Jeanette M. Scheid, MD, PhD

The Child Abuse Prevention and Treatment Act defines child abuse and neglect as “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.”1 Each state sets its own definitions of child abuse and neglect within the standard of federal law.

of abuse and neglect in 2018, representing approximately 7.8 million children.

 Astonishingly, almost 1800 children died of abuse and neglect, at a rate of 2.39 per 100,000 US children.

, representing 60.8% of the cases. This was followed by physical abuse (10.7%), sexual abuse (7.3%), and psychological maltreatment (2.3%). Parents are most commonly identified as perpetrators (77.5%). Almost half (49.6%) of the perpetrators were white; drug use disorder was common (30.7%) among maltreatment perpetrators.

The child’s developmental age during maltreatment exposures is an important consideration in assessment, diagnosis, and treatment. There are likely sensitive developmental periods that affect risk for psychopathology.

 For instance, maltreatment exposure during infancy and early childhood 

 necessary for subsequent development, including capacity for trust, recognizing cause and effect, emotional regulation, and frustration tolerance. Similarly, developmental stage affects the diagnosis of posttraumatic stress disorder.

Without normative attachment, children can move into their middle years without the tools to succeed in peer relationships, school, and extracurricular activities. In adolescence, the impact of earlier maltreatment increases the likelihood of risk-taking behavior and subsequent health effects, including risky sexual behavior leading to sexually transmitted diseases, substance use, and suicide attempts. Subsequently, the increased risk of health and mental health problems persists through adulthood.5 Because of these potential long-term effects, obtaining a comprehensive social history, including maltreatment exposures and the characteristics of subsequent environments, is important when conducting a comprehensive psychiatric assessment and considering treatment approaches.

is Associate Professor, Department of Psychiatry, Michigan State University, East Lansing, MI and Medical Consultant to the Michigan Department of Health and Human Services, Children’s Services Agency.

1. CAPTA Reauthorization Act of 2010 (P.L. 111-320)
	2. US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2018. Available at: www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment. Accessed April 14, 2020.
	3. Teicher M, Samson J. Childhood maltreatment and psychopathology: a case for ecophenotypic variants as clinically and neurobiologically distinct subtypes. 

2013;170:1114-1133.
	4. Pynoos RS, Steinberg AM, Layne CM, et al. 

DSM-V PTSD diagnostic criteria for children and adolescents: a developmental perspective and recommendations

2009;22:391-398.
	5. Sege RD, Amaya-Jackson L, et al. Clinical considerations related to the behavioral manifestations of child maltreatment. 

Articles

Without normative attachment, children can move into their middle years without the tools to succeed in peer relationships, school, and extracurricular activities, opening the door to perils in adolescence.

Understanding Child Maltreatment

On any given day, there are more than 400,000 children in foster care in the US (

). Children in foster care are at a higher risk for health and mental health problems.

 They are also connected to multiple systems, which require and challenge coordinated care.

 Further complicated by histories of maltreatment (Sidebar) and issues in assessment, diagnosis and treatment can be challenging-for children, their families and guardians, and their clinicians. In honor of 

, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

“Joseph” is a 3-year-old in foster care. After 2 out-of-home placements, he was returned to his parents. Each removal was connected to allegations of physical abuse. His permanency goal is changing to adoption, but he still has visits with his parents. He is physically healthy but hyperactive and impulsive and has problems sleeping.

When Joseph first arrived at his current foster home, he had temper outbursts at least once a day that included screaming, hitting, kicking, and breaking things. Over the course of a few months, the outbursts decreased to weekly; the outbursts seemed connected to visits with his parents.

Joseph has a diagnosis of attention-deficit/hyperactivity disorder and oppositional defiant disorder. He was prescribed 18 mg methylphenidate ER in the morning, 0.1 mg clonidine at bedtime, and 0.5 mg risperidone twice daily, all by his primary care provider. How and when these medications were started is not clear from the records.

Upon entering treatment with a community mental health provider, Joseph’s foster mom reported “we can’t handle him without these medications.” Discussions continue about the risks and benefits of risperidone and the circumstances under which it would be possible to start tapering.

