Clinical Issues - Wales Counseling
Download
Report
Transcript Clinical Issues - Wales Counseling
Mental Health Needs
Among Foster Children
Presented By: Whitney Hardcastle, LMSW
Foster Care
A temporary arrangement in which adults provide for the care of a child or
children whose birthparent, for a variety of reasons, is unable to care for
them.
Can be informal or arranged through a court or social services agency.
The goal for a child in the foster care system is usually reunification with the
birth family, but may be changed to adoption when this is seen as in the
child's best interest.
Factors leading to placement
Parental Substance Abuse
Child Abuse and Neglect
Homelessness
Poverty
Family factors
Behavior problems
Domestic Violence
Statistics
Approximately 500,000 children are in the foster care system in the U.S.
Between 50%-75% of foster children have mental health issues
18%-22% of children in the general population have mental health issues
30%-40% of children in foster care receive Special Education services
63% of children stay in foster care less than 2 years, and average 3
placements
70% of foster children achieve reunification with their families
Statistics
Children under the age of 5 are twice as likely as those 5-17 to enter the foster care
system
Younger children typically spend a longer amount of time in foster care than older
children
Infants remain in foster care the longest amount of time with the median length of stay
ranging from 11-42 months
Infants removed from their homes and placed in care are more likely than older
children to experience further maltreatment and to be in out-of-home care longer
Question
Under what age are children more likely to enter the foster care system?
Issues Foster Children Face
Removal from biological parents requires a substantiation of maltreatment,
not just an exposure
Children with a history of maltreatment who additionally endure the trauma
of separation from parents are susceptible to PTSD
Many children long to return to their families, regardless of the history of
maltreatment
Rates of PTSD in foster children are equivalent, if not higher than in veterans
Suggested that children exposed to child welfare with factors such as neglect
and poverty, necessitated a greater need for mental health services
Issues Foster Children Face
Children in foster care are more likely to develop psychological, social, and
developmental delays than those in the general population
Foster children have higher prevalence of conduct problems, language
difficulty, attachment disorders, behavioral problems, and neurological
impairments
Estimated that over half of children in foster care may experience at least
one or more mental disorders and have clinically significant emotional or
behavioral problems
Education
Foster children face many educational obstacles due to frequent moves and
their risk for developmental delays
Have more difficulty than the general population graduating from high school
Rates of GEDs of children in foster care verses those in the general population
were about 6 times greater
Lower rate of attending college
Trauma
Foster children have disproportionately high rates of trauma compared to
youth in the general population
Young children lack an accurate understanding of the relationship between
cause and effect
They believe that their thoughts, wishes, and fears have the power to become
real and can make things happen
Lower ability to anticipate danger or to know how to keep themselves safe,
making them particularly vulnerable to the effects of exposure to trauma
Young children are particularly at risk because their rapidly developing brains
are vulnerable
Trauma
Children may blame themselves or their parents for not preventing a
frightening event or for not being able to change the outcome
These misconceptions of reality compound the negative impact of traumatic
effects on children’s development
Young children experience both behavioral and physiological symptoms
associated with trauma
Cannot express in words whether they feel afraid, overwhelmed, or helpless
Trauma
Early childhood trauma has been associated with reduced size of the brain
cortex which is responsible for memory, attention, perceptual awareness,
thinking, language, and consciousness
These changes may affect IQ and the ability to regulate emotions
The child may become more fearful and may not feel as safe or protected
Trauma
Young children depend exclusively on parents/caregivers for survival and
protection-both physical and emotional
When trauma impacts the parent/caregiver, the relationship between that
person and the child may be strongly affected.
Without the support of a trusted parent/caregiver to help them regulate their
strong emotions, children may experience overwhelming stress, with little
ability to effectively communicate what they feel or need
Trauma
Children suffering from traumatic stress symptoms generally have difficulty
regulating their behaviors and emotions
May be clingy and fearful of new situations
May be easily frightened
Difficult to console
Aggressive and Impulsive
Difficulty sleeping
Regression in developmental skills, functioning, and behavior
Question
Approximately what percentage of foster children have a mental illness?
