What do foster parents need to know about their foster child’s health? Host Dawn Davenport, Executive Director of Creating a Family, the national infertility & adoption education and support nonprofit, interviews Dr. Elizabeth Wallis, an Assistant Professor of Pediatrics at The Medical University of South Carolina, the Director of their Foster Care Support Clinic and the Division of Adolescent Medicine.

Highlights of the show (click to expand)
  • We’re talking today about the health of children in foster care. And we are using the term “health” broadly to encompass physical, emotional, mental, behavioral, developmental, educational, and oral health.
  • Children who come into your home from foster care often come with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. Impact of trauma on kids physical and mental health.
  • Those areas of the brain most affected by trauma, especially early trauma, are those involved in stress response, emotional regulation, attention, cognition, executive function, and memory. Thus, childhood trauma, adversity, and toxic stress are correlated with poor emotional regulation, aggression, hyperactivity, inattention, impulsivity, and dissociation between thought and emotion.
  • An issue with foster care parenting is limited access to health care before entering foster care and lack of knowledge about previous health care.
  • Foster kids often come to us with a bag full of medications that have been prescribed somewhere along the line and a host of diagnoses. How common is over medication in foster kids?
  • Psychotropic medications are commonly prescribed for children in foster care. Although this may have improved lately, research has found that that children in foster care are prescribed psychotropic medications at a rate 3 times that of other Medicaid-enrolled children and they often are taking multiple medications at once. Once psychotropic medications are prescribed, children in foster care are likely to be kept on them longer than other Medicaid-enrolled children who are not in foster care.
  • What are they are psychotropic drugs and why are so many foster children on them?
  • The role of transience and uncertainty for kids in foster care provides challenges for foster parents and doctors in providing health care to kids in foster care.
  • What can foster parents do if they question the amount or type of medication their foster child is taking or even the underlying diagnosis? What are red flags to look for?
  • What role does a foster parent have in seeking a change in medication for their foster child?
  • What doctor do you take your foster child to? Your pediatrician? Their previous doctor, if they had one. The doctor that has prescribed the medication
  • One of the most confusing aspects of caring for a child in foster care is identifying who has the authority to consent for health care on behalf of the child or adolescent. Varies by state (caseworker can tell you).
  • Sleep issues with foster children. What causes sleep issues? What can foster parents or parents adopting from foster care do to help children in foster care sleep better?
  • How common are weight issues in foster children? Why is obesity and being overweight an issue? What can foster parents or parents adopting from foster care do?
  • Dental care for foster children. How much and how soon?
  • How to find a competent therapist knowledgeable about the impact of trauma? Evidence based therapy.
  • Disclosure of abuse? How to handle?
  • Coping with feelings of “why bother” when a foster child will return to the same chaotic household they came from.
Transcription of the show (click to expand)

* Note this is an automatic transcription, please forgive the errors.

[00:00:00] Today we’re going to be talking about physical and emotional health issues common with foster children. And we’ll be talking with Dr. Elizabeth Walls. She is an associate professor of pediatrics at the Medical University of South Carolina. She is the Director of Foster Care Support clinic as well as the director of their division of Adolescent Medicine. Welcome Dr. Wallace. Thank you so much for talking with us today about emotional and physical health issues with adopted kids adopted foster kids.


[00:00:36] Thank you for having me.


[00:00:38] We talk today about health the health issue of children in foster care. And I think it’s important to note at the beginning that that we’re going to use that term health broadly to incorporate compass physical issues emotional mental behavioral developmental even educational and oral health. All of that is under the broad rubric of health. So children come into your home from foster care. They often come with complex and serious physical mental health developmental psychosocial problems rooted in childhood adversity and trauma. So let’s start by talking about some of the impact of trauma on kids both their physical and their mental health. So what this trauma look like you know how is it physically look like in children and how does it emotionally look like in kids.


[00:01:32] Yeah well so it it depends a lot in children on the age of the child but I think a simple way to think about it is to think about sort of what are the normal kind of functions of a child of that age. So if you think about a young child who’s been exposed to trauma or who has you know symptoms of traumatic stress that might be a child who developmentally isn’t on the same pace as his peers or a child who may have issues with toileting whether it’s potty training or stalling or disruption in their sleep. You know older children may present with more behavioral symptoms as well as things like stomach ache or headache they may be children who are very wary of adults because adults haven’t been trustworthy in the past. So they may be kids who are easily upset by seemingly small things and they may react in sort of and out of proportion way or what seems out of proportion to us. They may also be children who hold a grudge or have a difficult time letting things go which which you know is something that seems sort of benign to us but isn’t. I think the important point to take away is that you know children regardless of their age you know significant neglect or traumatic stress can affect all aspects of their daily lives.


[00:02:58] So if you think about sort of their normal function their peer relationships their education as well as their physical health and you know trauma physically changes the brain and so we know that that the areas of the brain the brain that are most likely affected by trauma especially early trauma are those involving stress response emotional regulation attention more cognition executive function memory. So it would it be fair to say that childhood trauma that we would expect children who have experienced childhood trauma to have poor emotional regulation aggression hyperactivity trouble paying attention impulsivity and even this disassociation between their thoughts and their emotions. And being able to draw correlation between calls and action are all of those things possible could be caused by trauma.


