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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Child Youth Serv Rev. Author manuscript; available in PMC 2010 December 1.
Published in final edited form as:
Child Youth Serv Rev. 2009 December 1; 31(12): 1289–1297.
doi:  10.1016/j.childyouth.2009.05.016
PMCID: PMC2772213
NIHMSID: NIHMS128444

Context Specific Mental Health Services for Children in Foster Care

Abstract

Although a high proportion of foster children receive mental health services, existing research suggests limited accessibility and effectiveness of these services. This paper discusses strategies to develop a model to deliver evidence-based services using the unique opportunities apparent within publicly funded child welfare systems. An ecologically-focused model providing enhanced services in children’s homes and schools could capitalize on these opportunities and radically improve access and effectiveness of mental health services for foster children. We present data from four focus groups conducted with foster parents, caseworkers, and therapists to understand the feasibility of implementing this type of service model. Results support the need for services focused on enhancing interactions in children’s foster homes and schools, but also suggest that issues related to priorities and primary roles could limit the extent that caseworkers and agency-based mental health providers would follow through with the proposed service model.

Context-Specific Mental Health Services for Foster Children

Over the past two decades, child welfare advocates and researchers have increasingly recognized the need to address foster children’s mental health problems (Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004; Vandivere, Chalk, & Moore, 2003). Consistent with this trend, recent data suggest that child welfare involvement facilitates identification and treatment of children’s mental health needs, with a greater chance of mental health service use occurring with increased child welfare involvement. In the general population, 21% of children who need mental health treatment receive services (Kataoka, Zhang, & Wells, 2002). Similarly, among children who come into contact with any type of child protection service, 24% with significant needs have received services in the past 12 months (Burns et al., 2004). Among children who are in foster care for a year or longer, however, the majority with significant needs receive services, with 76% receiving at least one inpatient or outpatient service (Leslie et al., 2004). These data suggest that involvement in foster care systems exerts a strong, positive effect on children’s service use.

Given these high levels of service use, the frequent criticisms and even lawsuits alleging substandard mental health service provision to foster children (Dore, 1999; Lyons & Rogers, 2004; Klee & Halfon, 1987; Schneiderman, Connors, Fribourg, Gries, & Gonzales, 1998) might seem perplexing. However, examination of the content, effectiveness, and allocation of the services provided to foster children clarifies this contradiction; the services provided are fragmented, untested, and at best highly variable in quality (Dore, 1999; Leslie et al., 2004; McMillen et al., 2004; Zima, Bussing, Yang, & Belin, 2000). In this paper, we first discuss the need for mental health services reform in child welfare systems. We then propose that the unique characteristics of the child welfare system create an opportunity to develop an accessible, effective mental health service system for foster children. This ecologically-focused model would capitalize on the resources and strengths of the child welfare system and integrate empirically supported mental health prevention and treatment interventions into the core functions of child welfare to create self-sustaining services based in children’s homes and schools.

Finally, we present data from four focus groups that were conducted to understand more about the feasibility of shifting service provision to this type of context-specific service model. The focus groups included caseworkers, foster parents, and therapists working in a specialized foster care program that had agreed to participate in a pilot project focused on service development. Our findings support the need for mental health services reform and the relevance of context specific services for foster children. In addition, however, our findings highlight challenges for the implementation of this type of service model.

Effectiveness of Mental Health Services in Child Welfare Systems

Until recently, little was known about how mental health services are provided to foster children. The National Survey of Child and Adolescent Wellbeing (NSCAW), a representative, longitudinal study of children served by child welfare systems, has begun to address this gap. NSCAW results indicate that about three-quarters of foster children with significant mental health needs receive specialty mental health services on an outpatient basis (Leslie et al., 2004). A substantial percentage also enter an inpatient facility (9.3%) or see a medical doctor for emotional, behavioral, or learning difficulties (19.1%), with nearly all of these children also receiving outpatient services. Unfortunately, findings from this study do not clarify the extent that foster children receive services from non-mental health specialty settings such as schools, which are the most common route for entry and provider of services in the general population (Farmer et al., 2003). Additionally, these findings might underestimate the number of foster children receiving treatment, since interventions provided by child welfare placements (e.g., mileu-oriented treatment foster care homes and residential treatment centers) were not counted as mental health services.

The effectiveness of the mental health services provided to foster children is also largely unknown, but findings from available studies have generally not been positive. In a study involving 68 maltreated children, Kolko, Baumann, and Caldwell (2003) reported no association between receipt of community-based services and lessened emotional and behavioral problems over time. This is not surprising given that findings from studies in the general population have been mixed, with several studies reporting no effectiveness for children’s mental health services, including traditional child psychotherapy as generally practiced (Weiss, Catron, Harris, & Phung, 1999) and systems of care initiatives (Bickman, 1996, 1997; Bickman, Noser, & Summerfelt, 1999). This apparent lack of effectiveness might be related to the fact that empirically supported treatments are used infrequently in the general population (Weisz, 2000) as well as in child welfare settings. For example, foster or biological parents rarely participate in treatment (Leathers, Testa, & Falconnier, 1998), despite evidence that parental involvement is essential for many of the most commonly diagnosed childhood disorders, such as externalizing behavior disorders (Farmer, Crompton, Burns, & Robertson, 2002). Most foster children who are referred to outpatient services receive only a few sessions (Leslie et al, 2000), and almost two-thirds of foster children diagnosed with ADHD have not visited a physician for evaluation for psychotropic medication in the last year (Leathers et al., 1998; Zima et al., 2000).