Mental Health Needs
Children in foster care struggle to cope with the events that brought them
into the system such as abuse, neglect, homelessness, exposure to domestic
violence, and/or parental substance abuse
Foster children are experiencing unpredictable contact with family, multiple
placements, and an inability to direct their own lives at a time when they
need reassurance, understanding, and stability
Untreated mental health problems have been linked to higher rates of
placement disruption and lower rates of reunification and adoption in child
welfare involved youth
Unmet mental health needs can mean ongoing problems as they enter
adulthood
Early Identification
Early identification is key in treatment
Early intervention affects adult health outcomes and quality of life
Early assessment for physical, developmental, and mental problems is
necessary so appropriate interventions can begin early
Period assessments need to be completed
Family Involvement
Adequate mental health care for children in their biological homes can
sometimes prevent placement in foster care
Families stressed by children with untreated serious mental health needs can
be at increased risk for abuse and neglect
Social learning and behavior interventions can be implemented in the home
and be beneficial for the entire family
Can be taught skills for developing and maintaining positive relationships
Can be allowed and encouraged to maintain family connections
Question
List some of the reasons children enter into foster care.
Family Involvement
Family members should be involved and participate in children’s mental
health treatment
Includes treatment planning, implementation, and evaluation of services
Important for both parents and caregivers to understand the results of evaluations,
the diagnoses, and full range of treatment options
In general, participation of family results in improved treatment outcomes
Without the involvement of families, it is difficult for service providers to
ensure that gains achieved by the child are maintained and solidified
Family Involvement
Important for foster parents to be involved when children are already in their
care
Specific and active support form the foster caregiver is needed to prompt and
reinforce use of anxiety coping skills for children who potentially are faced
with a new environment, uncertainty about their future, court involvement,
and visits with family
Common Mental Disorders
Most Common mental health diagnoses:
Depressive Disorders
ODD
PTSD
Adjustment Disorders
Conduct Disorders
Depressive Disorders
Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder
Adversely affect mood, energy, interest, sleep, appetite, and overall
functioning
Symptoms of depressive disorders are extreme and persistent and can
interfere significantly with a young person’s ability to function at home, at
school, and with peers
Major Depressive Disorder
Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks.
Mood represents a change from the person's baseline.
Impaired function: social, occupational, educational.
Specific symptoms, at least 5 of these 9, present nearly every day:
1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Decreased interest or pleasure in most activities, most of each day
3. Significant weight change (5%) or change in appetite
4. Change in sleep: Insomnia or hypersomnia
5. Change in activity: Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt
8. Concentration: diminished ability to think or concentrate, or more indecisiveness
9. Suicidality: Thoughts of death or suicide, or has suicide plan
DSM-IV-TR
Dysthymic Disorder
Mild, but chronic, form of depression
A. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others,
for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
(1) Poor appetite or overeating
(2) Insomnia or hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty making decisions
(6) feelings of hopelessness
C. During the 2-year period of the disturbance, the person has never been without symptoms in Criteria A and B for more than
2 months at a time
D. No Major Depressive Disorder has been present in the first 2 years of the disturbance
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for
Cyclothymic Disorder
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as schizophrenia or
Delusional Disorder
G. The symptoms are not due to the direct physiological effects of a substance or a general medical condition
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
DSM-IV-TR
Bipolar 1 Disorder
A condition in which a person has periods of depression and periods of being extremely
happy, or being cross or irritable
A.
Criteria, except for duration, are currently (or most recently) met for a Manic, a
Hypomanic, a Mixed, or a Major Depressive Disorder
B.
There has been previously at least one Manic Episode or Mixed Episode
C.
The mood symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
D.