[00:03:53] Well so there’s a couple of things to kind of unpack in there so you are exactly right that we know that children who have been exposed to repeated complex trauma we do see changes in their ongoing brain development and brain chemistry and I am no neuroscientist however we know that for example the simple way to think about it is that those are kids who may have changes as you said in their stress response their reactivity so they may be kids who you know sort of fight or flight in sort of a simplistic way is changed so that they may react in an overexaggerated way or they may also have sort of an inappropriately low response to danger. The other piece of that to build in is remember that children who had neglect or abuse may not have learned some of the social emotional things that typically young children or older children would learn. So you know connecting thoughts feelings and actions is something that is not necessarily innate it’s something that has to be taught. So you know for children who have not had kind of a normal childhood trajectory they may not understand those things so they may not be able to connect their thoughts with their feelings and actions. They may not be able to understand why they’re feeling certain things in their body. So for example kids who are anxious right. You know a kid who identifies the feeling of anxiety may have a response that is very sort of aggressive or kind of externalizing behavior. And that that you know until a kid understands and can connect to those things they may not know how to respond.


[00:05:27] And so you know that’s something that has to be taught. Just like everything else that young children learn and so often kids who are in foster care have missed out on a lot of that learning.


[00:05:38] As you know it’s such a good point and it’s we just as a society particularly those of us who have been fortunate and not have had experience have not experienced trauma or abuse or neglect we just assume that that childhood is going to look like what we see normal kids look like and then we don’t realize that the impact of trauma truly changes what the kid is going to do how they’re going to respond. And they will respond in ways that we often think are are weird or bizarre they just don’t seem to make sense. But it’s a learned response oftentimes the protective response or simply having not been exposed to things that other children other learning environments other children have. One of the challenges for foster parents and for people who adopt from foster care is that so often children entering foster care have had limited access to health care before entering foster care before entering state care. But the challenge for parents is that they lack knowledge about the previous health care. We received a question from Ryan who says we are raising my husband two cousins. They came two or three months ago at three and four. We have no idea what type of health care they have had in the past if any we’ve made an appointment with a local pediatrician but she wants the kids past records which as far as we know don’t exist. The caseworker has not been much help in finding them. How can we tell if they had been immunized. We immediately get them immunized.


[00:07:15] What else other than immunizations should we worry about assuming that they’ve had little health health care before coming to us. And does it matter if they’re going to be with us for a short time or forever. So there’s a lot in there with Ryan Ryan’s question but it’s in essence that they have almost no information about health care. So what do you recommend for foster parents to do in this situation.


[00:07:39] Yes so I think that unfortunately the scenario that Ryan and his and her family are in is actually very common unfortunately. And I think there’s a number of reasons for that. You know I think as far as the first piece of the question in terms of immunisations so probably the best thing that somebody can do to try to find immunisations is many states actually do keep a registry of children who are immunized and allows parents so allows pediatricians and also allows parents to access that information from a state registry. Now whether or not the state. Everybody reports to that registry or not. The information is limited. The other recommendation is to try to find who a prior pediatrician could be if they know if they know the name of the office. Usually they can get at least an immunisation record. That being said if parents can’t find anything there is no harm in re vaccinating a child on a Catch-Up schedule. So if for example they are not able to get any information a pediatrician could assume that they’re sort of starting as a completely unimmunized child and catching them up if they happen to you know if they’ve ended up getting extra doses as a result of that there’s no adverse effects associated with that. As far as other health care needs you know it’s it’s tough.


[00:09:04] I mean a lot of times we play a little bit of detective one of the things that the American Academy of Pediatrics recommends which is one of the pediatric professional organizations is that children who are seen in foster care when they’re seen for an initial health appointment that they’re seeing again a month later. And the reason for that. And the reason for that close follow up is because children often there’s needs that aren’t identified at that first visit. So we may try to do all our sort of routine screening but then other stuff comes up and so that gives you know families and pediatricians an opportunity to gather more information and come back. What I tell parents and pediatricians who ask me about sort of where do I start with a 3 year old or a 4 year old or a 10 year old is I try to think about you know developmentally where is this child. They’re at risk for delays. And so I want to make sure I get a good developmental assessment. What screenings might a child have had up to the age of three so that might include oral health led screening screening for anemia. If I’m not sure that those things have been done then I go ahead and do them again. The other thing is that this often ends up being a lot of health care within one visit which is another reason to space the visits out a little bit as to say we’ll do as much as we can today and then we’ll see them back in a month. But I think most pediatricians if you know you are not able to get records and you call and say look this is the scenario most pediatricians are very willing to work with you and kind of understand the challenge that many foster parents face.


[00:10:37] Well and that raises the issue do foster parents have the authority to have a child immunized or even to try to access in Ryan’s case he is unable or she or I’m not sure if he or she isn’t able to find work trying to work. Sounds like trying to work through the caseworker but would he have the ability on his own to go and try to get the records. And can he ask that the child be immunized or must that come from caseworkers or from legal guardians our biological parents.


[00:11:20] So the answer to that question is complicated because it depends on the state. And I am not I am not a legal expert. I can certainly tell you that in the States. So I work in South Carolina and in the state of South Carolina. Parents foster parents and caseworkers can consent for routine care or care that is sort of medically urgent which would include things like vaccinations for any sort of more complicated care. Typically a reasonable effort must be made to consent the biological parent. But that is one of those things that if they’re running into barriers I think contacting a local legal advocacy group for example may help to navigate what the laws are in your state. Typically the other place that you can often get immunization records as a school. So as a child you know for a 4 year old for example oftentimes they can’t go to school without receiving at least sort of their minimum number of immunizations and so a lot of times school districts can can provide access to at least an immunization record as well.


[00:12:29] And as far as trying to find out what you have authority as a foster parent a couple places to check. As you said a legal advocacy group but also you can ask your caseworker. They may be able to tell you they should be able to tell you. And if you’re not sure of that information you can check with the child’s CASA or guardian ad litem or most states. Not all but most states do have an active state Foster Parent Association and they also will have information to provide. Because as you point out it truly does. Each state has different rules as to what foster parents can do what the state child welfare agency can do and what birth parents or previous legal guardians can do. So it’s one of those things you’ve got to you have to ask what their answers are not too hard to find.


