Mental Health Concerns for Children in Foster Care

Child maltreatment often results in removal from the parental home and increases the risk for behavioral health concerns.  The foster care experience can further increase this risk.  It is therefore wise to consider aspects of mental health for children in foster care including prevalence, risk, treatment, and policy recommendations.

Keywords: child maltreatment, foster care, mental health, behavioral health, adverse childhood experiences

Children who have experienced maltreatment are often placed in foster care.  Not only does child maltreatment increase the risk for development of behavioral or emotional difficulties (Hillen, T., & Gafson, L., 2015), but the foster care experience can have a negative impact on the child's mental well-being.

  With these concepts in mind, it would be beneficial to examine mental health issues of children in foster care including prevalence, risk factors, treatment options, and recommendations for policy makers.

The Issue

On any given day in the United States, there are about 400,000 children placed in foster care (U.S. Department of Health and Human Services, 2017).  Foster care is generally understood as any out-of-home placement for children who cannot safely remain in their parental home due to evidence of child maltreatment.  Child maltreatment is broadly defined as physical abuse, sexual abuse, emotional abuse, failure to provide necessary care, and failure to properly supervise resulting in actual harm or potential for harm to the well-being of a child (Cabrera, G., & Schub, T., 2018).

Child maltreatment and subsequent placement in foster care is a unique coupling of significant risk factors for behavioral health concerns.  Studies have documented the strong correlation between adverse childhood experiences (ACEs) and behavioral health struggles later in life (Garrido, E. F., Weiler, L. M., & Taussig, H. N., 2018).  While forms of child maltreatment such as sexual abuse, physical abuse, exposure to violence, etc. may be eliminated for a child removed from the parental home, this does not eliminate or even reduce the ACEs for the child.  Ironically, steps taken to protect maltreated children also increase their ACEs.  Removal from the parental home, multiple caregiver transitions, and multiple school transitions are all considered ACEs and are a reality for children in foster care (Garrido, et al., 2018).

Children in foster care, because of their higher number of ACEs, have a much higher risk of developing behavioral health issues (Marie-Mitchell, A., Studer, K. R., & O'Connor, T. G., 2016, Garrido, et al., 2018).  While mental health is a significant aspect, behavioral health is more expansive to include social aspects like substance use, delinquency, risky sexual practices, aggression, and criminality (Garrido, et al., 2018, U.S. Department of Health and Human Services, 2018).  For children, displays of aggression, delinquency or general rule-breaking, or substance use could be the result of ACEs, mental illness, or a combination of both.  Taking these concepts into account could explain the prevalence of mental health diagnosis among children in foster care.

Incidence and Prevalence

Of the children in foster care, research has indicated that 40 to 60% have a mental health diagnosis compared to about 15-20% of the general population of children in the United States (Scozzaro, C. & Janikowski, T., 2015; Conn, A.-M. A.-M. Rochester. ed., Szilagyi, M., Alpert-Gillis, L., Baldwin, C., & Jee, S., 2016).  While it would be imprudent to attempt to assign specific causes for the prevalence of mental health concerns among children in foster care, there are some identified risk factors.   These risk factors include pre-placement and placement aspects of foster care (Hillen, T., & Gafson, L., 2015).  Pre-placement risk factors include:  mental illness of biological parents (genetics), substance use of biological parents and exposure to substances, ACEs related to maltreatment and trauma, and age of the child at the time of removal (Hillen, T., & Gafson, L., 2015).  Placement risk factors to consider are:  sudden changes in placement, multiple changes in placement, and the relationship between the caregiver and the child (Hillen, T., & Gafson, L., 2015).

SAMHSA's Take

For children experiencing behavioral health concerns, SAMHSA (Substance Use and Mental Health Services Administration) endorses a shift of focus from treatment to prevention and early identification of behavioral health concerns (U.S. Department of Health and Human Services, 2013).  It is arguable how applicable this recommendation is for children already in foster care because these children are particularly vulnerable to behavioral health concerns given the nature of their experiences.  SAMHSA also recommends developing integrated systems that continuously address primary medical care, specialty care, behavioral health care, and social support services in a family-centered approach (U.S. Department of Health and Human Services, 2013).  Translating this recommendation for children in foster care could be a struggle given that some children in foster care tend to transition between placements often which would create a barrier to continuity of care and a family-centered approach (Conn et al, 2016; Hillen, T., & Gafson, L., 2015).  However, SAMHSA's recommendation that primary care clinicians serve as a conduit for integrated behavioral health care (U.S. Department of Health and Human Services, 2013) could potentially be beneficial to children in foster care since routine primary physical health screenings are a requirement for children in foster care (Missouri Department of Social Services, 2016).

