Mental and Behavioral Health Needs of Children in Foster Care

Childhood trauma takes many forms — abuse and neglect; death of a parent (foster or birth) or kin; severe chronic illness of a parent (foster or birth) or kin; ongoing absence of a parent (foster or birth) or kin; significant impairment of parenting skills (often because of parental mental illness, substance abuse, or cognitive impairment); exposure to criminal activity or violence in home and neighborhood, etc. Birth parents of children in foster care have often been unemployed or involved with the criminal justice system. Poverty and housing or food insecurity are common.  Many children have been cared for by a variety of adults, even prior to foster care, and may not have experienced the predictable nurturance necessary for healthy development.

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:

• Rejecting behaviors by the birth parent toward the child or teen
• Being blamed by family members for the involvement of social services
• Lack of flexibility and warmth on part of foster or kinship caregiver toward child
• Multiple transitions that occur in foster care (see Changes in life situations: transitions)
• Abuse or neglect in a foster or kinship placement
• Ongoing uncertainty of foster care placement
• Inappropriate parental behavior during visitation or chaotic, sporadic, unpredictable visitation
• Professionals without sufficient training who may use language or interact with a child in foster care in ways that are not therapeutic or healing

Children and teens entering foster care have already had many traumatic experiences that have adversely affected their well-being.  In foster care, ongoing uncertainty, multiple losses and transitions can further erode a child’s or teen’s sense of self and overall health. Some of the transitions beyond the initial separation from family and all that is familiar include:

• Separation of a child or teen from siblings who remain at or return home or are placed in a different foster care setting
• Visitation (sometimes chaotic and unpredictable)
• Movement to adoption either voluntarily by parent or through termination of parental rights
• Changes in foster home placement
• Changes in school or child care arrangements
• Court hearings in which decisions regarding living arrangements might be made
• Changes in caseworkers, therapists, teachers, or other significant adults
• Identification of and visitation with a newly identified relative, especially the biological father when there has been no prior relationship
• The adjustment to living with a new family for children and teens is an almost overwhelming task.  During a period of grief and bereavement, they must adapt to an unfamiliar family and environment. At the same time, that new family must adapt and change to welcome this new person into their home, often without any prior knowledge of the child’s needs, personality, likes, and dislikes. Attachments may form very quickly, or very slowly.  Foster parents and other family members are expected to treat the new child or teen as one of their own, and then the time comes to say good-bye.  The transitions, adjustments, and uncertainty of foster care not only place a great strain on children and teens, but also on foster parents, their family members, and birth parents.

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 child’s 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 child’s 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.

Because of the high prevalence of mental health and behavioral concerns of children and teens who are in foster care and because there are so many critical junctures that may adversely impact emotional well-being, health care professionals should conduct a more formal assessment of mental health status at entry to foster care and periodically during the child’s time in foster care. The health care professional is advised, at the least, to use a validated mental health screening instrument to assess need for further evaluation.  Ideally, every child entering foster care has a mental health evaluation by a trained pediatric mental health professional and receives services appropriate to their needs. Not every community has pediatric mental health services available. The health care professional may choose to engage the local mental health authority, the public health department, child welfare, or a local community health center to develop services appropriate for this population. The AAP has published Strategies for System Change in Children’s Mental Health: A Chapter Action Kit that offers guidance around finding and developing mental health resources for children.

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 child’s 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 child’s 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:

• Every child and teen in foster care should have a mental health evaluation by a trained pediatric mental health professional prior to the prescription of psychotropic medication.

• Any mental health diagnosis that is established should be supported by the child’s history and symptoms.

• Symptoms that would interfere with the child’s ability to function at home, school, child care, etc, should be addressed

• Psychotropic medication use should be part of a larger mental health treatment plan that includes therapy, support for the child and his or her parents, education about the diagnosis, etc.

• Psychotropic medication should be appropriate to the diagnosis and prescribed by a child psychiatrist, general psychiatrist who is experienced in pediatric mental health, or, in some cases, a pediatrician may be experienced and feel comfortable enough in prescribing such medication.

• Start any medication at a low dose and increase slowly with close monitoring for side effects and efficacy.

• Discontinue or reduce dose as appropriate for side effects.

• Use lowest dose that is effective with minimal side effects.

• Periodic review of the child’s mental health status should be undertaken with attention to the efficacy of the medication, whether there is an ongoing need for its use, presence of side effects, dosage, etc.

• Some children have significant mental health and behavioral problems and may benefit from treatment with more than 1 psychotropic medication. When more than 1 such drug is indicated by a child’s symptoms and partial response to the first medication, the provider should make a choice that follows all the guidelines above, plus ensure that the psychotropic medication does not interact adversely with the other medications the child may be taking.