Foster Care As A Mental Health System
(Originally published August 2016)
On August 26, The Salem Statesman Journal and Oregon Public Broadcasting published a story titled, “'I Was So Broken': 14 Years in Foster Care,” with the subtitle “The Story of One Tormented Path Through Oregon's Child Welfare System.” This story concerns a young woman, Mia Storm, who (along with her brother) was “given” to the Oregon child welfare system in 1988 at age 4 by her mother after incidents of physical abuse and her grandfather's sexual abuse, and due to her mother's drug abuse and mental health problems. After one failed attempt at reunification, Ms. Storm spent the next 14 years in Oregon's foster care system, “bouncing between foster homes, taking prescribed anti-psychotic drugs, and suffering physical and sexual abuse while in state care,” according to the reporters, Gordon Freidman and Ryan Haas.
What is different about Mia Storm's story from many others that resemble it is that she has obtained voluminous case records that confirm the broad outlines of her account. By age 7, Mia had already been placed in several foster homes. She began to accumulate mental health diagnoses during her early school age years, including ADHD, oppositional defiant disorder, bi-polar disorder and PTSD. According to the story, “she was prone to tantrums and screaming, hyperactivity and sexually inappropriate behavior.” Prior to adolescence and before her placement in residential care facilities, Mia was given prescriptions for Ritalin, Imipramine (a tricyclic anti-depressant now known to be dangerous for children), Lithium, Zoloft (for anxiety), and was subsequently prescribed several anti-psychotics such as Risperdal, Depakote, Zyprexa and Trilafon, sometimes in combination. According to the reporters, “In her teens, Storm was taking 3 anti-psychotics at once.” Ms. Storm gained 100 lbs. while taking anti-psychotic drugs, weight she has not lost, the story asserts. Ms. Storm is quoted as saying “my body is a scar for me, every stretch mark, every roll...” She does not believe that she was ever bi-polar or psychotic, but does believe she had PTSD.
Reading between the lines, it appears that Mia accused her various foster parents (17 total placements) of abuse on several occasions, but these allegations were viewed by her caseworker as manipulative, an attempt at “triangulation”, even after a school psychologist informed her caseworker that one of Mia's foster families was “too punitive and borderline abusive.” The caseworker's response to the psychologist's assessment was to move Mia to another school.
Ms. Storm claims that she was once punched in the face by a foster parent and locked in a room for hours. She told the reporters that after she entered group care at age 12, she was restrained by staff who forcibly straightened her recently broken arm, an excruciatingly painful experience. Prior to her 18th birthday, a caseworker who had befriended her and helped her gain access to independent living services convinced Mia to come to a psychiatric hospital where she was forcibly restrained, stripped and force fed anti-psychotic medications. The caseworker commented to the reporters that “it may be one of the worse things I've ever done in my life.” Ms. Storm says that after this event “I hated them, it was just me trying to keep breathing until my 18th birthday...”
Mia Storm is 32 years old. She was never adopted, in part because a juvenile court judge believed she was too attached to her birth family to accept an adoptive family and also because of the severity of her behavior problems. According to the story, Ms. Storm has avoided substance abuse and criminal activity, and has made considerable unsuccessful efforts to complete college. She did not become pregnant until she was 28. She has custody of her daughter to whom she is devoted, the reporters assert. Ms. Storm has slowly been reconciled with her birth mother.
Mia Storm says she grew up believing that “no one loved me.” From her perspective she did not have a caseworker who helped her or advocated for her until she was 17, nor is any other advocate or supportive individual mentioned in the story except for her initial foster parents who expressed a willingness to adopt her before marital difficulties changed their plans. The caseworker who helped her gain access to independent living services was party to a coercive act in which (by the caseworker's admission), Ms. Storm was given anti-psychotic medications against her will, an act that even today would perhaps be viewed as misguided but not abusive in many child welfare systems. The systemic abuses described in this story were committed by multiple caregivers and professionals under the banner of child protection!
Foster Care as a Mental Health Intervention
Mia Storm's story has elements that occur repeatedly in the experiences of behaviorally troubled school age children and youth in foster care. These children often enter foster homes angry at caregivers due to abuse and/or neglect in their early lives or due to the loss of their birth parents and siblings, or because of other victimization. A pattern of oppositional behavior is accompanied by “meltdowns” of frightening intensity. Foster families with little or no training in mental health and with limited commitment to caring for a behaviorally troubled child may engage in harsh and punitive disciplinary practices which suppress oppositional behaviors in the short run but steadily deepen a child's distrust of and antagonism to caregivers and other adults. At a loss for better ideas, foster parents turn to physicians or psychiatrists who offer multiple mental health diagnoses and prescribe psychotropic mood altering drugs, with the support of caseworkers attempting to prevent another placement disruption. As various mental health diagnoses increase, so do the number of powerful psychotropic medications children and youth may be taking at any one time. Children are moved from home to home until caseworkers lack other options, at which time children are referred to residential care facilities where they spend most of their adolescence. Efforts at finding a permanent family for many of these children and youth are usually quietly abandoned as one foster parent after another gives up on them, though caseworkers must maintain the fiction of permanency planning in their court reports.
