Decision-making around psychotropic medications for children in foster care: Perspectives from foster parents

Background and objectiveChildren in foster care have complex mental health needs and receive high rates of psychotropic medications. Rarely can foster parents make legal decisions about treatment, yet they are intricately involved in the child's life and responsible for the child's safety and well-being. We aimed to conduct the first study of foster parent perspectives on decision-making relevant to the use of psychotropics with children in foster care.MethodsWe conducted semi-structured phone interviews with 13 parents in a small northeastern state who had fostered a child receiving psychotropics in the past 5 years. The state child welfare agency sent information about the study via email to all foster and adoptive parents for whom they had email contact. Interviews queried parents' knowledge and attitudes toward psychotropics, engagement in decisions, and recommendations for the decision-making process. Interview responses were coded and synthesized using mixed inductive and deductive methods in Dedoose software.ResultsChildren came into care on an average of four psychotropics. Parents reported receiving little information about the medications and finding information on their own. Parents acknowledged the potential benefits of medications, yet attitudes were largely against their use. Internal and external pressures for and against the use of medications were described. Many parents felt left out of the decisions and recommended team decisions.ConclusionsEfforts to improve foster parents' knowledge of medications, side effects, and monitoring, as well as team decision protocols, are sorely needed to improve decisions for this population.     

Changes in parenting practices during Parent Management Training Oregon model with parents of children in foster care

This study examined changes in parenting practices among parents receiving Parent Management Training Oregon model (PMTO). These parents had children in foster care with serious emotional disturbance and were randomized to receive in-home PMTO for up to six months. Using data from the Parent Child Checklist, an observation-based measure administered by therapists after each parent-child session, latent growth curve modeling was conducted with a sample of 318 parents of children, aged 3–16 years old, in foster care. Results showed that overall parenting effectiveness improved and that the change trajectory was best fit by a cubic model (two changes in trajectory). Parenting effectiveness initially increased but was found to turn downward temporarily, then rebounded toward additional improvements. Similarly, three of the six subscales – skill encouragement, positive involvement, and communication/monitoring – demonstrated significant change and a cubic trajectory. In contrast, problem solving and effective discipline subscales showed significant improvement but the trajectory was best fit by a quadratic model, indicating that these parenting practices improved and then leveled off near the end of treatment. The ineffective discipline subscale did not demonstrate significant change. Additionally, parents with high initial scores experienced lower rates of improvement and higher rates of deceleration. However, parents who started with relatively high rates of change were better able to maintain improvements over time. Overall, the results suggested PMTO was associated with increased effective parenting but the trajectory for positive change included both gains and setbacks. Future research is needed to determine whether gains in parenting practices are sustained beyond the treatment period.     

Health and mental health services for children in foster care: the central role of foster parents

It is well documented that children enter foster care with special health and mental health needs and, while in care, those conditions are often exacerbated. However, less attention has been given to foster parents who have the most contact with these children. Results are presented from a national study on the developmental, health and mental health care needs of children in foster care that included foster parents' perspectives and observations. Their role in improving child well being is explained and recommendations for policy, practice and advocacy also are included.     

The language and policy of care and parenting: Understanding the uncertainty about key players’ roles in foster care provision

Recent debates about the care provided to looked-after children have been characterised by uncertainty about the differing roles and responsibilities of foster carers, birth parents, and social workers. To explore the assumptions underlying these uncertainties, we drew upon Foucauldian Discourse Analysis and compared the discourses used by professionals (social workers in a group discussion about foster placement breakdown) with those used by policy-makers (in the Governmental green paper ‘Care Matters’). In both cases, a discourse based upon Attachment Theory was used to explain why placements succeed and fail, and to predict the repercussions of failure. However, there was a key difference in the way that professionals and policy-makers constructed the roles of key players in foster placements. The social workers constructed the birth parents as the parental figures for children in care, constructing themselves in a non-parental role. ‘Care Matters’ largely ignores the role of birth parents, and instead constructs social workers as parental figures. Neither source viewed foster carers as parental and ‘Care Matters’ positions this group as strictly professional. We discuss the incongruence of foster placements being understood through Attachment Theory, while foster carers are understood as non-parental figures, and also the repercussions of labelling a social worker as a parent, and the professionalization of the role of the foster carer.     

The potential for successful family foster care: conceptualizing competency domains for foster parents

The potential to foster successfully starts with developing and supporting competency in 12 domains: providing a safe and secure environment, providing a nurturing environment, promoting educational attainment and success, meeting physical and mental healthcare needs, promoting social and emotional development, supporting diversity and children's cultural needs, supporting permanency planning, managing ambiguity and loss for the foster child and family, growing as a foster parent, managing the demands of fostering on personal and familial well-being, supporting relationships between children and their families, and working as a team member. This article describes each domain and reviews relevant research to help guide the assessment of practicing and future foster parents.     