[00:13:26] Correct. We say you know what can I add. I was wondering I would say you know I never would want someone to not seek care if they feel like it’s urgent or emergent. Most states have some sort of stipulation in terms of urgent care for children. And so you know if you are in a position where you are imminently worried about the health or well-being of your child and you’re not sure what you can do as a foster parent you know I would never discourage someone from seeking emergency care. You know emergency departments hospital social workers things like that are usually able to help navigate those pieces.


[00:14:03] Yeah. Very good point. Very good point. Yeah. Yeah. Any type of emergency situation is is generally outside of doctors can prescribe or treat children in an emergency. We sometimes have the opposite problem particularly when children have already been in foster care and are coming to you. And that is you know we hear all the time from foster parents that children arrive with a bag full of medications that have been prescribed somewhere along the line and often a host of diagnoses. So in a minute we’re going to talk about psychotropic medications. Right now I’m going to talk about some others just start by reading a question from Diana. She says My son is currently taking A.D.H.D meds blood pressure medication and melatonin supplements. A few doctors have expressed concern for the blood pressure med dosage he has on but no body has decreased it. I am not sure how to tell if or when he’s ready to wean off the blood pressure meds but I’m concerned of the long term effects of staying on it. How can we tell if he’s improving or just properly medicated. Now she has there’s a number of questions in there. But part of it is that she believes that her son has either been mis diagnosed or her foster son’s been misdiagnosed or is improperly taking too strong of a dosage of medication. So how common in your experience is it for children in foster care.


[00:15:36] Overmedicated Well that is a complicated question. So there is a lot of data that children in foster care are prescribed psychotropic medicines at significantly higher rates than their peers including their peers. You know so for example peers who also receive Medicaid or you know low income families regardless of diagnosis and things like that. So we do know that there’s some data that that often children in foster care are given too many psychotropic medicines and at doses or for indications are that there may not be an indication as far as health care.


[00:16:17] Doctor Well let me stop you for a second. I’m going to actually quote for some of the research. Now this may have improved because there has been this research was done before a change in the law a couple of years ago. But the research found that children in foster care were prescribed psychotropic medication at a rate three times that of other Medicaid enrolled children. In other words other children who would be of similar socio economic and they often are taking multiple medications at once. Once psychotropic medications are prescribed these kids are more likely to be kept on them longer than other Medicaid enrolled children as well who are not in foster care. So just support what you were saying through research. And I do want to swing back to talk about psychotropic because that’s a whole another section of what we’re going to be talking about. But in the case of non I’d like to focus right now on on Diana’s case it’s blood pressure medicine. So just in general our kids what do you do if you question as a parent or a foster parent if you question the diagnosis she’s not sure does he really have blood pressure problems or he’s taking apparently a high dosage. What are your what is your role as a foster parent for trying to solve this problem.


[00:17:39] Well so I think it’s first of all I would say I think it’s wonderful that foster parents are working so hard to be advocates for these kids. Right. So you know asking questions about medication is entirely appropriate. I think that one of the other things that can be helpful to try to figure out is why was the child prescribe the medication. So my guess without knowing the specific case is that this is a child who is on A.D.H.D medicine but is also on a second line medicine called an alpha agonist which is its primary use was initially blood pressure but they can also be second line medicines for A.D.H.D. And so if I had to guess my guess is that this child is being treated with one of those medicines as part of his A.D.H.D treatment. But this question brings up a really important point in that if you look up this medicine if listed as a blood pressure medicine and you know foster parents can get very stuck and kind of not knowing what the medicine is and what they’re taking it for. And so I think that detective work can often be part of the equation. You know obviously the best way to do that is to try to get medical records to understand what’s going on. Honestly sometimes the medicine bottles provide data so I have all I always ask foster parents to bring the bottles with them because if I can find who the previous prescriber is then I can get a release form from the DSS worker or whomever else so that we can request those medical records and try to put those pieces together.


[00:19:11] You know what I would say in this particular case is to say to whoever the clinician that this person is working with you know helped me understand why this why this kid is on this medicine is it for blood pressure or something else. And what do I need to do to figure out whether this child truly has high blood pressure or is being treated for something else. And then I think you can figure out where do I go from here in terms of whether or not the child needs the medication. The other piece I would say is I think that the foster parent was very smart in not sort of abruptly stopping the medicine. I think it can be very tempting when and I don’t blame parents when a kid comes on four or five or six medicines to say forget this we’re just going to stop everything. I don’t know what doing what. And that can obviously be pretty dangerous. But I think it is very reasonable to say to a pediatrician or a primary care doctor. Help me understand all these medicines or if these are things that feel out of your scope of practice many of these kids come on a lot of medicines who can help me to navigate this.


[00:20:22] CONAN Now let’s move to talking about psychotropic medications. First of all what is the psychotropic medications.


[00:20:30] Right. So great. Great point. So a psychotropic medicine is a term that is used to describe medications that are used to diagnose used to treat psychiatric illness or use to manage behavioral health symptoms whether that be anxiety depression aggression schizophrenia whatever the condition is why are so many foster kids on these medications and on them.


[00:20:58] I mean I think we could throw the ball that the use of these medications in children has increased in general however as we read from the research earlier it is certainly higher in foster kids. Why are foster kids generally and another number of reasons but what are some of the reasons why foster children are on these meds in a higher number than the average population.


