Challenges and Strategies in Foster Care

May 15, 2020

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

On any given day, there are more than 400,000 children in foster care in the US (Table 1, Figure). Children in foster care are at a higher risk for health and mental health problems.1 They are also connected to multiple systems, which require and challenge coordinated care.2 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 National Foster Care Month, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

Case Vignette

“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.

Challenges in collaboration

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.

Diagnostic challenges

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.3

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.4,5 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.6 Given that reunification is the most common goal, educating all team members about the importance of parental engagement is important throughout foster care placement.

Case Vignette

“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.

Common diagnoses

There are a wide variety of psychiatric diagnoses among children in foster care (Table 2). Rubin and colleagues7 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.8

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 bipolar disorder 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 al3 and Sege et al9 for an in-depth discussion of manifestations of maltreatment and impact on psychiatric diagnosis.)

Treatment approaches

Psychotherapy

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.9 The National Child Traumatic Stress Network (www.nctsn.org) provides information on a variety of evidence-based and promising psychotherapeutic approaches for children exposed to maltreatment.

Pharmacotherapy

Studies have shown an increase in the use of psychotropic medication, including antipsychotics, in children and adolescents through mid-2000.10 Use of psychotropics is even higher in foster care (Table 3).11 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.12

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.13 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.3,15

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 (Table 4).

Concluding thoughts

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.

Disclosures:

Dr Scheid 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.

References:

1. Szilagyi MA, Rosen DS, Rubin D, et al. Health care issues for children and adolescents in foster care and kinship care. Am Acad Pediat. 2015;136:e1142-e1166.

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. J Am Acad Child Adolesc Psychiatry. 2015;54:502-517.

3. Keeshin B, Forkey HC, Fouras G, et al. Children exposed to maltreatment: assessment and the role of psychotropic medication. Pediatrics. 2020;145:e20193751.

4. Marcenko MO, Lyons SJ, Courtney M. Mothers’ experiences, resources and needs: the context for reunification: Child YouthServ Rev. 2010;33:431-438.

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. J Pub Child Welfare. 2019;13:101-124.

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. Int J Drug Policy. 2015;26:820-831.

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. Child Youth Serv Rev. 2012;34:1492-1499.

8. Pennap D, Zito JM, Santosh PJ, et al. Patterns of early mental health diagnosis and medication treatment in a Medicaid-insured birth cohort. JAMA Pediat. 2018;172:576-584.

9. Sege RD, Amaya-Jackson L, et al. Clinical considerations related to the behavioral manifestations of child maltreatment. Pediatrics. 2017;139:e20170100

10. Olfson M, Blanco C, Liu L, et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry. 2006;63:679-685.

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. J Am Acad Child Adoles Psychiatry. 2019;58:1218-1222.

13. Singh AB, Bousman CA, Ng CH, Berk M. High impact child abuse may predict risk of elevated suicidality during antidepressant initiation. Aust N Z J Psychiatry. 2013;47:1191-1195.

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. J Am Acad Child Adoles Psychiatry. 2009;48:961-973.

15. Owens JA, Mindell JA. Pediatric insomnia. Pediat Clin N Am. 2011;58:555-569.

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