Providing psychiatric services to children and adolescents in foster care require collaboration not only with the clinical team, but also the child welfare team. Team members include parents, foster parents, and the social worker, at minimum. The team may also include representatives from courts and others engaged by the child welfare system to conduct assessments (eg, psychological, neuropsychological). Child welfare services’ organizational structure varies from state to state. State and/or local policy defines practice related to permanency and broader case planning, defining the consenting parties for health and mental health treatment, practices for obtaining informed consent for psychotropic medication, and tracking and oversight of psychotropic medication use for children in foster care.

Foster care workers typically serve 10 to 15 families. They are responsible for all aspects of case planning including monitoring placements, ensuring safety, arranging parental visitation, preparing for court, and planning for permanency. Case workers are often very knowledgeable about the youths and families they serve and can be a true partner in care. Psychiatrists and their office staff should reach out to local child welfare leadership to build collaborative relationships. In doing so, it is helpful to share office hours, emergency service policies, duration of initial assessment and follow up appointments, information needed prior to an initial assessment, and preferred pathways for communication between the office and the child welfare team. These outreach efforts are useful during usual care as well as when challenges or crises arise.

Children in foster care often experience placement changes. Maintaining continuity of care during treatment within a single organization as well as ensuring that comprehensive clinical information transfer occurs when children transition to new treatment providers presents a challenge. Psychiatrists should provide leadership in policy and practice development to accomplish this goal.

Child welfare systems present unique challenges for comprehensive psychiatric assessments. Psychiatrists must receive complete prior mental health records, including those prior to foster care placement; as such, they should establish mechanisms to obtain collateral history from parents, foster parents, and other caregivers (eg, staff in residential placement), and obtain health and school records. Psychiatrists should communicate these needs to the team, assist in developing protocols for consent for release of information documents, and maximize information transfer within systems.

Although most, if not all children, in foster care have suffered maltreatment exposure, the type, duration, and impact of such before foster care varies. Children may also experience traumatic exposures during foster care, including stress related to parental circumstances, separation from siblings, placement change, termination of parental rights, as well as illness and death of family members.

Although it may not be necessary or appropriate to ask children to recount specific experiences and/or exposures, psychiatrists should make the child and their family aware that they know that stressful events have occurred and provide psychoeducation on the impact of ongoing stressors in the context of maltreatment. Exposures need to be considered when conducting assessments. Doing so may include asking the child and caregivers to complete screening tools or diagnostic assessments specific to traumatic exposures as well as those related to other psychiatric diagnoses.

When a child in foster care is scheduled for a psychiatric assessment, clinical staff should inquire about the legal status of the child, the names and contact information for the person legally empowered to consent for treatment, and who will be bringing the child to the appointment. Unless the child and parent are prohibited from contact, arranging for parents to be present is optimal so that they can provide history, sign consents for release of information, and engage in consent for treatment. If a parent cannot be present, they can be contacted before the appointment for needed information.

The long-term priorities of the welfare systems are reunifying children and parents when possible and supporting family functioning. Engaging parents throughout their children’s time in foster care supports these goals; engaged parents are better equipped to address their children’s physical and mental health needs.

Unfortunately, involving parents is complicated by many factors. Maternal characteristics such as poverty, substance use, co-occurring disorders, and domestic violence as well as perception of the effects of sharing information may discourage involvement.

 Addressing parental needs (eg, substance use disorder treatment) is important for successful reunification, but may present a barrier to simultaneous engagement in a child’s health care.

 Given that reunification is the most common goal, educating all team members about the importance of parental engagement is important throughout foster care placement.

“James” is a 16-year-old admitted to a residential treatment facility after running away from 2 foster homes. His entrance into the foster care system was predicated by ongoing but undisclosed sexual abuse perpetrated by his stepfather that occurred for at least 5 years before discovery. At that time, he was diagnosed with bipolar disorder and anxiety. He was treated with ari- piprazole, titrated to 15 mg daily and 0.5-mg alprazolam up to 3 times daily for acute anxiety. During residential assessment, James reported periodic temper outbursts and moodiness without clear episodes of depression or mania. Also during this time, he reported significant anxiety and occasional panic attacks.

During residential treatment, he participated in individual and group therapy. The aripiprazole was gradually tapered and discontinued, alprazolam was also tapered. He made plans to transition from the residential facility to an independent living program.