[00:21:24] Yeah. So I think the study that you quoted I think you’re looking at Dave Rubin’s work who’s done a great amount of work on this topic looking at the rates of medicines as well as the types of medicines and really seeing that some of the more powerful psychotropic medicines that we worry about overprescribing are also being prescribed and particularly high rates to children in foster care. The answer to why is not a totally straightforward one. I can tell you what my clinical observation has been as well as what some of the literature has sort of suggested which is you know children. So there’s sort of a systems level issues there’s the individual child issue there’s everything in between. Right. So from a systems perspective right. We are working in a system of very fragmented care. So as you’ve pointed out children often you know come with medicines we don’t know why they’re on them. We don’t know what the rationale was. We don’t know whether or not the diagnosis matches we have difficulty getting that information to try to make a good comprehensive summary. So you know a lot of times medicines will be continued for a sort of lack of data. Right. The other thing that can happen right is that folks with expertise in child mental health or childhood trauma are not on every street corner. And so access to good psychiatric care is really challenging particularly for kids who bounce around or move from place to place. And so sometimes you know the best intentions somebody looks at the behavior and is trying to manage it and is using medication.


[00:23:01] But but they may not have expertise in child mental health or they may not have they may have expertise in mental health but they may not have expertise in childhood trauma which is very different. The other piece that I think is important to remember is that children who are in foster care often do things that bother people so they can leave kids who are very disruptive explosive reactive and sometimes we as clinicians don’t do a good enough job in trying to figure out the why. We focus on the what. So we focus on the behavior and the problem and we treat that rather than focusing on why is this child behaving this way. And the last point I’ll make about medication and again there could be a lot of there are a lot of other reasons I’m sort of scratching the surface here. But the other piece is that sometimes clinicians don’t have all the information so they may not know that a child has a very significant trauma history and that the reporter that is giving them that information may not be giving them all the information. And the other pieces that we don’t have as much access and you know expertise in evidence based treatments for trauma. So thinking about psychotherapeutic techniques and treatments you know it takes a lot less effort to prescribe a pill. But the truth is what these children also need are evidence based psychotherapy. There are a number that have you know some good research support for treating trauma and you know PTSD and those types of things.


[00:24:34] But but that takes time and effort and consistency and you know getting access to those providers or being able to see the same provider consistently can sometimes be challenging.


[00:24:47] You know I am so glad that you raised that because one of the other kind of systemwide problems but it also plays out in the home from the foster parents decision making standpoint is the whole uncertainty or transients parents. Foster parents often don’t know particularly at the beginning how long your child is going to be in their home. So you know how much do they how do they approach this. You know should they be attempting to seek out a doctor to help them figure out what these five medications are in and which ones can be wind down and setting up a process for for winning the child off with the same time as observing symptoms to try to figure out you know this is complex that we’re talking about and the system of foster care is not set up to give ultimately the give permanence. But but there’s a great deal of uncertainty. So how to foster parents navigate that and trying to figure out how proactive How active should they be seeking out care and then changing care health care for children.


[00:25:57] So I would always encourage foster parents to be proactive to seek out things that are in the best interest of the child. Right. So a child who you know whatever the permanency plan may be will benefit if they have you know the tools to manage their anxiety or their distress or whatever else is going on. You know therapy that is harmful certainly is out there but you know children who learn you know social emotional skills or able to complete sort of a trauma based evidence based therapy those things are going to benefit the child even if they’re not in that same home forever or they move to a different foster home. And I think the same is true for medications. So certainly a child’s medication needs may change based on the environment they’re living in and what other supports that they have. But you know remembering that these medicines can be very very helpful. But they also have the potential to do harm. And so evaluating you know what that medicine role looks like in the setting that the child is in is important. And so I would say parents should advocate for that knowing that if something changes we may need to re-evaluate. And you know as much as foster parents can gather data and provide that data back to caseworkers and other folks who are going to be involved in the permanency planning for that child that only helps. You know I think we all know that most states do not have enough caseworkers or enough support or enough training for caseworkers to be able to do everything.


[00:27:33] And so this is really something where everybody has to put a hand in and play a role in supporting the child. It’s not about the sort of ego or in my case worker should be doing X Y or Z. We could say that all day. But it’s actually not in the best interests of the child. So I think you know whatever role foster parents can play in really advocating for behavioral health educational support whatever these kids need is only going to help in the long run.


[00:28:01] So what Dr. do you take your foster child to do take them to. If you have a pediatrician that you’ve taken other children and take them to your pediatrician do you take them to the doctor that has prescribed the medication or or two if you can find their previous doctor. And if the previous doctor is reasonably located where you could easily get to them. What type. And as a general pediatrician who you should start with what type of doctor as well as what what doctors would you be working with.


[00:28:37] So my answer to almost every question is it depends. And this is the case for this too. So you know I think starting with a primary care doctor or primary care provider whether it’s family medicine or pediatrics is a good starting place. If you have a family doctor who you trust and have had had for years that’s a great starting place. I do think that if a child has a longstanding relationship with another primary care clinician and that person is accessible that can be a great opportunity to bridge some of those connections.


[00:29:11] Right. So that’s somebody that may have a relationship with the child but may also have you know records and other things that would be very helpful. Now for many you know families or children that’s not accessible because either they haven’t had consistent health care or it’s too far away. But you know in that case sometimes that can be helpful. And again I think in terms of who prescribe the medicine. Again it sort of depends. You know if there’s a psychiatrist or a mental health specialist who’s been prescribing medicine for a child for years and knows that child well and you have access to them that’s a great starting place at least it may not be that you ultimately end up seeing that person if it’s not convenient or you know accessible or whatever else. But it’s a good starting place to again gather some of that data as to what’s what’s the rationale been for treating this child before and what do they need now and what will they continue to need in the future. The other thing is that many states have sort of specialized foster care clinics which sometimes can be very good starting places so many states. And if you look at the American Academy of Pediatrics website there is a list of foster care clinic by state and foster care clinics can take on a couple of different roles. So some clinics see children as they come in to care and help make recommendations about their ongoing healthcare needs and set them up with community providers.


