Experts agree that there is an over-representation of children needing mental health services in the foster care system. Children in the child welfare system may have had increased exposure to risks such as violence, homelessness, poor nutrition, unsafe homes, prenatal exposure to alcohol or drugs and other risks that are greater for children living in poverty. The cumulative effects of these risks bring with them an increased likelihood of negative outcomes for children. The topic of mental health needs of children in foster care is not well researched so that current estimates vary and may not reflect the actual extent of the problem. Schneiderman (1998) cites studies that describe children in foster care diagnosed with psychopathological disorders to be between 29% and 63%. Blatt, et al (1997) reports that 51% of children in foster care who were seen for mental health screening displayed sufficient risks to warrant referral for psychiatric assessment or therapy.

The types of mental health needs displayed by children in out-of-home care are complex. Diagnosis is often difficult because of the multiple risks and trauma children may have experienced. These risks are further complicated by the extreme uncertainty and stress of being removed from their biological families and placed in unfamiliar living situations. Many children display disorders of attachment, depression or anxiety. These children may be at an increased risk for post-traumatic stress disorder resulting from trauma or self-regulation disturbances where children have difficulty regulating their own behavior and other sensory, physiological and emotional processes. It is therefore not surprising that children in foster care require extreme attentiveness to these potential problems as well as substantially more prevention and intervention services.

In 1988 the Child Welfare League published Standards for Health Care Services for Children in Out-of-Home Care. The American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care (1997) also addressed the mental health care needs of children in foster care. They recommended that: (1) children entering foster care should receive a comprehensive mental health evaluation within one month of placement and (2) while in placement, children’s mental health status and progress should be monitored at least twice a year in the first year of placement, and yearly thereafter. Currently, these recommendations have not become common practice.

Many children needing mental health services do not actually receive them, partially because these services are lacking in many communities (Morrison, et al 1999). Changes in welfare and health care reform could have an even greater negative impact on the availability and access of mental health services for children in foster care. The primary source of funding for physical and mental health services is Medicaid. There is often a lapse between entry into foster care and eligibility determination for Medicaid. Providers do not want to render services without assurances that they will be paid. Health care costs have risen and reimbursement rates remain low so that fewer physicians are willing to be Medicaid providers or may limit their caseload of Medicaid patients. There is also concern that services for Medicaid clients may be less comprehensive than for non-Medicaid clients. There have been efforts to secure mental health services for children in foster care. Medicaid mandates EPSDT (Early Periodic Screening, Diagnosis and Treatment) services. Children who are Medicaid eligible must be evaluated and provided treatment for any problems detected. The program is costly for states and the implementation has been poor. The promise of this comprehensive program for children is currently unrealized.

Children in the foster care system enter as survivors of troubled families. Wolin and Wolin (1994) remind us that: "Young survivors figure out how to locate allies outside the family, find pleasure in fantasy games, or build self-esteem by winning recognition in school" (p.5). Foster parents play a critical role in promoting and expanding skills which will, over time, expand children’s capacities to overcome adversities. The positive difference one caring adult can make in the life of a child is emphasized in resilience research. This research seeks to answer the question: Why do some children who have grown up under extremely adverse conditions, develop stable, healthy personalities? Rutter (1987) described resilience as a buffering process that does not eliminate all risks, but rather provides resources to enable individuals to manage risks effectively. Werner and Smith’s (1992) 37 year resilience study greatly contributed to the identification of protective factors which were present in the lives of resilient adults. They included; individual strengths, close relationships with caregivers who provide emotional support and external support systems. Grotberg (1995) investigated ways in which caregivers and children themselves supported the development of resilience. She   suggested that caregivers can promote resilience in children through their words, actions and the environment they provide. They encourage children to become more independent, responsible, empathic, altruistic and to approach people and situations with hope, faith and trust. They teach children ways to communicate their needs, solve problems and successfully handle negative feelings and thoughts. Foster parents have traditionally played this caregiving role. Support and assistance from the foster care community in promoting those protective factors can enhance the impact foster parents have in children’s lives.