Outcome studies of residential treatment have also failed to demonstrate consistent positive outcomes. Residential treatment services might help stabilize the behavior of children and youth with serious emotional or behavioral disturbance while they are in the residential setting, but children experience no long-term benefits in comparison to community-based care (Epstein, 2004; Chamberlain & Reid, 1998). Additionally, intensive, highly structured treatment foster care models are effective in treating emotional and behavioral problems, but the intensity of training and support that is required to implement effective models is not provided to most foster parents (Chamberlain, 2002). Overall, existing data provide little evidence for the effectiveness of the majority of the mental health services provided to foster children.

Problems also occur in the allocation of mental health services within child welfare systems. Although a significant correlation exists between severity of emotional and behavioral problems and intensity of service use (Burns et al., 2004; Leslie et al., 2004), factors unrelated to need for services also appear to determine referral and service use patterns. African American children, children entering care due to physical abuse or neglect, and preschoolers are less likely to receive services than other children (Burns et al., 2004; Garland et al., 1996; Glisson, 1996; Leslie et al., 2004). Racial differences in the allocation of residential treatment and community-based services also occur, with non-white foster youth more likely than white youth to receive more restrictive, residential services rather than community-based treatment (Berrick, Courtney, & Barth, 1993; McMillen et al., 2004), again replicating service patterns in the general population (Sheppard & Benjamin-Coleman, 2001).

Taken together, these findings support the need to develop, test, and disseminate effective service models for foster children. At present, services are provided to a large proportion of children at a high cost, but it appears that these services are largely ineffective and inequitably allocated. Given the large proportion of child welfare budgets allocated to clinical services (Naylor, Anderson, & Morris, 2003) and the number of foster children with significant mental health needs, an important question is how to develop effective mental health services for foster children.

Mental Health Services Development: An Ecological Approach

Efficacy studies have established evidence-based treatments for the most common childhood mental health disorders and, in the general population, evidence-based treatments lead to better outcomes than treatment as usual (Weisz, Jensen-Doss, & Hawley, 2006). Unfortunately, less is known about how to adapt these interventions to the realities of routine clinical practice with children (Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald, 2001). Similarly, effective treatment models with implications for model development in child welfare systems have been developed (Chaffin & Friedrich, 2004; Chamberlain, 2002; Kolko, et al., 2003; Timmer, Urquiza, & Zebell, 2005), but these models have not yet been systematically tested and disseminated within child welfare systems.

We suggest that the child welfare system has the resources and potential to promote a context-specific mental health service model in which mental health services are integrated into child welfare services and provided in children’s schools and homes, instead of office settings. This type of service system is based on an ecological perspective of child and family functioning. From an ecological perspective, child mental health problems occur in the context of complex embedded systems. Factors from multiple levels, including individual child physiology, family interaction, school and community environments, family transactions with outside systems, and social and cultural variables, affect child mental health both directly and indirectly (Belsky, 1980; Bronfenbrenner, 1979). The context-specific model we propose would focus on modifying the contingencies within the environments directly experienced by the child (e.g., foster homes and schools) to reduce emotional and behavioral problems. An essential aspect of the model is that it restructures transactions between the child welfare service system and the child’s environment to support context-specific treatment. This approach follows from an emerging body of research that focuses on delivering the clinical practices developed in traditional outpatient efficacy trials in innovative ways that depart from a clinic-based service model (Cappella, Frasier, Atkins, Schoenwald, & Glisson, 2008; Chamberlain, 2003; Henggeler, Schoenwald, Rowland, & Cunningham, 2002). These models propose a new definition of mental health that moves away from symptom reduction in the individual and towards enhanced functioning within the contexts in which children live.

A context specific service model departs from existing service models in several key ways. To begin, a context specific service model would shift the primary treatment focus from individual child treatment to training and support of the child’s parents, foster parents, and teachers. Although service systems vary by region, available data indicate that individual outpatient therapy is still the primary mental health service provided to foster children (Leslie et al., 2004). Children who require more intensive services might enter treatment foster care or residential treatment. In this paper, we examine the feasibility of training caseworkers and mental health providers to provide the majority of mental health services in the child’s environment, to reduce problems such as low caregiver involvement, poor follow-up with services, and inequities in service provision. By integrating mental health functions into ongoing child welfare services, services could reach a higher percentage of foster children and mental health needs could be met proactively. In this model, time-limited individual treatment would still be provided to children to address issues related to disorders with an empirical basis for individual treatment (i.e., depression, anxiety, and trauma related symptoms; see Weisz, 2004), but the majority of services would be shifted to an ecological service model.