[00:30:38] Other clinics like ours are a primary care medical home for children while they are in foster care as well as when they’re reunified if that is the wishes of the family or whoever is involved. But again many places do not have a personalized foster care clinic that is close by nor does every child need one. Many children who are well and may not have a lot of behavioral health needs may not need a specialized foster care clinic.


[00:31:05] A local pediatrician may be able and then it occurs to me also that if it is reasonable to keep the child at the with a pediatrician or a doctor that they’ve seen in the past. One advantage to that is that the majority of children will ultimately end up reunified with their birth family and that doctor would likely if they had taken the child to that doctor previously that’s likely the doctor they will be taking the child back to. So there is that advantage because it provides continuity of care even once you are no longer fostering the child. Not surprisingly we got. There have been a number of questions have been asked on sleep issues and had to smile because I think that that is certainly something that foster parents across the board have to deal with. I’m going to read two of them and then we’re going to talk about sleep issues will unpack those questions and talk about some of the issues that they’ve both raised. One by Diana she said our son has insomnia possibly due to a mix of trauma PTSD Post Traumatic Stress A.D.H.D attention deficit hyperactivity disorder. And the stimulus mode’s he takes for the A.D.H.D. He takes the melatonin supplement. We play with his melatonin dose giving him less or skipping it when he can stay up late or exhausted from football practice and not for other suggestions. And then we have a question from Lacey. She said of the four siblings were adopting from foster care three are on A.D.H.D meds and meds for sleep and I know at least two of them have a very hard time sleeping.


[00:32:52] We’re moving to overnight visits soon and once they’re officially ours and we can control what the doctor doctors say and what medications they take we will probably have them all reassessed for their meds and even diagnoses. Anyway all that to say what effect this trauma and A.D.H.D and its associated medications play in insomnia and how can we help it without additional meds. Let’s start with Laceys last question. That’s a good way into this. What effect is trauma have and what effect is A.D.H.D have on sleep.


[00:33:26] So trauma can certainly have a significant impact on sleep. In fact many mental health problems can have an impact on sleep so anxiety and depression for example can make kids sleep more or not sleep. Wow. You know children who have nightmares or hyper arousal meaning they’re sort of very reactive to small things in their environment. Sleep can very much be disrupted. I think the other point to think about is you know for many kids they are sleeping in an unfamiliar place initially and that can be very challenging for many people even if they don’t have a significant history. So I often give the example of you know if you’re staying in a hotel because you’re traveling for work or something like that many people note that they don’t sleep as well because they’re out of their familiar environment. So there are really a lot of things that go into sleep that may not be totally related to the to the trauma and the sort of impact on the body but may certainly have to do with the transitional nature that unfortunately a lot of these kids live in as far as A.D.H.D. So HD can certainly disrupt sleep. Kids will have trouble settling down to go to sleep. And the point that’s been made in the question sort of implicitly is also that A.D.H.D medicines particularly stimulant medications can have an impact on sleep and can disrupt sleep especially if they’re taken later in the day.


[00:34:53] Right. OK. So then her next question is this ties into Diana’s earlier question what can parents do to help with sleep issues without additional medication and with what Lacey specifically said and then I’d like to talk about the role of melatonin as well but let’s talk about you’ve got a foster child that is not sleeping well for any number of reasons. What are your options from choice as the foster parent can make. That might help the struggle right.


[00:35:27] So sleep is very I I fully empathize with these families because sleep is a very very challenging for many children but particularly for children in foster care. The first thing I would say is that the things that all of us need for sleep are not that different. So we need a quiet environment that is the right temperature we need sort of some safety and security so that may be sort of you know night late or sort of a certain object that is you know sort of a safety object. Many kids need a bedtime routine so that’s not going from rushing you know after practice eating three bites of food quickly doing homework and then going to sleep. A lot of kids need a routine where they can kind of wind down. So whether that’s you know sort of time to read or shower or whatever else but sort of time to wind down. The other thing that I strongly strongly encourage families to do and I fully admit I am not good at this is that screams within an hour of bedtime we know disrupt sleep so phones TV that type of thing really need to get shut off and really need to stay out of the bedroom. You know those things will absolutely disrupt sleep. The other thing is that many children have trouble where they wake up in the middle of the night and again sort of the same things need to be there. So having sort of safety and security not having screens or other things that will kind of wake our brains up can be really important.


[00:37:03] Yeah. And getting and keeping in mind that phones count screen time correct. Parents need to be right. Talk about melatonin. I hear so often parents talking about their children. They’re giving their children melatonin at night.


[00:37:20] Let’s talk about the effectiveness and the advisability of melatonin well so I think you know the caveat being that every child is different and that without you know specifically seeing a child I wouldn’t give any sort of particular medical advice. But we do know that for children who have sleep problems that are not fixed by the environmental things that sometimes melatonin is used and there is actually a decent amount of pediatric data that can show you know that shows safety and efficacy for melatonin. You know it is a reasonable thing to try. I encourage people to check with you know they need to check with their doctor first and make sure that there’s not something else going on. So the other thing right is is the kid not sleeping because they have sleep apnea or another medical problem that is preventing them from sleeping. You know and have we done all the behavioral stuff that will help to get that kid to sleep without medication. But then if those things you know if there’s nothing going on there that a lot of times melatonin can be a safe medication to be used for sleep. There’s also a limited amount of data for Clonidine which is an alpha agonist. So again that second line A.D.H.D medicine that I mentioned earlier in the talk. But to my knowledge those are the only two medications that have been studied in children and potentially have a role for sleep.


[00:38:47] Bottom line is it can be effective however check with your doctors because it’s not something that you necessarily want to be prescribing on your own.


