approximately 3 times the rate of externalizing disorders such as attention-deficit/hyperactivity disorder (17.3%), oppositional-defiant disorder (7.2%), and conduct disorder (2.3%) than their peer group. Other common diagnoses include anxiety disorders, eating disorders, elimination disorders, mood disorders, including major depression and mania, and disruptive behavioral symptoms.4

Executive Function and School Problems

Problems with executive dysfunction may manifest in school via learning problems or disruptive behavior with an estimate of as many as 40% of school-aged children in foster care reported to have educational problems.14 Higher rates of school change, failing grades, and dropouts may be likely. These rates may reflect the multifactorial stresses involved in children in foster care including environmental, genetic, and familial factors.

Posttraumatic Stress Syndrome

The prevalence of posttraumatic stress disorder (PTSD) is high in children in foster care.15–17 PTSD is diagnosed when someone has been exposed to severe trauma and has problems with intrusive symptoms associated with traumatic events such as memories, dreams, or dissociative reactions. Persistent avoidance to circumvent reminders of the event and negative changes in thoughts and moods related to the trauma are noted. Youth with PTSD may have trouble with irritable and explosive behavior consistent with overarousal. PTSD is diagnosed when the symptoms cause significant stress or dysfunction and persist for more than 1 month and may present with dissociative symptoms. Significant symptoms have been described in 19.2% of children who were referred to child welfare for investigation and eventually placed in foster homes.15 PTSD has been reported in approximately 25% of people who experienced foster care as compared to 4% in the general US population.16 Recovery may be adversely affected by continued compounded stress. Most youth recover from acute PTSD but lingering effects may persist.17

Reactive Attachment Disorder

Reactive attachment disorder (RAD) is another trauma-related disorder characterized by inhibited emotionally withdrawn behavior to caregivers and problems with emotional responses to stress resulting from extremes of insufficient care. Multiple changes in primary caregiving may pose a risk for the development of RAD. This disorder results from insufficient attachment during a child's emotional development and can explain unusual reactions children in foster care may have toward relationships. The prevalence of RAD within maltreated toddlers has been estimated to be as high as 40%.18 Long-term outcome of RAD is unclear, but the disorder shows moderate stability over time.19

The Role of the Pediatrician

The pediatrician plays a vital role in the care of children of all ages in the child welfare system as evidenced by policy statement and technical reports from the American Academy of Pediatrics (AAP) on the issues and care of children and adolescents in foster care and kinship care.2,20 Many of these children have complex physical and mental health problems as well as developmental and psychosocial challenges that may be rooted in past experiences of adversity and trauma from their childhood. Fragmentation of care issues pose problems with delivering quality health care to children in foster care. Often, little information is available on biologic family psychiatric history, early developmental history, or records from previous treatment. Once children are in the foster care system additional moves and changes in residence may also strain the ability to obtain a comprehensive history. The state guardian is the person most likely to provide longitudinal history so ongoing contact is essential. Statewide electronic medical records or “passports” hold the promise of providing complete longitudinal history.

The Medical Home

It is important for the pediatrician to ensure the well-being of these children by providing high-quality health care including health care coordination and advocacy in a medical home setting. The development of medical homes in pediatrician offices for children in foster care may also address these concerns by providing continuous comprehensive, compassionate care using a trauma-informed model to deliver care in a culturally sensitive manner. The medical home should also be charged with the coordination of the child's care across disciplines.

The AAP has provided guidelines of care for these children including timing of visits.20 The initial evaluation is recommended within 3 days of new entry into the foster care system. This visit is important in identifying health conditions requiring prompt care, such as the identification and treatment of acute and/or chronic illnesses. Examination for signs of child abuse or neglect, urgent behavior difficulties, and/or mental health problems should be addressed. This time is a high-risk period for the child with increases in the needs for mental health services.21

Pediatricians need to be attuned to the ongoing proper/appropriate fit of the child within the foster home. The initial visit provides an opportunity to observe the interaction between the guardian and the child allowing for guidance and open discussion of effective strategies to enhance the relationship. Also, the child should be allowed time, preferably separately if age appropriate, to discuss his or her functioning in the foster home. Efforts to improve family dynamics through communication and awareness of trauma-related behavior may improve the ability of the child to maintain placement.