The mood symptoms in Criteria A and B are not better accounted for by another mental
disorder
E.
The mood symptoms in Criteria A and B are not due to the direct physiological effects
of a substance or a general medical condition
DSM-IV-TR
Bipolar Disorder
A.
Presence (or history) of one or more Major Depressive Episodes
B.
Presence (or history) of at least one Hypomanic Episode
C.
There has never been a Manic Episode or a Mixed Episode
D.
The mood symptoms in Criteria A and B are not better accounted for by
another mental disorder
E.
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
DSM-IV-TR
Anxiety Disorders
As a group are the most common mental illnesses that occur in children and
adolescents regardless of foster care status
Prevalent among 13% of children and adolescents in the U.S.
Generalized Anxiety Disorder
A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of
events or activities
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three or more of the follow symptoms
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance
D. The focus of the anxiety and worry is not confined to features of an Axis 1 disorder
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
F. The disturbance is not due to the direct physiological effects of a substance or a general medical
condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive
Developmental Disorder
DSM-IV-TR
Post Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying
event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and
severe anxiety, as well as uncontrollable thoughts about the event.
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or
actual or threatened sexual violence, as follows: (one required)
1. Direct exposure.
2.Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the
event involved actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the
course of professional duties (e.g., first responders, collecting body parts; professionals
repeatedly exposed to details of child abuse). This does not include indirect nonprofessional
exposure through electronic media, television, movies, or pictures.
PTSD
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (one required)
1.Recurrent, involuntary, and intrusive memories. Note: Children older than six may express
this symptom in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to
the trauma(s).
3.Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief
episodes to complete loss of consciousness. Note: Children may reenact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event:(one required)
Trauma-related thoughts or feelings.
Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or
situations).
PTSD
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic
event: (two required)
Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to
head injury, alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or the world
(e.g., "I am bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic event or for resulting
consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
PTSD
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic
event: (two required)
Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
Criterion F: duration
Criterion G: functional significance
Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
ADHD
Affects an estimated 4% of children and adolescents in the U.S.
Developmentally inappropriate levels of attention, concentration, activity,
distractibility and impulsivity.
Usually have impaired functioning in peer relationships and multiple settings
including home and school
Question
As a group, what are the most common mental illnesses that occur among
children in the U.S. regardless of foster care status?
Attachment Issues
A healthy attachment style can play a crucial role in the psychological effects
of foster children.
Attachment styles are developed in childhood and continue to affect the
ability to form intimate and healthy relationships as adults
Bowlby believed that the infant-caregiver relationship forms an internal
working model that later influences interpersonal perceptions, attitudes, and
expectations.
This invokes trust and a secure base for the child to develop
Attachment Issues
Foster children experience ambiguous loss as a result of the removal of
significant family members from their internal family structure.
Family systems theory suggests that this ambiguous loss may leave them
confused about who is in or out of their internal family system
To develop into a psychologically healthy human being, a child needs a
relationship with an adult who is nurturing and protecting and who fosters
trust and security
Attachment Disruptions
Placement outside of the home is typically associated with attachment
disruptions in the children’s relationships
Disruptions and lack of permanence can lead to a difficulty for the child to
develop the ability to form a secure attachment to a primary caregiver
The more changes in placements a child experiences, the more likely they are
to exhibit oppositional behavior
These disruptions lead to an increase in the likelihood the child will develop
Reactive Attachment Disorder
Attachment Disruptions
• Maintaining attachment relationships with parents is difficult for
children in foster care
• It is common for family visits to be stressful or upsetting for the
children, sometimes causing disruptions in their development
• Children may experience toileting problems, sleep disturbances,
aggressive behavior, clinging, and crying prior to, during, and after
the visits
Early Insecure Attachments
Care that meets the young Childs' needs, but is unresponsive to their
attachment signals and emotional needs can lead to an insecure caregiver
attachment
Early insecure attachment relationships places the child at an increased risk
for emotional and interpersonal difficulties
Question
List some of the behaviors a child may display after returning from a family
visit.