[00:38:55] Correct. I think it’s one of those things that just making sure especially if a child is on other medications or is very young that it’s something that’s safe for your child.


[00:39:05] Well you have to worry that if by taking melatonin which is a as I understand it naturally occurring in the brain that you’re going to prohibit the brain from actively making it. I’m not explaining this question very well making it on its own because you’re artificially supplementing with it hope that that question makes some sense.


[00:39:27] It does. And to be honest to my knowledge there is no data to suggest that that is the case. But you know again that’s one of those questions that you know we do know that you can use melatonin long term if you need to. But the goal right is to have a child who uses medicine for a short term and then is able to come off and sleep without medication even if people don’t think of melatonin as a medication.


[00:39:53] But in fact that is correct. OK. All right. Another issue I don’t know how common it is. We received a question and that is dealing with weight issues children being I suppose it could be underweight or overweight. But we have seen more of the questions we tend to get our children coming in overweight. Here is one from when our foster son is 13 and a great kid. He’s been with us for four months and I’m not sure what his permanency plan will ultimately be. I’m worried about his weight. He is pushing obesity on his BMI. I am not sure my role as a foster mom is to help him with his weight. Other than modeling healthy eating I don’t know the reason he is so overweight. But I do know that he loves all things bad for him. He also hates to do anything active. I don’t know how proactive I should be I don’t know how long he will be here. I don’t want to take a major security blanket away from him she says food is going to go right back into the situation where all he will get is unhealthy food. Should I just let it ride or should I take action if I take action. What would be effective. Should two basic things here one. And this goes back to the the transit nature of foster care and the uncertainty of it. How proactive should she be. This is going to be not a quick thing. And this is a. Apparently she doesn’t know the reasons. We’ll start there.


[00:41:24] What are some of the reasons that children come in with being significantly overweight into foster care. We’ll start with some of the reasons why that might be right.


[00:41:35] So some of the reasons that children come in overweight or obese are the same as the typically developing children in the population. Right. Too many calories not enough activity. You know focus on hyper processed food that type of thing. But I think another really important thing to remember is that believe it or not it sounds counterintuitive but children who have had food insecurity or inadequate or sort of irregular access to food are often obese or overweight. And if you think about it a little bit it makes sense.


[00:42:13] What’s happening right is children who have food insecurity may not have access consistently to food. And so when there’s access they may overeat or eat whatever’s available or when they see food they eat it not knowing when food is next going to be available or if it’s going to be consistently there. And so in that case children aren’t learning to listen to their hunger and full cues and so they sort of turn those off and just eat you know basically with whatever’s available if that’s been going on for a long time that can be really challenging to shift. But it can happen. And again I think you know going back to the question before about sort of what sort of things can I instill in a child not knowing what kind of permanency plan there is. You know there is no downside to teaching a kid sort of how to listen to their body about when they’re hungry and stop when they’re full.


[00:43:09] Rather than focusing on losing weight or dieting but really helping a kid to realize you know am I eating because it’s a comfort. Things are sort of emotional. Eating is kind of the buzzword for that. Am I eating because I’m scared that there might not be food later. Am I eating because you know because I’m truly hungry now. Again kids aren’t going to figure that out overnight but you know access to lots of healthy foods a good variety of food. You know there are some things you can do to kind of ensure kids that they’ll be access to food if they’re hungry.


[00:43:43] Those are all things that can be important for kids you know and also most children come from foster care from poverty. And we know that the obesity rate is higher and and the poor and the poorer section classes of our society and part of that I think is because food is often highly caloric processed caloric but it’s also inexpensive. So I would imagine that that would play a role as well.


[00:44:20] That may very well be the case. And you know again I’m not an expert on the literature on you know sort of. But you are exactly right. There is this concept right of food deserts. The idea that there may not be access to healthy nutritious foods within sort of urban poor areas particularly.


[00:44:39] All right. So let’s move now to talk about dental health. Very often children have not seen dentists that are when they come into foster care. I think a question to ask is how much and how soon should you give a example a visit to a dentist can be a traumatic experience for children particularly those who’ve had no experience going to a dentist. So how soon should you bring your child to administer Medicaid cut Medicaid coverage. Dental care doesn’t work.


[00:45:18] So again probably a little bit of state wide variation on Medicaid but typically children should have access to oral. Like health maintenance visits with Medicaid or other public assistance insurance. But again you would have to sort of check with your state Medicaid office or with the individual plan that your child has. As far as when to take a kid to a dentist you know you’re exactly right that often kids have significant oral health needs when they come into care because it’s not something that has been prioritized you know and so it is pretty important I think to try to get a child in soon to have a routine dental visit. Again taking the opportunity to use a dentist that maybe you’ve seen with your children or a dentist who has comfort you know has comfort with young patients is really important. You know as much as you can prep a child for what that is it’s going to look like as much as you can call ahead to a dentist or to the staff and say look this is the situation I want this child to get the help they need. But I don’t want them to be traumatized or have a really negative experience because they’ve been going through a lot. So again you know if you have your own kids or you have you know access to a pediatric dentist or a dentist who has good experience with children you start there to try to make that experience as easy as possible. But it is very important to make sure these kids get oral health maintenance visits.


[00:46:47] Exactly. All right. So how do we find earlier when we were talking you mentioned that evidence based therapy but that kind of begs a bigger question and that is how to foster parents or parents in general find competent therapists that are knowledgeable about the impacts of trauma who are knowledgeable about the children in foster care and know what type of therapy to use. There seems to be a dearth of a lack of people with this training so what’s a foster parent to do to find competent help for their Cotner child.