The initial evaluation is followed by a comprehensive evaluation within 30 days during which screening for mental health conditions should take place ideally by a mental health specialist trained in trauma-informed care.2,3,20 Continued assessment of the child's feeding and sleep patterns, as well as issues pertaining to elimination, should be addressed. As previously discussed, children in foster care have much higher rates of mental health problems, yet only 25% have received mental health care within the previous 12 months prior to child welfare investigation.22 Pediatricians should be familiar with common screening instruments that are available from the Bright Futures Tool and Resource Kit website.23 These screening tools focus on psychological and behavioral assessment, autism, and substance use abuse. Screening tools for psychosocial issues and specific disorders, such as anxiety and attention-deficit/hyperactivity disorder are also available (Table 1).24,25


            Developmental, Behavior, and Socioemotional Screening Tools in Primary Care

Table 1.

Developmental, Behavior, and Socioemotional Screening Tools in Primary Care

When a problem is identified, referral to the appropriate mental health service is needed. Children in foster care benefit from trauma and attachment-focused approaches that address what role their histories may have on their health. Trauma-informed, evidence-based therapies have been shown to be effective in the management of trauma-based symptoms.4,8,20 Specific therapies include Parent-Child Interaction Therapy, Trauma-Focused Cognitive-Behavioral Therapy, and the Incredible Years (Table 2).4 However, with the shortage of mental health specialists in many areas, pediatricians are being asked to assume more of a mental health care role. Therefore, it is important for pediatricians to recognize and treat common mental health conditions, as well as refer more serious concerns for further specialized care.


            Evidence-Based Trauma-Informed Therapies

Table 2.

Evidence-Based Trauma-Informed Therapies

State-supported collaborative consultation and treatment models developed to better integrate primary care and mental health services are one avenue being pursued to improve the mental health care of foster children. Pediatrician feedback from these programs has been positive, and these collaborative programs have led to increased access to mental health services for youth.26–28

Treatment Options: Medication or Psychosocial Therapies

Children with mental and/or behavior health problems may benefit from a variety of treatment options including behavior management therapy, counseling and drug therapy, or a combination of these modalities. Children in foster care are exposed to much higher rates of psychotropic medications. In general, children in foster care have about 3 times the rate of treatments with psychotropic medication and polypharmacy29 and tend to be treated with medication for longer durations than children who are not in foster care.30 Much of the treatment involves the use of antipsychotic medication focused on disruptive and aggressive behavior. Nationally, the increased use of psychotropic medications is not accompanied by increased delivery of psychosocial therapies.31

The use of second-generation antipsychotics in youth has been associated with significant weight gain and metabolic changes involving glucose and lipid metabolism.32 Also, increased rates of diabetes are being reported for children and adolescents treated with these medications.33 Unfortunately, studies show children on antipsychotic medication do not reliably receive recommended monitoring for metabolic changes for glucose, lipid, or monitoring of weight.34 It is not clear if the rates for laboratory monitoring of these side effects differ for youth in foster care but the population's overall risk profile raises concerns. In response to the increased rates of psychotropic medication use in children in foster care, many states are implementing monitoring and consent systems. For example, California recently signed into law three bills to increase the surveillance of children in foster care prescribed medication. Public health nurses will monitor the rates of psychotropic drugs in children in foster care and require group homes with high rates of medication use to take corrective action.35 Pediatricians will need to be aware of side effects, professional guidelines, and legislative efforts regarding the use of medications for children in foster care that are in place to minimize unwanted health outcomes.36

Pediatricians are positioned to re-address the balance of psychotropic medication in children in foster care and should recognize that disruptive and aggressive behavior commonly found in children in foster care might be related to past and/or ongoing trauma, a mismatch of caregiver-child fit, or other psychosocial factors. After a comprehensive psychiatric evaluation to identify all of the risks and factors involved in the mental health picture, evidence-based psychosocial therapies addressing trauma-related conditions should be provided before medications are used.37 Trauma-informed treatment may also enhance a child's educational performance. Pediatricians are in a position to advocate for improved educational services such as Individual Education Plans, and, in young children, referrals to early education programs such as First Steps or Head Start where rehabilitative services may address some of the shortcomings described previously.