Generally speaking, SAMHSA advocates the importance of trauma-informed care in behavioral health settings (U.S. Department of Health and Human Services, 2015).  The principles of trauma-informed care are relevant to children in foster care given the high level of ACEs for maltreated children and the trauma associated with those experiences.  Additionally, trauma-informed care is a concept that can be taught to child welfare agency personnel, partner agencies, placement providers, and other stakeholders.  This is beneficial because it could facilitate continuity of behavioral health care for children in foster care.

Recommendations

Considering the high prevalence of mental health diagnosis of children in foster care coupled with the relationship between ACEs and behavioral health concerns, it may be prudent to implement mandatory mental and/or behavioral health screenings for children in foster care.  Given the evidence of the negative impacts of removal from the parental home and sudden changes in foster placement (Hillen, T., & Gafson, L., 2015), mental and/or behavioral health screenings should take place at the time of removal as well as anytime children in foster care have a sudden change in placement.  In most states, it is a requirement that foster children be seen by a primary care physician immediately following removal from a parental home and following a placement change (Missouri Department of Social Services, 2016).  With consideration to SAMHSA's recommendation that primary care clinicians have a more active role in identification of mental or behavioral health concerns, the recommendation that children in foster care receive mental and/or behavioral health screenings is certainly feasible.

Efficacy of a mental or behavioral health screening for infants or toddlers may come into question, though it is important to keep in mind the importance of attachment.  Attachment disorders, such as insecure attachment or disorganized attachment, are associated with behavioral health concerns like educational, social, and mental health problems (Wright, B., & Edginton, E., 2016). Studies suggest that removal from the parental home after the age of 6 months can have a more detrimental effect on the child's mental and behavioral health than removal earlier in life (Hillen, T., & Gafson, L., 2015; Wright, B., & Edginton, E., 2016).  This seems reasonable as infants younger than about 3 months do not show a preference for caregivers (Cherry, K., 2018). It is from the ages of about 4 to 7 months infants begin to develop attachments for preferred caregivers (Cherry, K., 2018).  This preferential attachment continues until about 12 months (Cherry, K., 2018).  It stands to reason that a disruption during stages of attachment when an infant can recognize preferred caregivers could have negative impact for the child beyond infancy.  Therefore, a basic behavioral health screening, potentially focused on secure and healthy attachment, would be reasonable for infants and toddlers removed from the parental home after 6 months of age.

As discussed previously, trauma-informed care is applicable in the realm of foster care.  It may be beneficial for policy-makers to be educated on trauma-informed care to help them recognize policies and practices that may be detrimental.  Further, policy-makers could implement trauma-informed care education at every level of the foster care system, including caregivers, case-workers, agency leadership, and partner agencies.  Understanding trauma and the principles associated with trauma-informed care can help child welfare agencies and other stakeholders fulfill their responsibility to act in the best interest of the child.  Trauma-informed care education may be especially beneficial for agencies that operate with a focus on a criminal justice model, such as juvenile delinquency and detention agencies or court systems.  In these systems the primary focus is often on penalizing behavior rather than preventing it.  Trauma-informed care does not excuse behavior, but rather it seeks to identify potential causes and build resilience in the service participant (U.S. Department of Health and Human Services, 2015).

As the adage goes, "an ounce of prevention is worth a pound of cure, thus, policy-makers turning the focus of child welfare more toward prevention may be valuable.  As had been discussed, children who experience maltreatment have a high prevalence of mental illness and behavioral health concerns (Scozzaro, C. & Janikowski, T., 2015; Conn et al, 2016; Hillen, T., & Gafson, L., 2015; Marie-Mitchell, A., et al., 2016; Garrido, et al., 2018).  Coupled with the ACEs associated with the foster care system, the risk for these vulnerable children is a "double-whammy (Hillen, T., & Gafson, L., 2015; Garrido, et al., 2018).  In a perfect world, children would never have to be removed from their parental home, but that would only be possible if child maltreatment by parents was eliminated completely.  It is unlikely that will ever happen.  However, that doesn't mean that preventative programs can not be developed and implemented to reduce the incidence of child maltreatment.  Because parents who maltreat their children have a high incidence of mental health and substance use disorders, (Cabrera, et al., 2018; Dong, et al., 2004; Stromwall, et al., 2008), one option could be improved access to behavioral health care (mental health and substance use treatment) for adults of child-bearing age.  The benefits of this intervention would reach well beyond reducing incidence of child maltreatment.