[00:47:28] Right. So foster parents and caseworkers and other folks who advocate for children in foster care really have to be informed consumers and really ask a clinician so you know a potential therapist should not be you know offended or taken aback when somebody asks them what sort of what do you think is going on with this child who I’m bringing to you. And and what evidence supported therapy are you planning to use. So most people many people will say for example they do cognitive behavioral therapy and they may to some degree. But it’s important for consumers you know whether that’s a parent of a child in foster care or you know or themselves honestly to kind of know what that looks like. The other thing is that there are a number of evidence based trauma treatment modalities that are used for different kids and different populations. For example the California clearinghouse lists all of the evidence supported trauma treatments that are available and they go through the evidence and rationale. And so a parent or a clinician or a pediatrician can look at it to try to understand what therapies might be available and also what therapies you know might be appropriate for that child. Now again that’s a lot of work on the part of a foster parent who may or may not have much background in mental health. So the more simple thing I would say is to ask a clinician about what it is they’re doing and what the evidence is that supports that technique and also ask about goals. Right. The goal is not for a child to have to be in therapy for the rest of their life.


[00:49:07] The goal is not to have a child who’s spent two years in therapy talking about their behavior. That’s not going to get them where they need to be. So the other thing is to really think about if the child’s been seeing clinicians for a period of time and you don’t feel like you’re making progress to have a conversation with that person about you know what’s going on. Is there something that we’re missing. Is there something else that we need to be doing.


[00:49:31] You know as far as getting suggestions we often tell people when we talk with the caseworker talk with your local caseworker who may well know of conditions nearby and in Calcasieu. Another thing you can do is contact that agency you’re not working with contacted adoption agency particularly one who places children who are past infancy and ask them who who they recommend for their families because that at least gives you a starting point. And I mentioned before the state foster parent associations there statewide often and you’re really looking for something local. But they may be able to connect you with other foster parents who are in your location. And if you’re fortunate and have a local support group obviously that would be a great place. And then. And then last but not least is online support groups. Again they tend to be national. But you can sometimes find state support groups or the national ones if they’re large enough you can post and say I live in blank. Has anybody used a therapist in this area. So there are a lot of options but asking somebody to guide you is a good first step. Somebody who is seeing other foster kids or for adopted kids who might also have some of the same trauma based issues. So all of that are there.


[00:51:05] The other group I would add to that list is your local child advocacy center. So a child advocacy center right. We’ll see children often for child abuse evaluation or a forensic interview. But many of them also offer treatment or can connect you with trauma trained therapists or other treatment providers. And those are located. You know there’s there’s several hundred now nationwide and there is often one for your county or several counties and that could be another place to access or get information about evidence based mental health treatment.


[00:51:40] Great. And when we should have said they actually said this at the beginning that’s a great suggestion which you just gave and another one is your pediatrician. That is a another often very good resource and specifically telling your pediatrician that what you’re looking at you’re looking for somebody who has experience working with children in foster care or adopted kids who’ve experienced trauma. Another really good resource. So let’s say this is a little off topic but it comes up and it is part of mental health. And so I want to talk about as as children have been in your home for a while they often begin to relax and feel more comfortable and feel safe. And it is endless in this environment of safety that children will often disclose prior abuse from a foster parent. We hear from foster parents that they are they want to know the best way to handle that and what to do with this information. So let’s talk first about the best way to handle in the moment a conversation with a child who is telling you about previous abuse.


[00:52:56] Right. So I think the point you make is that when children start to feel comfortable or feel safe or trust in adult things might slip out. And the truth is it usually happens at sort of impromptu times. And so foster parents don’t necessarily have the chance to prepare. Right. It’s just information that all of a sudden is right there and so it can take foster parents off guard. I think the important thing to remember is that if a child discloses something it’s a really good opportunity to let them make that disclosure. That doesn’t mean question them. In fact I’m suggesting the opposite. But what we don’t want is for kids to feel discouraged to disclose so that if a foster parent you know well-meaning says oh you know you’re safe now we don’t have to talk about that or whatever it is the child may be getting the unconscious message that that’s not something that I’m supposed to talk about. That’s bad. I’m not supposed to talk about it. And the truth is they may have heard that from somebody else particularly if you know there is a longstanding abuse or something else they may have been coached not to talk about it but it is important not to question a child especially if it’s a new disclosure. If it’s a disclosure that is you know you know parents foster parents should not play forensic interviewer. They should let a child talk as much as they want to but they shouldn’t ask specific questions.


[00:54:24] They should follow up with their caseworker if there’s a disclosure that may be something that’s well documented or it may be something new that somebody needs to look into. The other important part of a disclosure is to take the opportunity to correct any distortion. So for example a child may say you know I’m in foster care because I was I behaved really badly and my dad beat me. And you know the truth is the child may be in foster care because dad beat him but there’s no type of behavior that makes it OK for a parent to be their child. And so a foster parent can say that you know they can say you know honey I know that you know there are probably times that you didn’t make good choices or you didn’t follow the rules. But it’s actually never ok for grownups to to be children or had children. And so you have that opportunity to correct the distortion Yeah I think that.


[00:55:22] Exactly. And children often believe because they’ve been told that it’s their behavior that has caused the problem or their behavior or their inability to have helped their their parent her. And that is a distortion that most children come into. If they’re if they’ve been told that are coming into foster care with.


[00:55:47] Right. And I think remembering that you know you’re saying it once is probably not going to shift that child mindset necessarily. But by not saying it you may be implicitly agreeing with the child may get that message that you’re in grieving. You know and it is really important to help set kids as to what their role is as kids. Right. Their job is not to be the parent. Their child is not to fix their parents alcoholism or whatever you know substance abuse problem or whatever’s going on.