Interventions
Trauma-Focused CBT
Parent Child Interaction Therapy
Psychotherapy
Behavioral Intervention
Psychopharmacology
Most are more effective when a caregiver is present
TF-CBT
Essential Components:
Establishing and maintaining a therapeutic relationship with child and parent
Emotion regulation skills
Connecting thoughts, feelings, and behaviors associated with the trauma
Stress management skills
Parenting skills training
Personal safety skills training
Coping with future trauma reminders
TF-CBT
Short-term: Results expected in 12-16 weeks
Linked to improvements in PTSD, depression, anxiety, behavioral problems,
and feelings of shame and mistrust
Positive effects for the children increase when the parent is involved
Family-level intervention, with caregivers receiving approximately half the
active treatment time
Focuses on parenting, to equip caregivers with necessary skills to handle
trauma-related and general behavior problems
TF-CBT
Designed to reduce negative emotional and behavioral responses following
abuse, domestic violence, traumatic loss, and other traumatic events
Treatment based on learning and cognitive theories
Addresses distorted beliefs and attributions related to the abuse and provides
a supportive environment in which children are encouraged to talk about
their traumatic experience
Also helps parents who were not abusive to cope effectively with their own
emotional distress and develop skills that support their children
Multisystemic Therapy
A home and community-based intervention that addresses conduct related
mental health needs by intervening in all systems that impact youth
Important all systems the child is a part of work together
Family
School
Neighborhood
Built on the principle that a seriously troubled child’s behavioral problems are
multidimensional and must be confronted using multiple strategies
Multisystemic Therapy
The behavior problems of a child typically stem from a combination of
influences, including family factors, deviant peer groups, problems in school
or the community, and individual characteristics
Counselor works closely with teachers, neighbors, extended family, peer
groups, and parents
Good for antisocial behaviors or substance abusing behaviors
Goal is to develop independent skills among parents and youth to cope with
family, peers, school, and neighborhood problems
Parent-Child Interaction Therapy
Family-centered treatment approach proven effective for abused and at-risk
children ages 2-8 and their caregivers
Therapists coach parents while they interact with their children, teaching
caregivers strategies that will promote positive behaviors in children who
have disruptive or externalizing behavior problems
Addresses the negative parent-child interaction pattern that contributes to
the disruptive behavior of young children
Parent-Child Interaction Therapy
Parents learn to bond with their children and develop more effective
parenting styles that better meet their children’s needs
Parents learn to model and reinforce constructive ways of dealing with
emotions
Children, in turn, respond to these healthier relationships and interactions
Dyadic Developmental Psychotherapy
Goal is to help the child’s relationship with their parents
Therapist has a conversation with the child about their experiences, feelings,
and thoughts and explores all aspects of the child’s life; safe and traumatic;
present and past
The therapist and parents’ intersubjective experience of the child helps the
child get a different understanding
Therapist talks in a way that is like telling a story rather than giving a lecture
Dyadic Developmental Psychotherapy
Involves the child and parents working together with the therapist
Child gains relationship experience which helps them grow and heal
emotionally
Family members develop healthy patterns of relating and communicating
Leads to less feelings of fear, shame, or need to control within the family
Question
True or False: Most therapy models proven successful with foster children
involve the biological family or the foster parent.
Therapeutic Foster Care
Originally started to help children and youth in the juvenile justice system,
but has grown to include foster care
Model actively includes foster parents in mental health treatment by having
them provide the primary intervention in their homes.