Making parents pay: The unintended consequences of charging parents for foster care

Most families in the child protective services system also interact with the child support enforcement system. This study exploits a natural experiment in Wisconsin, created by the state's large regional variation in child support referral policy, to estimate a potentially important effect of child support enforcement on the duration of out-of-home foster care placement. The effect we examine is whether requiring parents to pay support to offset the costs of foster care delays children's reunification with a parent or other permanent placement. We find evidence of this unintended effect, which is important not only because longer foster care spells are expensive for taxpayers, but also because extended placements in foster care may have consequences for child well-being. Our results highlight the potential importance of cross-systems analysis and the potential consequences when the policies and fundamental objectives of public systems are inconsistently coordinated. We discuss the implications of our findings for child support and child protective services policy.     

The biological children of foster parents in the foster family

This paper derives from a study of 15 biological children of foster parents, ages 6–12. While foster children have quite properly been the subject of much investigation, practically no research has explored the reactions of the foster parents' own children to the fostering experience. Findings of the study and examples from interviews will be cited which point to the possibility that these children exhibit, among other things, separation anxiety and superego conflicts related to fostering. Certain differences between the reactions of the younger (ages 6–8) and the older (ages 9–12) children will be highlighted.Submitted in partial fulfillment of the requirements for the Doctor of Social Welfare degree at New York University School of Social Work, 1985. The author wishes to thank Dr. George Frank, Emily Shachter and Dr. Irving Steingart for their valuable suggestions.     

A comparison of outcomes for children and youth in foster and residential group care across agencies

Working collaboratively with two state associations and their member (nonprofit) agencies providing out-of-home care to children and youth, University researchers conducted a multi-site project to examine whether there were any differences in individual child-level outcomes between children placed in residential group care and those placed in foster. The study employed a quasi-experimental repeated measures design, with data collected at a minimum of two intervals (at intake and 3-month follow-up) and at subsequent intervals of 6 and 12 months for children remaining in care. Samples for analyses were drawn from 1082 youth in either residential group care (n = 903) or foster care (n = 179), in one of 37 agency sites across two southeastern states, who participated in a broader evaluation project. The average ages of participating youth in residential and foster care were 13.97 (SD = 2.43) and 13.65 (SD = 2.73), respectively. Based on his or her score on the Children's Global Assessment Scale (CGAS) at intake, each participant was also assigned to the low functioning group (n = 526; 53.1%), the borderline group (n = 232; 23.4%), or the high functioning group (n = 232; 23.4%). Analyses confirmed that youth in foster care tended to have higher levels of general functioning at baseline than did youth placed in group care. However, the degree to which youth progressed in care on measures of general functioning and mental and behavioral health problems did not differ based on placement setting; youth in residential group care settings progressed at the same rate as youth in community-based settings, regardless of their level of functioning at intake. The only exception to this pattern was in regard to anxiety; there was an observable, but non-significant trend of youth in foster care reporting decreases in anxiety levels, while those in group care reported increased anxiety.     

Fostering homeless children and their parents too: the emergence of whole-family foster care.

Children should not be placed in out-of-home care simply because their families lack the means to provide for their basic needs, yet this practice continues nationwide. A new program based in St. Paul, MN, gives county social service departments the placement option of whole-family foster care. The target population is adult parents and minor children without stable residences, where the children are at risk of placement in out-of-home care. Although the parents and children may have special needs, there are no safety risks that would necessitate separating children and parents. The program's design is described and policy questions discussed.     

Continuity of care for youth in foster care with serious emotional disturbances

Continuity of mental health care has long been considered an essential component to the delivery of a high-quality mental health services, particularly for children with special needs. Unfortunately, discontinuities in care are common for children in foster care due in part to placement instability, disruptions in health coverage, and the fragmented health system. This retrospective cohort study examined factors associated with continuity of care for youth (aged 5–17 years) in foster care diagnosed with schizophrenia and bipolar disorder. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Continuity of care was defined as regularity of care—utilization of at least one outpatient mental health visit per month during the year. Multilevel modeling was used to assess the association between individual and contextual-level variables and continuity of care. Of the 952 youth in the study sample, 439 (46.1%) received regular monthly outpatient visits over the 1 year follow-up period. The odds of receipt of regular outpatient treatment were associated with prior outpatient care (odds ratio (OR): 7.43, 95% confidence interval (CI): 2.60–21.20), the presence of a chronic medical illness (OR: 1.45, 95% CI: 0.98–2.16), comorbid anxiety (Or: 1.76, 95% CI 1.22–2.53), or conduct disorder (OR: 1.57, 95% CI: 1.13–2.18), and the use of multiple psychotropic medications as compared to no medications (OR: 1.55, 95% CI: 1.08–2.23). The odds of receiving regular outpatient treatment were higher for youths who resided in suburban areas as compared to metropolitan areas (OR: 1.97, 95% CI: 1.04–3.73) and for those who resided in areas with greater supply of psychiatrists per capita (OR: 1.22, 95% CI: 1.02–1.45). Study findings underscore the need for quality improvement initiatives that improve access to care, care coordination, and continuity of care.     

