GOING BEYOND FOSTER CARE
Sharon W. Cooper, MD
Developmental & Forensic Pediatrics, P.A. University of North Carolina Chapel Hill
School of Medicine
OBJECTIVES
• Adverse childhood experiences can and often do result in high risk
behaviors, particularly in children in foster care.
• Such children have a higher incidence of mental health conditions
which can hinder successful navigation of life after foster care.
• Pediatricians can play a pivotal role in educational success for these
“AGING OUT”
• Since 1999, the number of children in foster care has been decreasing,
though the number of children aging out, has remained stable over the past 10 years.
• In 2014, DHHS noted that from 2003-2012, ~ 262,730 young people
“aged out” of foster care, at a steady rate of about 20,000 children per year.
• Contrary to popular belief, the average age of a child in foster care is
over 9 years old.
• The average amount of time spent in foster care is 2 years, but 10% of
Adverse Childhood
Experiences determine the
likelihood of the
ten most common causes of
death in the United States.
TOP 10 RISK FACTORS
• Smoking • Severe Obesity • Physical Inactivity • Depression • Suicide Attempts • Alcoholism • Illicit Drug Use • Injected Drug Use • 50+ Sexual Partners • History of STDsTHE ACE QUESTIONNAIRES
• Originally, the ACE questionnaires were designed to be completed at
home, before a person was medically evaluated
• This is in contrast to a typical medical visit which begins with taking a
medical history, then examining a patient, obtaining symptom related studies and then having another visit for conclusion
INSTEAD, EVEN THE SHORTER VERSION……
• Helps people to rate the extent of trauma they have experienced in
childhood and to predict the likelihood that she or he will experience one or more forms of health, behavioral, and/or social problems.
• The trauma are in the areas of abuse: (psychological (by parent),
physical (by parent) or sexual (by anyone) and/or
• Household dysfunction: substance abuse, mental illness, mother
CASE EXAMPLE
• L.P. grew up in a family with severe IPV, and having been the victim of
CSA by her mother’s boyfriend, she was placed in the foster care system at the age of 11.
• She became a homeless youth at about 16 and was recruited from a
shelter by a trafficker who sexually assaulted her and threatened to harm her while exposing her to his violent behaviors towards other girls that he had living in his hotel room.
• LP described having had long term depression, anxiety and PTSD
from the CSA and she was a compliant victim to the trafficker for alcohol and cocaine use. She was able to run away after 3 months of his control during which she had a 2nd trimester miscarriage of an
Childhood Experiences vs.
Adult Alcoholism
0 2 4 6 8 10 12 14 16 18 % A lc o h o li cACE Score
0 1 2 3 4+Adverse Childhood Experiences
vs.
Likelihood of > 50 Sexual
Partners
0 1 2 3 4 A d ju s te d O d d s R a ti o 0 1 2 3 4 or more ACE ScoreAdverse Childhood Experiences
vs.
History of STD
0 0.5 1 1.5 2 2.5 3 A d ju s te d O d d s R a ti o 0 1 2 3 4 or more ACE ScoreAdverse Childhood Experiences
vs. Current Smoking
0 2 4 6 8 10 12 14 16 18 20 0 1 2 3 4-5 6 or more ACE Score %FOSTER CARE HEALTH RISKS
• Research has shown that this population includes children with more
complex physical, mental and emotional health care needs then the general Medicaid population. As a group they have:
• More chronic health problems.
• A higher incidence of congenital disorders and birth defects.
• An increased incidence of problems with developmental and growth
delays.
BARRIERS TO A HEALTHY MENTAL STATE
• The impact of foster care and the process of aging out has both
psychological as well as behavioral impact.
• Contributors include the lack of financial, emotional, educational and
protective support typically found in permanent or intact families.
• Consequently, children aging out often try to reconnect with family
but without planning, preparation and clinical support, the results are often very problematic.
BARRIERS TO A HEALTHY MENTAL STATE
• Children in foster care internalize what surveys reveal as a “culture of no” i.e. things taken for granted by peers such as faith practices,
participating in sports, getting senior pictures taken or joining friends’ family special outings.