There are a wide variety of psychiatric diagnoses among children in foster care (

 looked at Medicaid claims data (2002 to 2007) from a national sample of youths aged 3 to 18 years who were enrolled in foster care. The findings indicated that rates of mental health diagnoses generally increased over this time with 2 exceptions: depression was stable from 2002 to 2005 but decreased from 2006-2007, and schizophrenia remained stable throughout. Generally, the rates of diagnoses in this sample of children are higher compared with cumulative diagnosis by age 7 from a single state 2007 birth cohort sample.

Because of maltreatment, children in foster care often have trauma-related diagnoses, with posttraumatic stress disorder as the most specific trauma-related diagnosis. DSM-5 includes guidance about how PTSD may manifest in childhood. More general responses to trauma exposure may be captured by “trauma and stressor related disorder unspecified” if PTSD cannot be diagnosed with confidence.

To diagnose disorders common in childhood (eg, ADHD, anxiety disorders, and depressive disorders), psychiatrists should determine whether symptoms are present, the timing and duration of symptoms in relation to trauma exposures, and persistence after substantial reduction in trauma-related symptoms. Emotional dysregulation is a common response to traumatic exposures; if considering 

 or disruptive mood dysregulation disorder, clinicians must determine if full symptom, duration, and pattern criteria are met or if symptoms may be better explained by trauma.

Perception and thought disturbances are also relatively common in children with maltreatment exposure. Explanations may include intrusion of traumatic experiences (eg, nightmares, flashbacks, involuntary memories) and negative thoughts and feelings (eg, distorted beliefs about the self or others) rather than emerging psychosis.

Finally, the potential for other co-existing factors that affect diagnosis-such as exposure to substances and maternal stress in utero, perinatal stress related to neonatal abstinence syndrome, and the effect of any abuse-related physical or neurological injury-must be included in differential diagnosis, treatment planning, and assessment of longer-term services, supports, and prognosis. (See Keeshin et al

 for an in-depth discussion of manifestations of maltreatment and impact on psychiatric diagnosis.)

Psychotherapy is generally considered first line when addressing trauma- and stressor-related emotional and behavioral conditions in children. Strategies with empirical support include trauma-focused cognitive behavioral therapy (TF-CBT); parent-child interaction therapy (PCIT), which is suggested for children aged 2 to 7 years to improve parenting skills and reduce children’s disruptive behavior; and attachment and bio-behavioral catchup (ABC), which has been tested in toddlers in foster care.

 The National Child Traumatic Stress Network (

) provides information on a variety of evidence-based and promising psychotherapeutic approaches for children exposed to maltreatment.

Studies have shown an increase in the use of psychotropic medication, including antipsychotics, in children and adolescents through mid-2000.

 Use of psychotropics is even higher in foster care (

 Although this trend has raised over-medication concerns, other factors must be considered, eg, a higher risk of emotional and behavioral concerns related to family/genetic history and maltreatment exposure. Since its peak in the mid-2000s, psychotropic medication use has plateaued, possibly a consequence of oversight efforts.

Treatment with psychotropic medications should not be considered first line when targeting emotional and behavioral difficulties related to trauma. However, evidence-based use for co-existing disorders, and judicious use to target symptoms that cannot be managed by psychosocial treatments alone, may be considered.

Psychopharmacological treatment for psychiatric diagnosis such as ADHD, major depressive disorder, and bipolar disorder in the context of maltreatment should follow existing recommendations and guidelines. However, closer monitoring and re-evaluation should occur if the child’s response is not as expected, as children exposed to maltreatment may be more likely to experience side effects such as suicidal ideation on antidepressants.

 As generally recognized, clinicians should start with lower doses, advance slowly, maintain monotherapy versus multiple medications in combination and monitor for adverse reactions per clinical guidelines.14

When the child has symptoms that do not clearly meet diagnostic criteria for a specific disorder, the clinician should proceed more cautiously. Children, families, the psychiatrist, and other team members should discuss the full range of psychosocial interventions. If evidence-based interventions have not yet been implemented, the team should develop a plan to do so. The team should consider whether additional supports are needed, including the implementation of a parenting curriculum for children exposed to trauma or other support (eg, respite services).

Sleep disturbances are common in children but more frequent in the setting of trauma; the evidence for medications is limited. Melatonin is one option; other options such as benzodiazepines or second-generation antipsychotics should be avoided.

