- I. Introduction
Children who are removed from their primary caregivers because of suspected child abuse, neglect, or caregiver impairment have compelling and urgent mental health needs and are at risk for use of alcohol and other drugs problems. The American Academy of Child and Adolescent Psychiatry (AACAP) and the Child Welfare League of America (CWLA) urge that these children receive immediate mental health and use of alcohol and other drugs screening1 followed by a comprehensive mental health and use of alcohol and other drugs assessment2 and periodic reassessments. This screening and assessment is to assure that these children receive prompt and appropriate mental health and use of alcohol and other drugs care. In order to achieve this, the screening and assessment should be:
- II. Completed in a Timely Way by Trained and Qualified PRofessional
An initial mental health and use of alcohol and other drugs screening should be conducted within 24-hours of a child’s placement in the care of the child welfare agency. The mental health and use of alcohol and other drugs screening is intended to identify children in urgent need of emergency mental health and use of alcohol and other drugs services, including youth whose behavior may pose a danger to themselves or others. Appropriate training should be provided on the screening protocol, and the individual administering the screening should have on-site or readily accessible mental health and alcohol and other drugs use consultation. Ideally, the mental health and use of alcohol and other drugs screening will take place as part of a child’s health examination upon entry into care and be conducted by a health professional with expertise in the developmental and mental health and use of alcohol and other drugs needs of children in foster care.3
Children who are removed from their family may require an intervention to address their separation issues immediately. The screening process should assess the internalized and externalized levels of distress the child is experiencing regarding the separation. It should also identify and support the child’s strengths and successful coping strategies. Based on the outcome of the individualized screen, the child should be provided a triage intervention to address the child’s feelings regarding the separation, what kind of placement will best meet the child’s needs, and support the child through the separation. It is recommended that the process be monitored to ensure all children receive the mental health and use of alcohol and other drugs screen and appropriate intervention based upon their individualized needs.
Children entering foster care and their families should receive a comprehensive mental health and use of alcohol and other drugs assessment within 60 days of placement, or sooner based on the severity of the child’s needs as identified in the screening process. Assessments should be conducted by qualified mental health and alcohol and other drugs providers and include the active involvement of a child and adolescent psychiatrist. The comprehensive assessment should incorporate use of developmentally appropriate techniques and tools, be conducted in a comfortable and accessible setting, and address the child and family’s strengths as well as needs. Informed consent should be obtained from the party or parties legally responsible for the child. Where indicated, the child or adolescent ought to be directly involved with procedures such as informed assent and be made partner to all assessments and treatment.
This process should include support for the child that acknowledges and addresses that removal from primary caregivers usually constitutes a psychological and social crisis for the child and family. The initial screening should be developmentally sensitive and seek to understand the child’s internal experience of the placement and the nature of the child’s attachments.
Placement often suddenly separates a child from everything familiar, including places (home, neighborhood, school) and people (primary caregivers, birth family, other family members, friends). This sudden and complete loss may result in unrecognized experiences of trauma and bereavement, which in turn can interfere with making new attachments and with the success of placement. New caregivers may need immediate advice on how to help the child make a positive adjustment. Children may need mental health and alcohol and other drugs services to cope with the trauma of placement, even in the absence of symptoms that constitute a psychiatric diagnosis. Children with internalizing problems, such as depression and anxiety, should receive the same consideration for mental health and use of alcohol and other drugs care as those with externalizing problems, such as disruptive behavior. A child’s wishes about placement and visitation should be ascertained and given as much weight as possible.
Children and adolescents should be assessed individually, and adequate time and preparation must be devoted to the assessment so that every child and adolescent has the opportunity to freely express his or her concerns.
Approximately 80 percent of children placed outside of the home are returned to their family of origin. In order to achieve successful reunification, whenever possible, we must consider the family of origin including siblings in assessments and services/supports for children placed in out-of-home care. Assessment and services/supports should be both child-focused and family-centered. The definition of family includes biological, foster and adoptive parents, grandparent and their partners, as well as kinship caregivers and others who have primary responsibility for providing love, guidance, food, shelter, clothing, supervision, and protection for children and adolescents (National Peer Technical Assistance Network, 1997). Finally, other persons may be considered members of the family for purposes of assessment and services/supports depending on the family of origin, their culture, ethnicity, language and the culture of their community.
Professionals are expected to work in partnership with the family to:
- assess the individual strengths and needs of the child;
- assess the parents/families strengths and needs to effectively address their child’s needs;
- identify ways to effectively provide the appropriate mental health and use of alcohol and other drugs services/supports to the child and their family; to determine the level of involvement required with the foster family to successfully return the child home; and
- determine the level/type of relationship which is needed between the foster parents and the birth parents to ensure the emotional/mental health and use of alcohol and other drugs needs of the child are met.
- if a child and his birth family can be in immediate and continuing contact (face-to-face visitation and/or by telephone) to decrease the trauma of separation; and
- if the birth parents and foster parents can be expected to communicate with each other to maximize continuity and mutuality in accomplishing therapeutic goals.