• Denials are often by foster families, group homes or GAL because of
custodial system requirements.
• Eventually, foster care youth stop asking often resulting in a pervasive
BARRIERS TO A HEALTHY MENTAL STATE
• Children approaching aging out speak of fractured foster care family
relationships worsened by:
• Separation from biological siblings
• Sibling visits of 1 hour/week in a building waiting/visiting area
• Experiencing being sent to “respite care” when foster care family goes on
BARRIERS TO A HEALTHY MENTAL STATE
• On a day-to-day bases, youth feel different from their peers • Being in foster care is stigmatizing particularly if they are in
congregate care (group homes)
• They experience early curfews, no sports or after school activities • Many experience a “level” lifestyle:
• Zero Level on entry ~ like “lock down”
• Privileges must be earned such as having a sibling visit
FOSTER CARE CONSEQUENCES
• Aging out of foster care at the age of 18 is somewhat of a recipe for
failure.
• Systems recognize that children cannot care for themselves at this
point in their social and cognitive development, even if they were enrolled in secondary education, primarily because of meager social capital – relationships rooted in family, school, peer and community networks.
UNINTENDED CONSEQUENCES
• Children who have had adversities have a higher incidence of running
away – from home or from a foster care home and this can lead to a series of losses (multiple placements) that affect a youth’s sense of permanence or having any kind of enduring relationship across the life course.
• High risk behaviors can contribute to “cross-over kids” ~children who
are in both the child welfare system as well as the juvenile justice system.
MENTAL HEALTH PROBLEMS NOTED IN
“CROSSOVER KIDS”
• Conduct Disorder
• Gender and sexual orientation
issues
• Mood Disorders
• Depression Disorders
• Suicidality and Non-suicidal
self-harm
EXTENDED FOSTER CARE
• The Fostering Connections to Success and Increasing Adoptions Act
of 2008 provides states with the option of extending foster care to 21 with federal financial support.
• As of 2014, 24 states had adopted extended foster care.
• Best practices include sustaining social capital, providing permanency
COMPLEX TRANSITION NEEDS:
[1] SUSTAINABLE SOCIAL CAPITAL
• The ability to navigate resources, build relationships, and develop a
community is sustainable social capital.
• Youth transitioning from foster care often lack critical support
networks and healthy relationships to achieve this.
• Ideal programs and policies emphasize strong connections with a
supportive adult, developmentally appropriate services, and opportunities for youth voices in transitional planning.
MODEL PROGRAMS PROMOTING
SUSTAINABLE CAPITAL
• Youth Villages Transitional Living Program
• Southern California’s Foster Family and Adoption Agency • Oregon Foster Youth Connection
COMPLEX TRANSITION NEEDS:
[2] PERMANENCY SUPPORTS
• Housing
• Transportation • Healthcare
• Without these supports, youth in transition cannot maintain
education
• Without these supports, youth in transition cannot maintain
MODEL PROGRAMS FOR PERMANENCY
SUPPORT
• Covenant House
• Jim Casey Youth Opportunities Initiative
• John Burton Foundation’s California Transitional Housing Program • National Center for Housing and Child Welfare
COMPLEX TRANSITION NEEDS:
[3] POSTSECONDARY OPPORTUNITIES
• Youth in transition should know about and be able to access a range
of postsecondary opportunities including two-year and four-year education.
• Of those who enroll in a four-year college, less than 10% are able to
complete their education because of persistent difficulties.
MODEL PROGRAM FOR POSTSECONDARY
OPPORTUNITIES
• NPowering My Success Program at the university of Michigan-Flint • Foster Forward in Rhode Island
SUMMARY
• Best practices include sustaining social capital, providing permanency
supports and assisting with postsecondary opportunities.
• There are numerous model programs in the U.S. and a consistent
component is taking pro-active measures to assure access to :
• Healthcare • Housing
SUMMARY
• Aging out of foster care is a difficult and daunting process associated
with significant negative life experiences for youth and young adults.
• State adoption of federal funds to provided extended foster care for
youth until 21 is a first step in aiding youth in the aging out process.
• Improved outcomes occur with there are youth voices in planning