Achieving Long-Term Outcomes

Pediatricians should be aware of the importance of the resiliency of the child as a determinant of long-term outcomes. Resiliency is the adaptation of protective factors to mitigate the challenges of the adversity that a person experiences in life. Potential protective factors for resiliency may be identified beyond the immediate environment of the child but can include specific child characteristics and the broader socioecological context in which the child is situated. Treatment plans that take resiliency into consideration are likely to provide helpful guides to enhance the mental health outcomes of youth in foster care. Finding stable mentoring relationships, rewarding socially engaged activities, and educational progress are some examples of resiliency-promoting interventions that can promote healing from the complex trauma narratives often associated with children in foster care.3

Another form of resiliency develops from permanence. More children are now placed with kinship families, and appropriate supports to kinship families can allow a protective relationship to continue. Many of the adverse effects on attachment and behavioral problems are worsened by multiple transitions. A study38 shows that disrupted placements are associated with an increase in behavioral problems. Pediatricians can function to provide caregiver support and training to enhance their ability to regulate and promote effective coping strategies and reduce placement disruption. Helpful interventions include promoting positive parenting and management strategies and helping caregivers understand that negative behavior may result from trauma-influenced processes. Improved attachment between children in foster care and their care givers is associated with a decrease in behavioral problems and presumably fewer disrupted placements.39

Along with resilience, the idea of wellness behavior involves promoting activities and behaviors associated with healthy living. Most people assume these behaviors are part of a good “quality of life” but the evidence4,8 for wellness behavior on depression and anxiety is emerging. Wellness behavior promotion includes providing access to normalizing activities such as music, sports, and attending community worship activities; encouraging aspects of good nutrition; and offering opportunities for mindfulness practices such as meditation and yoga. By promoting and fostering development of these behaviors, pediatricians are likely to improve positive outcomes.

Pediatricians are in a position to ease the transition of youth in foster care to adulthood. Many youth exiting the foster care system have increased rates of mental health problems, unemployment, homelessness, and PTSD.40 There is some evidence that enhanced foster care extending beyond age 18 years with improved access to services may improve outcomes.41

Summary

Overall, pediatricians play an essential role in safeguarding the physical and emotional health of children in foster care. Understanding the multiple complex problems and toxic stress that lead children into child welfare systems allows providers to approach the multiple barriers to their care with a trauma-informed perspective. As such, pediatricians, working within a medical home context, are likely to be crucial allies in helping children in foster care and their caregivers navigate the fragmented health care system. Additionally, by identifying sources of resiliency in children and their socioecological environments, pediatricians can offer an important counterbalance to the adversity children in foster care experience, which, in turn, can lead to engagement in positive behaviors directed toward healing and wellness.

References

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Developmental, Behavior, and Socioemotional Screening Tools in Primary Care

Screening Tool Target Population Screening Focus
Pediatric Symptom Checklist Youth-Pediatric Symptom Checklist Children age 4–18 years Adolescents age 11–16 years A psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems
Strengths and Difficulties Questionnaire Children age 2–17 years Brief behavioral screening questionnaire
Ages and Stages Questionnaire Children age 4 months–60 months Parent completed developmental and social-emotional screen
Modified Checklist for Autism in Toddlers–Revised Children age 16–30 months Assesses risk for autism spectrum disorder
Car, Relax, Alone, Forget, Friends, Trouble Screening Questionnaire Adolescents age 14–18 years Screen for substance use disorder and related risks and problems
Screen for Child Anxiety-Related Emotional Disorders (child and parent versions) Children age 8–18 years A 41-item child and parent self-report scale forchildhood anxiety disorders
Center for Epidemiological Studies Depression Scale for Children Adolescents older than age 14 years(modified version for children as young as age 6 years available) A 20-item self-report depression inventory
Vanderbilt ADHD Diagnostic Rating Scale Children age 4–18 years A 55-item parent scale; a 43-item teacher scale

Evidence-Based Trauma-Informed Therapies

Intervention Target Age Focus
Parent-Child Interaction Therapy Children age 2–8 years and their caregivers Behaviorally based therapy that involves enhancing the parent-child relationship
Trauma-Focused Cognitive-Behaviorial Therapy Children and adolescents age 3–18 years Treatment model that incorporates various trauma-sensitive intervention components
Coping with Depression for Adolescents Adolescents age 12–18 years Skills-based, small-group treatment program for actively depressed adolescents
The Incredible Years Children age 4–8 years and their caregivers Designed to promote emotional and social competence, and to prevent, reduce, and treatbehavior and emotional problems in young children
Authors

W. David Lohr, MD, is an Associate Professor of Child Psychiatry, University of Louisville School of Medicine; and a Clinical Co-Director, University of Louisville Autism Center. V. Faye Jones, MD, PhD, MSPH, is a Professor, and the Assistant Vice President for Health Affairs/Diversity Initiatives, University of Louisville School of Medicine.

Address correspondence to W. David Lohr, MD, University of Louisville School of Medicine, Bingham Clinic, 200 E. Chestnut Street, Louisville, KY 40202; email: william.lohr@louisville.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20160919-01

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