When children’s aggressive behaviors put them or others at significant risk, medications can be considered as one part of a comprehensive treatment plan. Medications should be used at the lowest possible dose and monitored carefully. The team should develop a plan to monitor response to medication (ie, improvement in target symptoms) and a target timeline for tapering and/or discontinuing medication. A plan to switch medications should also be in place; such a plan should include tapering of the first medication before starting the second. Additional support for the child and/or family may be needed during medication transitions.

Children in foster care who demonstrate symptoms such as severe aggression are also more likely to experience placement transitions in community and residential settings. Under these circumstances, there is risk of polypharmacy, and it is more difficult to assess individual medications. After any transition that involves a new treatment team, both written and verbal communication is critically important-some medications may need to be discontinued (

Young adults transitioning out of foster care may be less inclined to accept recommendations from treatment providers, if only because they perceive lack of control over their lives. They may also have fewer natural supports to help them navigate adult responsibilities. It is, therefore, important to inquire about support systems as well as to acknowledge their lived experience and engage them in shared treatment decision-making.

Children in foster care present with extra challenges and unique situations, but with thoughtful assessments and coordination, they can have positive outcomes. Psychiatrists are in the unique position to provide comprehensive clinical care and policy leadership supporting all children’s health and well-being.

1. Szilagyi MA, Rosen DS, Rubin D, et al. Health care issues for children and adolescents in foster care and kinship care. 

2. Lee T, Fouras G, Brown R, AACAP Committee on Quality Issues. Practice parameter for the assessment and management of youth involved with the child welfare system. 

3. Keeshin B, Forkey HC, Fouras G, et al. Children exposed to maltreatment: assessment and the role of psychotropic medication. 

4. Marcenko MO, Lyons SJ, Courtney M. Mothers’ experiences, resources and needs: the context for reunification: 

5. Cao Y, Bunger AC, Hoffman J. Caregiver engagement in the behavioral health screening and assessment for child welfare-involved children: child welfare and behavioral health workers’ perspectives. 

6. Doab A, Fowler C, Dawson A. Factors that influence mother-child reunification for mothers with a history of substance use: a systematic review of the evidence to inform policy and practice in Australia. 

7. Rubin D, Matone M, Huang Y-S, et al. Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care. 

8. Pennap D, Zito JM, Santosh PJ, et al. Patterns of early mental health diagnosis and medication treatment in a Medicaid-insured birth cohort. 

9. Sege RD, Amaya-Jackson L, et al. Clinical considerations related to the behavioral manifestations of child maltreatment. 

10. Olfson M, Blanco C, Liu L, et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. 

11. GAO. HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. 2011. GAO-12-270T.

12. Perry, B. Harris Walsh K, et al. Change in psychotropic prescribing patterns among youths in foster care associated with a peer-to-peer physician consultation program. 

13. Singh AB, Bousman CA, Ng CH, Berk M. High impact child abuse may predict risk of elevated suicidality during antidepressant initiation. 

14. Walkup, J for the American Academy of Child and Adolescent Psychiatry Workgroup on Quality Issues. Practice parameter on the use of psychotropic medication in children and adolescents. 

15. Owens JA, Mindell JA. Pediatric insomnia. 

In honor of National Foster Care Month, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

Challenges and Strategies in Foster Care

Child maltreatment is a broad term that includes neglect, physical abuse, sexual abuse, and emotional abuse; however, the US Department of Health and Human Services reports only on neglect and physical and sexual abuse. In the US, neglect is the most common form of maltreatment (75%), followed by physical abuse (17%), sexual abuse (8.3%), psychological maltreatment (6%), and medical neglect (2.2%).

The response to a report of alleged maltreatment is set by each state but typically includes an initial screening. When the screen is positive, Protective Services conducts an investigation to determine whether maltreatment occurred or provides an alternative response to identify the needs of the child and family.

The number of children in foster care has declined substantially over the past decade, from about 800,000 in 2005 to roughly 650,000 in 2014 (

 This trend has been true across most racial and ethnic groups; however, the rate has increased among mixed-race children (

Although the percentage of African American children in foster care has declined substantially, the rate is still about twice the national average. The overall duration of stay in foster care has declined during this period as well. These trends coincide with concerted efforts at the national and state level to increase family preservation services and to achieve permanency.

Mental health disorders of children in foster care

The prevalence of both medical and mental health problems among children in foster care is high. One study of children in foster care aged 2 to 14 years identified nearly 50% with clinically significant mental health problems.

