What is the role of the mental health clinician for children receiving child welfare services?

Child Welfare services are provided to over two million families annually. Most of them are very short-term services and do not extend beyond an investigation of child abuse or neglect. Two-thirds of these allegations are not substantiated, which usually terminates further contact between the child and the child welfare system. However, the largest population of children receiving on-going child welfare services is in foster care. At this time, over 500,000 children reside in some form of foster care. Children in foster care often have great need of mental health services.

Children may be removed from their homes for a variety of reasons, including severe abuse and neglect (physical and sexual), severe behavioral problems in the child, or an unmet need for mental health services. A variety of parental problems may also precipitate removal, such as abandonment, illness (physical and emotional), incarceration, AIDS, alcohol/substance abuse, domestic violence, and death. Despite the fact that most children do not enter the foster care system due to a mental health diagnosis, it is estimated that 85% of children in foster care have an emotional disorder and/or substance use problem. Most children in foster care are coping with the events that brought them into care, while enduring the personal grief and trauma that accompany the loss of a family.

Children in care frequently struggle with the following issues:

• Blaming themselves and feeling guilty about being removed from their parents;

• Wishing to return to their family despite previous maltreatment;

• Feeling unwanted if awaiting adoption for a long time;

• Having mixed emotions about attaching to foster parents;

• Feeling insecure and uncertain about their future;

• Reluctantly, acknowledging positive feelings for foster parents.

These children usually receive mental heath treatment only during a crisis. The crisis-induced treatment takes place in emergency rooms, pediatric wards, or adult facilities, while they await an appropriate placement. However, even before reaching crisis situations, behavior problems in foster children are very common. These behavior problems are often mistaken for "acting out" or "aggression" and their mental health implications are often missed. Chronic behavior problems can indicate a need for clinical intervention because they are frequently symptoms of an agitated depression or a dual diagnosis with oppositional defiant and/or conduct disorders. Thus, foster children need ongoing treatment with the same clinician, whenever possible, to ensure continuity of treatment once a mental health need has been identified

The role of the mental health clinician working with children in the child welfare system includes:

• Providing a comprehensive assessment upon entry into care and periodically during the child's stay; (Medicaid funds this through EPDST) 

• Recognizing that issues of attachment are significant to the emotional well-being of foster children;

• Recognizing the trauma experienced by the child who will/has experienced multiple placements;

• Assisting children with the development of meaningful new attachments, while maintaining existing attachments if possible;

• Identifying best practices in providing mental health treatment for foster children and their families;

• Including both foster and birth parents in the child's treatment, if this does not endanger the child;

• Creating a balance between the child welfare mandate of safety and the emotional wellbeing of the child.

Mental health clinicians working with children in the child welfare system need to have:

• A willingness to continue working with the child in multiple placements and multiple schools; 

• Sufficient flexibility to involve non-custodial and extended family, when this does not endanger the child; and 

•  The skills to coordinate with other service providers, whenever possible