Usually lasts 6-12 months and is often used as an alternative to residential
treatment
Multidimensional Foster Care
Contrasts to regular foster care
Places children singly or with one other child in a very structured and
professionally supported foster home for 6-9 months while engaging the
family to which the child will return in weekly therapy and parent training
Barriers to Treatment
Multiple placements in foster homes
Leaving and re-entering the foster care system
Under reporting of mental health concerns by foster parents
Only about 25% of foster children receive mental health services
Older children are more likely than younger children to receive services
Lack of specific policies regarding mental health concerns for foster children
Fragmentation of responsibility and funding
Failure to provide foster parents with adequate information
Barriers to Treatment
Shortage of child and adolescent providers and long waits
Lack of training on issues specific to foster children to providers, foster care
workers, and foster parents
Providers’ inability to recognize problem and make appropriate referral
Reliance of case workers on foster parents’ judgment of identifying mental
health problems
Lack of coordination between child welfare staff and mental health providers
Barriers to Treatment
Failure of community providers to identify mental health needs
Failure of the system to conduct screening assessments
Limited collaboration between providers and biological parents
Mental health needs being overshadowed by physical medical needs, or
disruptive behaviors such as substance abuse, anger, and opposition
Foster Care Alumni
Estimated 20,000 young people leave foster care each year.
Just over half earn a high school diploma
Estimated that a quarter become homeless
Overall, with the exception of PTSD recovery, alumni rates were similar to
those of the general population
Foster Care Alumni
When aging out of foster care at 18, many children will find themselves with
little, if any, financial, medical, or social support
Many will experience mental illness, criminality, and an inability to function
productively and independently in society
Many will not know or remember their bio families and will not have close ties
to their foster families
References
Bruskas, D. (2008). Children in Foster Care: A Vulnerable Population at Risk. Journal of Child and Adolescent Psychiatric Nursing, Volume 21,
Number 2. pp. 70-77. Retrieved from www.alumniofcare.org/assets/files/jcap_134.pdf
Craven,P., Lee,R. (2006). Therapeutic Intervnetions for Foster Children: A Systematic Research Synthesis
Landsverk, J., Burns, B., Stambaugh, L., Reutz, J., (2006). Mental Health Care for Children and Adolescents
in Foster Care: Review of Research Literature. Retrieved from:
http://www.casey.org/resources/publications/pdf/mentalhealthcarechildren.pdf
Parent-Child Interaction Therapy with At-Risk-Families. Child Welfare Information Gateway. (2013). Retrieved from:
www.childwelfare.gov/pubs/f_interactbulletin?f_interactbulletin.pdf
Polihronakis, T. (2008). INFORMATION PACKET: “Mental Health Care Issues of Children and Youth in Foster Care”. Retrieved from:
www.hunter.cuyn.edu
Troutman, B., Ryan, S., & Cardi, M., “The Effects of Foster Care Placement on Young Children’s Mental Health”. Retrieved from:
www.healthcare.uiowa.edu
The National Child Traumatic Stress Network. (2010). Early Childhood Trauma. Retrieved from:
www.nctsn.org/sites/default/files/assets/pdfs/nctsn_earlychildhoodtrauma_08-2010final.pdf
www.adopt.org
www.ddpnetwork.org
www.mstservices.com
www.youthvillages.org
References
Grayson, J. (2012). Mental Health Needs of Foster Children and Children at Risk of Removal. American Psychological
Association Children, Youth, and Families Office. Retrieved from:
www.apa.org/pi/families/resources/newsletter/2012/01/winter/pdf
Dorsey, S., Conover, K., Berliner, L. (2012). Trauma-Focused Cognitive Behavioral Therapy with Youth in Foster Care:
The Impact of Caregiver Engagement.
Orlando, S. (2013). The Intersection of Foster Care and Mental Health. National Council on Disability. Retrieved from
www.ncd.gov/newsroom/PolicyCorner/05062013
Austin, L. (2004). Mental Health Needs of Youth in Foster Care: Challenges and Strategies. The Connection. Winter
2004, Vol. 20, No.
4. Retrieved from www.lisettaustin.com/pdfs/CASA_MentalHealth.pdf