Foster family acceptance: Understanding the role of foster family acceptance in the lives of LGBTQ youth

LGBTQ youth in the child welfare system have historically received very little attention. The limited research available suggests that they encounter a number of disparities and double standards when compared to straight youth. The current study examines the role that foster family acceptance plays in the lives of LGBTQ youth as they navigate the child welfare system. The experiences of LGBTQ foster care alumni who had accepting foster family experiences are compared to those who had rejecting experiences. Findings suggest that foster family acceptance plays a pivotal role in creating an affirming and inclusive environment for LGBTQ youth. Similarly, findings provide further evidence for the need to educate, train, and recruit affirming and accepting foster families.     

Characteristics and trajectories of treatment foster care youth

Using cross-sectional analyses in conjunction with dynamic modeling (hierarchical linear modeling), the authors profiled 119 treatment foster care youth and constructed behavioral change trajectories for a subset of 97 children. Children generally showed improvements in internalizing and critical pathology problem domains but remained the same on measures of externalizing behaviors and total problem score. The number of previous out-of-home placements was positively associated with increased levels of psychiatric symptomatology and served as the most robust predictor for modeling treatment response trajectories across problem domains. Placement instability places the well-being of children at heightened risk, therefore, accurate assessment of child need and risk in relation to caregiver capacities is critical.     

Needed services for foster parents of sexually abused children

Foster parents with little preparation and short notices must often deal with severe emotional and behavioral difficulties of sexually abused children. This article reports on a survey of the services provided to foster parents who care for sexually abused children in a large city in the Northeast United States. Agency directors, social workers and foster parents were asked to respond to mailed questionnaires. The results indicated that foster parents consistently reported that they received less extensive educational and support services than were reported by social workers and directors of foster care agencies. All groups recommend further expansion of training programs for foster parents of sexually abused children.This paper was presented at the Temple University Chapter, Phi Delta Kappa, Philadelphia, PA, April 5, 1990.Ms. Egan is a Research Assistant; Ms. Cossett and Ms. Auletta were studients from Smith College School for Social Work.     

Creative cooperation: involving biological parents in long-term foster care

There are some children in care for whom "permanency" means a long-term foster family placement. The author suggests that permanency for these children requires facing the reality of their biological parents in some form of relationship.     

Bibliotherapy for children in foster care and adoption

The bibliotherapeutic technique can help children adjust to the foster care and adoption experience. Appropriate children's books are described and the application and limitations of bibliotherapy are discussed.     

Parenting stress and parenting behavior among foster mothers of foster children with externalizing problems

Foster children often have externalizing problems. Since foster parents are selected and trained, they are often expected to be able to handle the externalizing problems of these children. Very little is, however, known about foster parents' parenting stress and parenting behavior in the context of challenging foster caregiving. In this study, the parenting stress and parenting behavior of 39 foster mothers of recently placed foster children with externalizing problems were studied. By using standardized measures with normative data, foster mothers' scores on different parenting stress and parenting behavior subscales were compared to published norms. Foster mothers of children with externalizing problems experienced more parenting stress than the norm group. The parenting context, provided by these foster mothers, was similar to the parenting context provided by the norm group. The prevalence of specific dysfunctional parenting behaviors (e.g., less involvement in positive parenting) was small to moderate, but nearly half of the foster mothers could be classified as making dysfunctional adaptations to their parenting environment. Moreover, only the minority of foster mothers provided an adaptive parenting context (e.g., more than average involvement in positive parenting). The implications of these results for pre-service training and on-going support for foster parents are discussed.     

Mentoring and social skills training: ensuring better outcomes for youth in foster care

Youth in foster care face significant life challenges that make it more likely that they will face negative outcomes (i.e., school failure, homelessness, and incarceration). While the reason(s) for out-of-home placement (i.e., family violence, abuse, neglect and/or abandonment) provide some context for negative outcomes, such negative outcomes need not be a foregone conclusion. In fact, interventions created to serve at-risk youth could ostensibly address the needs of youth in foster care as well, given that they often face similar social, emotional, and other challenges. Specifically, the author posits that supporting foster care youth through the use ofmentoring and social skills training could reduce the negative outcomes far too common for many of these youth.