Conclusion

Of the approximately 400,000 children in foster care, about half have a mental health diagnosis.  These children have faced struggles associated with maltreatment, removal from the parental home, and adjustment to the foster care system.  They are particularly vulnerable to behavioral health concerns of mental illness and substance use.  Options exist to reduce the negative impact of maltreatment and the foster care experience.  However, it may be beneficial to focus more resources on interventions to prevent child maltreatment.

References

1. Cabrera, G., & Schub, T. (2018). Substance use disorder and child maltreatment. CINAHL Nursing Guide
2. Cherry, K. (2018, September 20). The story of bowlby, ainsworth, and attachment theory:The importance of early emotional bonds, Retrieved October 09, 2018, from https://www.verywellmind.com/what-is-attachment-theory-2795337#the-stages-of-attachment
3. Conn, A.-M. A.-M. Rochester. ed., Szilagyi, M., Alpert-Gillis, L., Baldwin, C., & Jee, S. (2016). Mental health problems that mediate treatment utilization among children in foster care. Journal of Child & Family Studies, 25(3), 969978. https://doi.org/10.1007/s10826-015-0276-6
4. Dong, M., Anda, R., Felitti, V. J., Dube, S. R., Williamson, D. F., Thompson, T. J., & Giles, W. H. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction Child Abuse & Neglect: The International Journal, 28(7), 771-784
5. Garrido, E. F., Weiler, L. M., & Taussig, H. N. (2018). Adverse childhood experiences and health-risk behaviors in vulnerable early adolescents. Journal of Early Adolescence, 38(5), 661680. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=eric&AN=EJ1176056&site=eds-live&custid=083-900
6. Hillen, T., & Gafson, L. (2015). Why good placements matter: Pre-placement and placement risk factors associated with mental health disorders in pre-school children in foster care. Clinical Child Psychology & Psychiatry, 20(3), 486. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edb&AN=108521866&site=eds-live&custid=083-900
7. Marie-Mitchell, A., Studer, K. R., & O'Connor, T. G. (2016). How knowledge of adverse childhood experiences can help pediatricians prevent mental health problems. Families, Systems & Health, (2), 128. https://doi.org/10.1037/fsh0000179
8. Missouri Department of Social Services, Child Welfare Manual, (2016)
9. Scozzaro, C. & Janikowski, T. (2015). Mental health diagnosis, medication, treatment and placement milieu of children in foster care. Journal of Child & Family Studies, 24(9), 25602567. https://doi.org/10.1007/s10826-014-0058-6
10. Stromwall, L., Larson, N., Nieri, T., Holley, L., Topping, D., Castillo, J., & Ashford, J. (2008).Parents with co-occurring mental health and substance abuse conditions involved in child protection services: clinical profile and treatment needs. Child Welfare, 87(3), 95-113.
11. S. Department of Health and Human Services; AFCARS Report, (September 2017) https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport24.pdf
12. S. Department of Health and Human Services, SAMHSA (2018) Retrieved October 9, 2018, https://www.integration.samhsa.gov/glossary
13. S. Department of Health and Human Services, (2013) SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS INTEGRATING BEHAVIORAL HEALTH AND PRIMARY CARE FOR CHILDREN AND YOUTH (Tech.). Retrieved October 9, 2018, from https://www.integration.samhsa.gov/integrated-care-models/ Integrated_Care_ System_for_Children_final.pdf
14. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Substance abuse and mental health services administration Center for substance abuse treatment. (2015). Quick guide for clinicians based on TIP 57: Trauma-informed care in behavioral health services. Retrieved October 09, 2018, from https://store.samhsa.gov/shin/content//SMA15-4420/SMA15-4420.pd HHs publication no. (sMa) 15-4420
15. Wright, B., & Edginton, E. (2016). Evidence-based parenting interventions to promote secure attachment: Findings from a systematic review and meta-analysis. Global Pediatric Health, 3, 2333794X16661888. http://doi.org/10.1177/2333794X16661888

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