Behavioral challenges and children and teens in foster care

• A pathway to build “seeds” for resiliency
• Common, particularly for children entering into care
• Often their best attempt and a normal response to dealing with an abnormal situation (removal)
• Completely normal; parents (birth or foster) and kin should NOT take it personally
• Often the result of confusion; children and teens in care are coping with their life situations through their behaviors
• Not likely to disappear immediately
• Have often served them well in other traumatic situations
• A common reason for placement disruptions

Post-traumatic stress disorders (PTSD) and children and teens in foster care

• A common reaction to trauma
• A result of all kinds of trauma, including the loss of a parent, sudden disruption of their entire lives (eg, losing own home, school, community, peer group, everything that is familiar), and placement with strangers
• Likely to be displayed through a range of behaviors (such as “rage,” or “anger” that seems to come from nowhere from the viewpoint of parents [birth or foster] and kin and professionals)
• Often experienced by the child or teen in foster care as a crisis every day or in response to even minor changes or triggers
• Treatable; with proper treatment and support, it is possible to overcome PTSD
• Experiencing trauma and the effects of PTSD allows many young people to develop compassion for others, excellent coping skills, and insight.

Depression among children and teens in foster care

• A normal reaction to an abnormal situation. When children and teens have experienced significant loss, it is normal and healthy to feel grief and sadness. Learning to identify these feelings, name them, understand where they come from, and how to manage them builds emotional skills that can be useful across the lifespan.
• Visible through symptoms in many forms (eg, some children become quiet and withdrawn; others have angry outbursts)
• Gender neutral; both boys and girls are susceptible
• Often a root cause of behaviors identified as Oppositional Defiant Disorder or Conduct Disorder
• Sometimes associated with suicidal thoughts, behaviors
• Often associated with feelings of not being wanted, worthlessness, and uncertainty
• Often occurs along with other disorders or difficulties
• Often associated with a lack of energy, insomnia, sleeping too much, lack of interest in things normally found pleasurable

Sexual and reproductive health are important topics for professionals and parents to discuss (eg, pregnancy, contraception, sexually transmitted infections [STIs], sexual behaviors, sexual abuse) with children and teens in foster care.

• For many children who reach out sexually to others, this is evidence of wanting to make a real connection, find some closeness, and build relationships.  Those desires are healthy and supporting youth in finding more appropriate ways to meet these goals is an important task of parents and care providers.
• Developing a sexual identity is a normal task for all children, including youth in care.
• Often abuse is a precipitating factor of inappropriate sexual behaviors.
• There has often been exposure to early and different sexual behaviors and issues compared with other children.
• Children in care frequently come from hypersexual backgrounds.
• Both before or during placement in foster care, children are often subjected to a lack of privacy.
• Inappropriate sexual behavior may be a way of coping, of feeling close to others, but these behaviors can have lasting negative consequences.
• Gay, lesbian, bisexual, and transgender (GLBT) children and teens are more likely to be abused or neglected, and are more likely to end up in foster care.
• Learning about healthy ways to express sexual feelings and to develop healthy relationships is an important part of growing up.

Eating and feeding are important topics for professionals and parents (eg, overeating, undereating, Pica, anorexia, bulimia, obesity, malnutrition, hoarding) to discuss with children and teens in foster care.

• Foster parents and kin should ask about food preferences, developing family rituals, or traditions that provide a sense of belonging.
• Often children in foster care have little control over their lives.  They can control their own intake of food (which is common in people generally, but exacerbated in those in care).
• Attempting to take control in a situation that feels out of control is often a factor in eating problems.  Supporting children and teens in finding more appropriate ways to have a voice and power in their own lives is an important task for parents and care providers.
• There may be cultural differences around food of which professionals and parents should be especially aware.
• Childhood and adolescence are times during which young people develop eating habits that last a lifetime — it’s a good time to make sure those are healthy habits!

Attention deficit disorders/attention deficit hyperactivity disorders (ADD/ADHD)
and children and teens in foster care

• Coming from situations where there has been abuse or neglect and going into a new and unfamiliar situation is disorienting.  Children and teens, who are often grieving the separation from their family, often have difficulty in understanding what is going on around them. Confusion, anxiety, and poor attention are common reactions to all these changes and may not be ADD or ADHD. 
• “Hyperactivity” can occur for many reasons — when children are upset or depressed or anxious, they may “discharge” their energy through activity.
• Important to thoroughly and properly evaluate, to make sure the diagnosis is accurate. This will require obtaining information from a variety of sources: child care, schools, parents, and perhaps coaches. Accurate diagnosis should be made before treatment is begun. The first and most compelling part of treatment is ensuring the child or teen lives in a stable environment and that all of the caregivers agree about the treatment plan. Treatment should include education and behavior management in addition to medication (when appropriate) with close follow-up.
• ADD/ADHD tends to run in families, and sometimes other disorders co-occur with it. For example, it is very common for children with ADD/ADHD to have learning disorders.
• Unpredictability and uncertainty make ADD/ADHD symptoms worse.
• Symptoms of inattention and hyperactivity that are the result of depression or anxiety and ADD/ADHD itself often improve in a stable, nurturing home environment.

Hygiene issues and children and teens in foster care are:

• Often children and teens come into foster care without having had the usual teaching about hygiene that other children and teens have had. Sometimes a family may not have had the access to supplies (including personal hygiene items) needed for appropriate hygiene.
• Teaching self-care in the area of hygiene can be a fun interaction between children or teens and foster parents or kin. Shopping for appealing products and experimenting together with scents and textures can be a non-threatening way to build rapport.
• Sometimes, children and teens have been sexually abused and poor hygiene can be a “protective” choice (keep people away from them).
• Poor hygiene can also be related to poor self-esteem, a manifestation of trauma, or issues with body image.
• Developing a sense of pride in one’s body and caring for one’s personal appearance is one way to improve self-esteem and body image.

Encopresis and children and teens in foster care is:

• Defined as soiling one’s clothes with stool (feces)
• Important to assess; a complete physical health screening is needed to determine causes and treatments for encopresis. Many children and teens in foster care have encopresis because they are constipated, and it hurts to have a bowel movement. A doctor can help to solve constipation problems and relieve the pain of having a bowel movement, but it is important to let a doctor know.
• Sometimes related to fear (afraid of what happens in the bathroom; some children or teens have been abused in the bathroom)
• Sometimes related to poor nutrition (leading to constipation) or trauma (injury to the areas of the body involved in stooling)
• Necessary to treat; if constipation has been going on for a long time, children and teens may no longer “feel” when they need to go to the bathroom and may just stool in their underwear; treating the constipation will help the bowel movement to shrink in size so that the child or teen can tell when they need to go.

Immunizations and children and teens in foster care

• Many children enter foster care with incomplete immunization records, or incomplete immunizations.
• In cases where information about immunizations is not available, the doctor’s office should communicate with state registries (which exist in some places), the child’s most recent school or child care center, and most recent health professional to find information; however, if information cannot be found within 30 days, “catch-up” immunizations should begin because there is little risk in repeating vaccinations.
• Children who have not been immunized are at a higher risk of communicable diseases, some of which have potentially severe consequences.
• Immunizations are one way to optimize the health of a child or teen in foster care.

Autism and children and teens in foster care

• Often associated with child abuse and neglect; those with autism are more likely to be victims of child abuse or neglect — they are simply more difficult to parent.
• Important to carefully evaluate in any child with developmental delays, especially language delay and personal or social delay, or atypical behaviors
• Often manifested as behavioral problems, but odd behaviors are not necessarily autism