In addition to focusing on prevention of problems, early identification and intervention must be available to children in foster care. As children enter care, they need an evaluation of their mental health status. Schneiderman (1998) recommends that information be gathered from as many sources as possible including; written records, school reports and interviews with biological and foster parents. Treatment is needed to prevent additional trauma and to address current mental health problems. This must be accessed on an ongoing basis while children are in out-of home care. Frequent, clear and timely communication must take place among the many adults in the welfare, health and judicial systems who are part of the caring community for children in foster care.

Currently, programs are being established across the country to provide comprehensive health services that include mental health services for children in foster care. The Birth to Five Consultation Model (Morrison, et al 1999) uses a mental health clinician to provide guidance and support to foster parents in promoting mental health and meeting the emotional needs of the young children in their care. The establishment of a medical home (American Academy of Pediatrics, 1997) also serves as a model to provide comprehensive services for children. The medical home represents a partnership between caregivers and providers to identify and access all of the physical and mental health services needed to help children achieve their maximum potential.

Mental Health Services for Children in Foster Care

Guiding Principles

 

1. Mental health services for children in out-of-home care and their families should be integrated with the social service system of child welfare agencies.

 

2. Mental health services for children in care should focus on prevention as well as dysfunction.

 

3. The menu of mental health services available to children and their families must be tailored to the various reasons for placement as well as the consequences of placement.

 

4. Short-term and, in some cases, long-term treatment interventions must be available at critical junctures in the placement lives of the children and their families.

(Schneiderman et al, 1998)

Outcomes for children in the child welfare system are mixed. Negative results are often the result of the interaction and build-up over time of many risks.  A comprehensive, caring community offering continual preventive services and early identification of needs can improve outcomes for children. With a strong focus on enhancing the capacity for resilience for children in foster care through comprehensive physical and mental health services, early intervention services and strong, positive supportive caregivers, the lives of these children can improve.

Given good soil, water, and sun, one small seed can produce a large, round and healthy pumpkin. Responding to a child’s seemingly simple request is a nurturing act. A foster child’s mental health, like that pumpkin seed, can blossom, grow and flourish under careful nurturing, intervention and treatment.

REFERENCES

Blatt, B., Saletsky, S., Meguid, R., Church, V., & Critzet, C. (1997). A Comprehensive, Multi-disciplinary Approach To Providing Health Care For Children In Out-of Home Care. Child Welfare, 87 (2), 331-347

Grotberg, E. (1995). A Guide To Promoting Resilience In Children: Strengthening The Human Spirit. The Hague, Netherlands: Bernard van Leer Foundation.

Morrison, J., Frank, S., Holland, C., & Kates, W. (1999). Emotional Development and Disorders in Young Children in the Child Welfare System. In J. A. Silver, B. J. Amster & T Haecker (Eds.), Young Children and Foster Care (pp. 33-65). Baltimore, MD: Brookes

Rutter, M. (1987). Psychosocial Resilience and Protective Mechanisms. American Journal of Orthopsychiatry 57 (3), 316-329.

Schneiderman, M., Connors, M., Fribourg, A., Gries, L., & Gonzales, M. (1998). Mental Health Services for Children in Out-of-Home Care. Child Welfare, 87 (1), 166-183.

Simms, M., Freundlich, M., Battistelli, E., & Kaufman,D.(1999). Delivering Health and Mental Health Care Services to Children in Family Foster Care After Welfare and Health Care Reform. Child Welfare, 78(1), 166-183.

Werner E., & Smith, R. (1992). Overcoming the Odds:High Risk Children from Birth to Adulthood. Ithaca NY: Cornell University Press.

Wolin, S & Wolin, S (1994). The Resilient Self: How Survivors of Trouble Families Rise Above Adversities. NY: Villard Books

American Academy of Pediatrics. (1997). Health Care of Children in Foster Care in Managed Care and Children with Special Health Care Needs. Elk Grove, IL: author

Child Welfare League. (1998). Standards for Health Care Services for Children in Out-of-Home Care. Washington, D.C: author

Weinreb, M. (1997). Be a Resiliency Mentor: You May Be a Lifesaver for a High-Risk Child. Young Children, 52 (2), 14 - 21

Bernard, B. (1995). Fostering Resiliency in Kids. Educational Leadership 19 (3), 44-48