Family members, as defined above, should be considered essential partners for successful treatment unless there is evidence to the contrary. Unless mandated otherwise by the courts, there should always be family involvement in the assessment and reassessment process, the development of the individualized treatment plan and the treatment/support process. All treatment plans should be individualized for the child and family and include family treatment services and supports as part of the plan unless the courts have restricted access/contact due to safety issues or there is evidence to the contrary. The treatment plan should also be in keeping with the permanency plan for the child as well as the family service plan. When parents are mandated to not have contact and/or are not available to have contact with the child, the initial assessment and reassessments must address the impact of this loss upon the child and recommend effective interventions.
Placing a child in out-of-home care automatically expands the definition of their family, at least temporarily, to include the foster parents. This means including the foster parents’ input in the ongoing assessment and treatment/support process. With family-centered practice, when indicated, families are supported and empowered to be an advocate for the needs of their child and themselves and for the services which will facilitate their being successful in addressing the emotional/mental health and use of alcohol and other drugs needs of the family and child. Other key components of family-centered practice include:
- focusing on the whole family as the unit of attention;
- organizing assistance in accord with the family’s strengths while acknowledging but not emphasizing deficits;
- except where a child’s safety and/or well-being is at risk, service planning and delivery should take family priorities into consideration;
- structuring treatment/support service delivery to ensure accessibility, minimal disruption of family integrity and routine; and
- sharing results of assessments/reassessments with the birth family when a child is returning home (should this not have been done for some reason during out-of-home care) or with the adoptive families when a child is being adopted.
- V. Culturally Sensitive and Administered in a Culturally Competent Manner
The assessment and reassessment of children and their families must take into account the influence of each family’s heritage. This includes culture, ethnicity and religion and consists of—but is not limited to race, religion, gender, socioeconomic status, language, sexual orientation, geographic origin and location, and their immigration status.
Clinicians and/or staff who perform assessments should develop specialized knowledge and understanding about the history, tradition, values, family systems, perceptions, communication styles and artistic expressions of major client groups that they serve (NASW, 2001). Acquiring this knowledge should be accompanied by a regular assessment of their own personal values, beliefs, and biases in an effort to inform their practice and increase the quality of relationships they have with the children and families they serve (NASW, 2001).
This cross-cultural knowledge and personal awareness should be considered and applied to all approaches, skills, and techniques when working with children and families (NASW, 2001). This kind of approach is necessary to understand the stigma and shame that many cultures associate with mental health and use of alcohol and other drugs issues. This insight will help clinicians and/or staff to better understand the kind of help people seek, the types of coping and communication styles, social supports needed and the level of resistance to treatment that can be expected from the children and families they serve (DHHS, 2001).
In all circumstances, special consideration should be given to ensure that there are adequate numbers of clinicians and staff who speak the language(s) of the client groups served and when not available that there are procedures in place for obtaining translation and/or interpreter services.
In addition, it is necessary to ensure that all screening tools, protocols, instruments and approaches used in the mental health and use of alcohol and other drugs screening, assessment, reassessment and treatment process are tailored for the population being served.
This commitment to cultural competence is essential to adequately assess and treat the mental health and use of alcohol and other drugs needs of children and families in the foster care system. It is recommended that there be a monitoring process to ensure this takes place (DHHS, 2001).
- VI. Periodically Repeated with Standardized Collection of Health Information
Since all foster children are at serious risk for mental health and/or use of alcohol and other drugs problems, they need individualized reassessment. The appropriate intervals depend on the severity of the child’s disturbance and the family’s needs and must be determined on a case-by-case basis that is consistent with requirements for case planning.
Children who are found at initial screening to have mental health and/or use of alcohol and other drugs problems need to be treated and reassessed at regular intervals as recommended by guidelines from AACAP, the American Academy of Pediatrics and/or CWLA. Reassessments should collect standardized information needed to ensure continuity of care.
Children who need psychotropic medications, including psychostimulants, should be reassessed following the AACAP Policy Statement, “Prescribing Psychoactive Medications for Children and Adolescents.” During the initial stabilization period, children should be reassessed frequently and have immediate access to a psychiatrist if they experience any difficulty adjusting to their medication. Once the child is stabilized on a standard dose of medication, he or she should be reassessed in a face-to-face interview no less than every three months. When children are moved to a new placement, all medications should be turned over to the caregiver at the next placement to ensure continuity of care. Once a child has settled into his or her new placement, all medications should be reassessed to determine if any adjustments are needed. It is crucial that this assessment and reassessment process include clear and regular communication between the clinical service provider and the caregivers where the child is living.
Children and families who are adjusting well to foster care and are in no apparent need of mental health and use of alcohol and other drugs intervention should also be reassessed in face-to-face interviews at regular intervals—no less than every 12 months or as requested by the child or family. Given the level of vulnerability of children and the potential to be re-victimized/traumatized, professionals must assess and reassess to ensure the ongoing safety and well-being of children in out-of-home care.