 In a similar study of teenagers, 42% had at least one mental health disorder; of these, nearly one-third had 2 disorders and one-fifth had 3 disorders.

A number of factors contribute to risk. Children in foster care are more likely to have been exposed to substances in utero, have a higher rate of family psychiatric problems, are more likely to experience substance use in parents and caregivers (2- to 3-fold higher in victimized vs non-victimized children), are less likely to have had consistent prevention and primary care services and, by definition, have experienced one or more instances of maltreatment. The presence of health and mental health challenges can also increase the risk of disrupted foster care placements and poor continuity in health and mental health care, thus compounding the loss and trauma.

Tony, a 7-year-old boy, is placed in a short-term residential facility for assessment following failure of a foster care placement related to aggression and destructive behavior. From birth until age 6 he was in the care of his birth mother, but protective services were engaged periodically following allegations of neglect. Tony’s father briefly had custody several months before residential placement, but custody was revoked after an allegation of abuse stemming from physical discipline. Tony has been taking stimulant medication for the past 3 years.

While in the assessment facility, Tony demonstrates highly disruptive behavior, including property destruction, physical aggression, and self-injurious behavior. He also makes suicidal and homicidal threats. These behaviors become unmanageable in the residential setting, and Tony is hospitalized.

During admission, the stimulant is discontinued and an alternative stimulant and topiramate are started with Tony’s mother’s consent. On return to the assessment center, behavioral problems continue and after discussion with Tony’s father, clonidine extended- release is added. Tony’s mother objects to this recommendation but chooses not to fight it legally. Within 1 week, Tony is moved to a foster home.

Medicaid prescription claims data from 5 states showed that the rates of psychotropic medication use ranged from 2 to 5 times higher in children in foster care compared with non-fostered children served by Medicaid.

 A follow-up report based on in-depth child welfare case reviews in each of these 5 states raised concerns about the effect of care quality on prescribing trends.

 Specifically, the child welfare case reviews revealed that:

• In a substantial minority of cases, the clinical documentation within the child’s foster care record did not support psychotropic medication use.

• Only in a minority of cases did the child welfare record reflect efforts to provide evidence-based psychotherapeutic interventions.

• In those cases in which concomitant psychotropic medications were used, the documentation of rationale in the child’s case file was much less common.

• Documentation of informed consent was absent in about one-third of the cases and fully documented in about one-fourth.

• In one-third of the instances in which psychotropic medications were used in infants, there was no clear documentation in the child’s case file of the reason for the medication recommendation.

• Multiple medications at relatively high doses were common during inpatient treatment.

Jessica is a 17-year-old who has been in the foster care system for many years. She was placed in residential care because of conflict with her latest foster family. She has a long history of mental health treatment in outpatient and inpatient settings. She reports highly variable emotional states, typically brief in duration and reactive to circumstances.

At the time of admission to residential care her medication regimen included chlorpromazine, fluoxetine, lurasidone, lamotrigine, trazodone, and oxcarbazepine. There is limited information about the chronology of medication treatment and no records of psychotherapy services.

Jessica is not able to provide much information about her response to the medication regimen, and there are no other sources of collateral information. In spite of this complex regimen, she continues to demonstrate frequent shifts in emotions and aggressive behavior, most often related to interpersonal conflict or to small disappointments. On one occasion, she became physically aggressive, which led to assault charges and a 72-hour incarceration. The plan is for her to transition to an adult foster care facility after her 18th birthday.

Adam had been placed in residential care for sexual offender treatment following allegations of criminal sexual conduct. He had received a diagnosis of bipolar disorder and was taking olanzapine, fluoxetine, and lorazepam. Past assessment and treatment records are limited. Adam reports that between the ages of 8 and 16 his stepfather sexually abused him. The abuse was discovered inadvertently, and soon thereafter Adam was placed in foster care. Notably, the abuse was not disclosed or discovered when bipolar disorder was diagnosed. Adam reports multiple symptoms consistent with PTSD, most prominent of which are nightmares and hypervigilance.

In residential placement, Adam participates in formal sexual offender treatment and receives intermittent exposure to cognitive behavioral techniques, but no sustained course of cognitive behavioral therapy or any other treatment specific to PTSD. The fluoxetine dosage is increased with some reduction in anxiety, and prazosin is added to address nightmares with some success. The olanzapine is maintained, although Adam does not report any benefit from it.