[00:56:19] But it’s important to validate a child and say you know that must be really hard or you know I’m I’m really sorry that that happened to you or to correct the piece in terms of what the child’s role is and that anything you specifically would like to talk about with teen mental and physical health issues teens in care. We use the word children and child. And I know from years of having worked with youth that sometimes grating to them and I probably should have said at the beginning that when we say child we are actually meaning adolescents and young adults as well. Even though I realize that’s probably not the best term view. So let’s take a moment to talk about Pacific issues that we need to think about with teens and their particular mental and physical health issues.


[00:57:14] So yeah very broad question I would say sort of one overarching thing for me is that many many teenagers who are placed in foster care as teenagers are likely to age out of care. So they are likely to either have you know they may not be reunified or they may you know not be adopted they may age out of care and then be a young adult who’s often very isolated and may not have a lot of social support. We know rates of homelessness. You know mental illness things like that are very high educational underachievement. Correct. So you know I think in general for teenagers one of the most there’s a couple of really important things we can do one is try to teach them life skills so simple things you know how to balance a checkbook how to I open a bank account how do I make a job application to encourage them in whatever sort of pursue positive pursuit they had. And I also think that probably more than anything teenagers will tell me that they don’t feel heard. So they may see and this goes with providers clinicians but also with foster parents you know they are often told what they’re doing or what they shouldn’t be doing. But people don’t take a chance to listen to them and to hear their input on something. These kids have often been through a lot or have become very self sufficient because they’ve had to be. And so really taking the opportunity to listen to what they want to listen to what their goals are to listen to what they’re struggling about can really go a long way.


[00:58:52] I think it is very important in teenagers that we talk with them about psychiatric medicines and how we might be prescribing them and why we might be prescribing them and what they think about them. And I know so I think and I think that goes with foster parents as well because we don’t know what their life experience has been prior to that. I think we also have to be very careful to not try to replace a role that a parent might have filled even if they didn’t feel it very well. Often often kids are fiercely loyal to their parents because they are their parents and so trying to navigate that with somebody who has much stronger ideas and values and opinions can be really hard. So never ever you know trashing a biological parent never saying negative things. You know really allowing the child to exist in that space where their family is pretty complicated and may include a biological parent who hasn’t always made the best choices but who may have some capacity to care for that child and a foster parent who’s trying to fill a really challenging role.


[00:59:59] Bet Becquerel point all I want to end with someone who asked to remain anonymous foster mom I’m going to read her her more of a comment actually and give you an opportunity to respond. She says it is very likely that my two foster kids will be going back to their family within the next year. I have a good relationship with their mom and I know that she means well but these kids will be going back to a very chaotic house with boyfriends coming and going. Older siblings doing drugs fending for themselves for food and little supervision. While they have been with us for the past year we’ve gotten them on a schedule. We have one of them on a low dose of Adderall which has done wonders. We have gotten them off of sleep medications that their mom gave them to knock them out. They now sleep through the night. Have friends at school and they actually look forward to going to school. I know that this will all be undone when they go back home. And I sometimes wonder why we bother. I know that their mom won’t get that their mom won’t get his medication refilled or even if she does she won’t remember to give it to him. I know that they will only go to school if they get themselves up in the morning and they will have no bedtime. What good is all this care when it only lasts for one to one and a half years. Thoughts from that.


[01:01:17] Dr. Wolfe Yeah. So it’s really I think that sometimes we don’t realize how hard it is to be a foster parent and how much parents want to do the right thing and want to sort of promote support and stability for kids. And how hard that is. I think a couple of points I would make one is that if you ask children who were in foster care as children many of them remember periods of safety and stability even if it wasn’t permanent. And so knowing that that exists and is possible actually doesn’t mean doesn’t count for nothing. The other point that I would make is that it is so easy for all of us to assume that all those things will happen when when the child the children go home and they may very well. But I think for many of us it is hard to imagine a life in poverty that is very different from our own. And so trying to pick out the little pieces that could be better for these children or the little things like you know these kids have learned a bedtime routine. It’s possible that they might continue a little bit of it you know and understanding that their life with their parents will not be exactly the same as it was in any foster home but it might not all be worse. And I realize that I am asking something that is very very challenging. And trust me I have been I have struggled with the same thing that the person wrote in and said because I have certainly been in that position.


[01:03:01] But I do feel strongly that children do remember periods of safety and stability. And they also you know there is capacity for people to change. And so there may be times where you know there may be little bits if if the foster parent has taken the time to get to know the biological parent and has a good relationship she may continue to look to that person for a little bit of support and her ability to kind of take in some of the good skills that these kids have learned and do them in her own way that you know is feasible and workable and etc I think is possible and so I really praise the foster parent for taking the time to get to know this biological parent and trying to understand where they’re coming from.


[01:03:50] Thank you. We’ve been talking today with Dr. Elizabeth Wallace. She is an assistant professor of pediatrics at the Medical University of South Carolina and the director of their foster care support clinic. This show as well as all the resources provided by creating a family could not happen without the generous support from our partners who believe in our mission of providing unbiased education and support to those struggling to create a family and to foster parents as well. Some of our partners include adoptions from the heart. They have helped build over 6000 families since 1985 through domestic infant adoption. They work with people all across the United States but they’re fully licensed in Pennsylvania New Jersey New York Delaware Virginia and Connecticut. We also would like to thank Spence shapen they are a licensed and accredited non-profit organization in New York City metro area. They have been offering adoption services for more than 100 years. They’re robust and I do mean robust post adoption support services provide all members of the triad. Birth parents adoptive parents and adoptees it was a supportive community for those who would like more information about Dr. Walls or about the medical university of South Carolina or their foster child support clinic. Simply go to their website. M U S see kids dot org. Again that is him. USC kids dot org thanks for joining us and I will see you again next week.

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