Children about to leave the system whether moving to self-sufficiency or returning home should be reassessed. Recognition should be given that children moving into self-sufficiency may still require assistance in dealing with issues related to their family and their individual mental health and use of alcohol and other drugs needs. Those who need, or desire further mental health and use of alcohol and other drugs services should have adequate referral and follow-up plans in place to assure continuity of care. All parties involved in the child’s care should be notified of any follow-up appointments. The clinician should follow the standard procedures (locale specific) that are in place to document summary reports and to assure that the child’s health data is conveyed to the next provider or caregiver.
These most vulnerable and traumatized of children need and deserve appropriate screening, comprehensive assessment and reassessments, effective mental health and use of alcohol and other drugs treatment services/supports provided by appropriately trained individuals, including the active involvement, when indicated, of a child and adolescent psychiatrist. We urge local, state and federal authorities to work together with the mental health, use of alcohol and other drugs and child welfare professions and other relevant child and family serving systems to assure that these children's mental health and use of alcohol and other drugs needs are met and that the children have the skills, capacities, and support necessary to thrive.
1Screening—the process for identifying the immediate/current mental health and use of alcohol and other drugs needs of the child. For children who are removed from their family, the screening process should assess the internalized and externalized level of distress of the child regarding the separation.
2Comprehensive mental health and use of alcohol and other drugs assessment—a thorough look at the child in all life domains as well as the strengths and needs of the child and family.
3States may opt to utilize Medicaid’s Early Periodic Screening Diagnosis and Treatment (EPSDT) funding as a vehicle for obtaining health screenings for children entering foster care as developmental and mental health screens are a mandatory component of the EPSDT screen exams. The EPSDT mandate in section 1905 ( r ) of the federal Social Security Act entitles all Medicaid-eligible children under the age of 21 to receive regular screens for physical and behavioral health conditions, including mental health and substance abuse.
American Academy of Child and Adolescent Psychiatrists. (2001, September). Psychiatric care of children in the foster care system. Retrieved from http://www.aacap.org/publications/policy/ps45.htm
American Academy of Pediatrics. (2000). Developmental Issues for young children in foster care. Washington, DC. Pediatrics Vol. 106 No.5. Pg. 1145-1150.
American Academy of Pediatrics. (2002, March). Health care of young children in foster care. Washington, DC. Pediatrics Vol. 109 No.3. Pg. 536-541.
Child Welfare League of America. (1988). CWLA Standards for health care service for children in out of home care. Washington, DC. Author.
National Association of Social Workers. (2001, June). Standards for cultural competence in social work practice. In Standard 3: Cross-cultural knowledge. Retrieved from http://www.naswdc.org/pubs/standards/cultural.htm#Standard2
National Peer Technical Assistance Network’s Partnership for Children’s Mental Health. (1997). Family-professional relationships: Moving forward together. Alexandria, VA: Federation of Families for Children’s Mental Health.
U. S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—a supplement to mental health: A report of the surgeon general. (DHHS Publication No. SMA-01-3613). Rockville, MD: DHHS, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
Glossary of Terms
Child—Any child placed in out-of-home care.
Child-focused—When both the physical and emotional well-being of the child is central to all levels of decision making and a process is in place for resolving conflicts between these two domains. The child’s own views are expressed, where possible, directly through the child’s words and behaviors or, as required, through an adult whose offers the child’s perspective along with the viewpoint of members of the child’s family.
Child safety—A child is considered safe when an analysis concludes that the child is not in immediate danger of serious harm and no safety interventions are necessary. This analysis takes into account the child’s emotional well-being also.
Cultural competence—A system is considered culturally competent when there is professional, formalized competence throughout the system in policies, procedures, outreach, advocacy efforts, and training. Cultural competence, sensitivity, and relevance is demonstrated through the array of services, delivery, framework, and recognition of the importance of community-based, informal support networks such as churches, extended kinship networks, and social organizations. Cultural competence is demonstrated when there are skilled staff who are aware of cultural issues within the community and who understand the diversity of the community.
Family—Families can include birthparents, foster and adoptive parents, grandparents, as well as kinship caregivers and others who have primary responsibility for providing love, guidance, food, shelter, clothing, supervision, and protection for children and adolescents. It is the extent of daily interaction with and responsibility for a child, not a legal construct, that identifies a family member.
Family-driven—A system is family-driven when the family is involved in all decision making. Identification and engagement of the family receiving services is required so the family’s experiences and perspectives drive the planning and outcomes for the foster child. This moves the system beyond being centered and focused on the family to having service delivery be more family-driven.
Prevention and early intervention—
- Primary prevention: Efforts to avert mental health and substance abuse problems altogether. For children, these efforts include interventions directed at parents or professionals involved with children.
- Secondary prevention: Efforts to detect mental health and/or substance abuse problems in their early stages of development and to apply techniques to reduce the severity and duration of incipient problems.
- Tertiary prevention: Attempts to arrest further deterioration in individuals who already suffer from severe mental health and/or substance abuse problems. Treatment is tertiary prevention.
System of care—A system of mental health, substance abuse, social services, education, medical, physical health, primary care, juvenile justice, and other organizations, and formal and informal services that work with the family to meet the child’s needs.