Clinical Issues - Wales Counseling

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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