This is a story of failed practices and dysfunctional child welfare and mental health systems which occur around the world. In 2006, an Australian study which found that foster care had developmental benefits for most children in care, concluded that conduct disordered children and youth were “wretched in care” and “effectively homeless.” The authors, James Barber and Paul Defabbro (one Australian and the other Canadian), maintain that foster care is “unsuitable for disruptive children” and that “the child welfare field urgently needs to find an alternative.” Barber and Delfabbro insist that they do not support a return to use of institutional care for disruptive youth, asserting that “Many alternatives to conventional family based foster care now exist...” without spelling out what they are.
It is noteworthy that as children like Mia Storm become angrier and more out of control, child welfare caseworkers, caregivers and mental health professionals rarely consider the possibility that their practices are causing these children to become more desperate and emotionally dysregulated. Instead, a common response of professionals is to “double down” on use of psychotropic medications and various forms of coercion rather than reconsidering why “treatment” is having disastrous effects.
Needed: Foster Parents with Therapeutic Skills
Foster care that lasts for months or years is a powerful intervention, with a great potential for healing or doing further harm. Children removed from their parents due to abuse or neglect are in a highly vulnerable position, temporarily or indefinitely without caregivers who have a strong unwavering commitment to their welfare. What happens to children during periods of extraordinary vulnerability affects more than their behavior: children develop strong beliefs about the world that are difficult to change and that begin to shape their future. For example, children who seem determined to antagonize caregivers and other authority figures may believe “No one cares about me,” “maybe it would have been better if I was never born,” “unless other children are afraid of me, they will hurt me,” “my foster parents may kick me out for any reason or no reason” and follow the rule, “trust no one.”
Foster parents with the capacity to help children with oppositional behavior and a tendency to “meltdowns” need several sets of complex skills:
the capacity to respond to children's disruptive behavior without taking it personally and without becoming harsh and borderline abusive, while recognizing and rewarding positive pro-social behaviors as often as possible.
the capacity to recognize early indicators of “meltdowns” and take steps to prevent these demoralizing events; and to help children learn to self soothe and make use of caregivers to calm down when they are upset.
the capacity to discern and articulate to children the dysfunctional beliefs that lead to oppositional behavior and self sabotage; and to help children begin to interpret their feelings and behaviors. Foster parents must work at dis-confirming children's dysfunctional beliefs again and again.
the capacity to coach birth parents in how to respond to children's misbehavior without giving in or saying emotionally hurtful things, or resorting to abusive physical discipline.
the capacity to effectively advocate for behaviorally troubled children with schools, caseworkers, courts, etc.
In addition, these skills must be combined with a commitment to no “serial evictions” of children from the foster home and with a willingness to work in partnership with a therapeutic team. Children may have to be moved to other homes or settings from time to time due to their specialized needs, but not through placement disruptions that contribute to feelings of rejection.
This is an extraordinary array of skills and commitments that cannot be reliably provided by poorly trained volunteer foster parents with limited interest in caring for behaviorally troubled children. A commitment to the development of professional knowledge and skills and to challenging professional work is required. Child welfare systems need to engage in initiatives to increase the number of foster parents with these therapeutic skills, and be able to fairly compensate these foster parents for their service.
Foster Care at the Crossroads
Foster care systems are at a crossroads. During the past 15-20 years, there has been a steadily increasing disenchantment among child welfare managers and policymakers with residential care due to the widespread abuse of youth in many of these facilities by both staff and other youth. Congress is on the verge of passing comprehensive child welfare finance reform legislation that contains disincentives to the continued state funding of residential care. In addition, in recent years foster care alumni have found their collective voice. Many of these young adults have powerful disturbing stories of being physically abused and sexually abused in foster care (sometimes over a period of years), and of being mistreated in ways that child welfare systems don't even classify as abuse. The misuse or overuse of psychotropic medications with powerful side effects on health and mental health of foster youth is the most flagrant example of systemic abuse. Overuse of psychotropic medications with foster children and youth has been reduced to some extent during recent years and is more tightly regulated than when Mia Storm was in care, but remains a widespread practice around the country.
The current practice of depending on unpaid and inadequately compensated volunteer foster parents to care for children with oppositional behaviors is a proven failure. Most state child welfare systems are having a difficult time recruiting and retaining enough foster parents to accommodate the number of children needing foster homes. This is not a sustainable state of affairs even in the short run. However, unless there is a major change in the foster care “business model” needed to create therapeutic practices for children and youth with oppositional behaviors, foster care will soon come to be be viewed in the same light as mental hospitals, i.e., possibly necessary but a misfortune for the persons housed in them.
Barber, James & Delfabbro, Paul, “Psychosocial well-being and placement stability in foster care: Implications for policy and practice,” Chapter 9 in Promoting resilience in child welfare, edited by Robert Flynn, Peter Dudding and James Barber, University of Ottawa Press, 2006.