After his 18th birthday, he is ambivalent about treatment. Sometimes he expresses a desire to complete sexual offender treatment and then transition into the community; at other times he expresses a desire to leave but needs a set of supports and treatment in place. His social worker and residential staff believe his plans about leaving are unrealistic; however, they cannot do much to help him. Now that he is 18, all the parties involved in his care are limited to providing advice.

Consensus guidelines for children served by child welfare

The American Academy of Child and Adolescent Psychiatry (AACAP) has published guidelines to help clinicians who provide clinical services to children in foster care. In 2011, the AACAP Committee on Community Based Systems of Care developed a set of basic principles for the care of children in state custody 

). In 2015, an additional set of guidelines specifically related to the use of psychotropic medications in this population (

) was published. The AACAP also published a practice parameter for the assessment and management of youth involved in the child welfare system (

Psychiatrists encounter multiple challenges in providing quality care for children served by child welfare agencies across the continuum of care. The first of these are limitations in the existing knowledge base, especially the impact of maltreatment on clinical presentation and diagnosis. It is incumbent on psychiatrists to pursue continuing education in this area and to support advocacy efforts to fund bench and clinical research.

A second challenge is obtaining treatment records. Records may exist in several places and might predate foster care placement. Although some state laws expressly require legal parents to disclose all current and prior providers and to provide consent for release of records, it is difficult to get all of the parties (health care providers, foster care personnel, and parents) to coordinate efforts and obtain records.

A third challenge is ensuring that health and mental health care organizations fully support the infrastructure needed to provide quality care as recommended by the AACAP. Allowing time to review earlier records, ensuring access to all collateral sources of information, and committing to child and family engagement in shared clinical decision-making are critical. Child and adolescent psychiatry must provide leadership within their organizations to develop the means to ensure quality assessment and treatment.

Finally, young adults coming from foster care are legally empowered to engage in decision-making about health and mental health care. However, the consequences of trauma exposure and the current realities of the broader systems of care leave them ill-equipped to engage in independent decision-making. These young adults are more likely to engage in behaviors that increase their odds of inpatient psychiatric care and criminal justice involvement.

The general psychiatrist can play a greater role in better outcomes for children in foster care. Understanding the long-term consequences of child maltreatment and child welfare systems allows psychiatrists to help the treatment team provide appropriate services and supports and to advocate for community-wide support systems for these youths.

Dr. Scheid is Associate Professor in the department of psychiatry at Michigan State University. She is former President and current Chair of Membership of the Michigan Psychiatric Society. She reports no conflicts of interest concerning the subject matter of this article.

 US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. 

http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2014

. Published January 25, 2016. Accessed May 12, 2016.

 US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Trends in Foster Care and Adoption: FY 2005 – FY 2014. 

 US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Recent Demographic Trends in Foster Care. 

http://www.acf.hhs.gov/programs/cb/resource/data-brief-trends-in-foster-care-1

. Published September 2013. Accessed May 12, 2013.

 Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. 

 Heneghan A, Stein R, Hurlburt MS, et al. Mental health problems in teens investigated by US child welfare agencies. 

 Government Accountability Office. Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. GAO-12-270T. 

. Published December 1, 2011. Accessed May 12, 2016.

 Government Accountability Office. Foster Children: HHS Could Provide Additional Guidance to States Regarding Psychotropic Medications. GAO-14-651T. 

. Published May 29, 2014. Accessed May 12, 2016.

 American Academy of Child and Adolescent Psychiatry. Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline. 2011. 

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/FosterCare_BestPrinciples_FINAL.pdf

 American Academy of Child and Adolescent Psychiatry. Recommendations About the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems. 2015. 

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/AACAP_Psychotropic_Medication_Recommendations_2015_FINAL.pdf

 Lee T, Fouras G, Brown R, for the AACAP Committee on Quality of Care Issues. Practice parameter for the assessment and management of youth involved with the child welfare system. 

Here's how the general psychiatrist can play a greater role in better outcomes for children in foster care. 

Jeanette M. Scheid, MD, PhD

Articles

Understanding Child Maltreatment

Challenges and Strategies in Foster Care

Children in Foster Care: Issues and Concerns