The relatively intensive nature of child welfare services provides an ideal environment to develop an ecologically focused service model, consistent with the theoretical perspective of empirically supported approaches such as Multisystemic Treatment (MST) and Multidimensional Treatment Foster Care (MTFC). These models provide more intensive services than could be realistically provided to the majority foster children with emotional and behavioral problems, given the very low caseloads required by the models. However, Henggeler et al (2002) identified several features that could be incorporated into less intensive models relevant to child welfare settings. These include (1) viewing caregiver’s parenting capacities as a central target for interventions; (2) eliminating barriers to service access by delivering services in homes, schools, and other community settings; (3) using evidence-based interventions within the child’s environment; and (4) addressing the multiple determinants of children’s mental health problems (pp. 5–10).

To understand the feasibility of implementing this type of model in an actual child welfare agency, we proposed a pilot study to the administrators of a large, urban child welfare agency. We suggested targeting foster parent-child interactions by using parent management training delivered in a manualized group format (“Project Keep” as developed by P. Chamberlain; for a description, see Price et al., 2008). This training program focuses on (1) training foster parents to reinforce positive behavior and proactively discipline using mild punishments and (2) providing emotional support by involving foster parents in foster parent groups. Recent research supports the effectiveness of this intervention when it is provided to foster parents who are interested in attending groups (Price, et al., 2008). In Price’s research, however, 38% of foster parents who were contacted were not interested in participating in the study, mainly because they did not have enough time or were not interested. To increase access to the intervention, we proposed that caseworkers provide the group material adapted into a home visiting model for all foster parents who were unable to attend groups. By involving caseworkers in the provision of the intervention during regularly scheduled home visits, we hypothesized that foster parents would receive ongoing support of the use of new skills.

In addition, we proposed including a school visiting protocol and school-home notes to facilitate stronger connections and better communication between foster homes and schools and address children’s behavior problems at school (Atkins, Frazier, & Cappella, 2006; Power, Karustis, & Habboushe, 2001). Caseworkers and/ or therapists would facilitate group sessions with foster parents; provide home visits to foster parents who were unable to attend groups, using an adapted version of parent management training; and visit schools to identify classroom-related issues and set up school-home notes. Because caseworkers in this program were already required to visit the foster home at least three times a month and to visit the school three times during the school year, these activities could occur during contacts that were already occurring.

Previous research supports foster parents’ need for more training, particularly in how to manage behavior problems, as well as their need for more emotional and tangible support (Hudson & Levasseur, 2002). Research also supports the need for better communication and training of caseworkers and school personnel on how to help foster children succeed in school (Altshuler, 2003; Zetlin, 2006). However, agency administrators were not sure that foster parents would be open to the proposed services. They thought that caseworkers needed behavior management skills to use in their work with foster parents, but did not know how many foster parents would participate or benefit from this approach. We also had questions about how foster parents would respond to the content of the intervention, whether the intervention would be consistent with foster parents’ needs, and whether caseworkers would implement the intervention in homes and schools. To better understand the feasibility and appropriateness of the proposed intervention, we conducted planning focus groups with foster parents, caseworkers, and agency therapists to address the following questions:

  1. Does the content of the proposed intervention (i.e., parent management training, homework support, strengthening school-home connections) meet the needs of foster parents and their children?
  2. How much support and information do caseworkers and agency therapists currently provide to foster parents? Could caseworkers and/ or therapists play a primary role in providing the intervention?
  3. What type of contacts do caseworkers and therapists currently have with schools, and how open are they to working in the school environment?

Methods

The focus group participants were a convenience sample drawn from a single Chicago child welfare agency serving mainly urban foster children and families. The first focus group included nine foster parents who sat on a parent advisory council; the second group included eight caseworkers from a specialized foster care team; and the final two were groups of psychotherapists employed by the agency, with one group including six therapists and the other including seven. Foster parents on the advisory council were chosen as informants because of their interest in providing feedback to the agency about current services. The selection of this group might have resulted in perspectives that do not reflect those of an average foster parent; however, because of their involvement in the advisory council, they were expected to have more contact with other foster parents than the average foster parent and so be more able to describe the experiences of foster parents in general. The selected caseworkers were all on a single specialized case management team that had been selected to be the intervention group for the proposed pilot study. This team was selected based on the number of children eligible for the study served by the team, which was comparable to the number served by two smaller teams that were to be the comparison group. Caseworkers in the comparison group were not included in planning groups to minimize contamination of the comparison group by providing information about the intervention to these workers. All therapists employed by the agency were included in the groups; since therapists treated children across different teams, there was no benefit in restricting the sample to certain therapists.

Foster parents received a $40 gift card for their participation, and agency staff each received $30 that was deposited in a special events fund, since staff could not directly receive incentives because of agency restrictions. At the beginning of the focus group, each group member completed a consent and demographic questionnaire and received a handout with a description of the proposed weekly intervention topics. Participants also received an outline of the questions that would be discussed. Group questions focused on (1) eliciting feedback on the content of the groups and home visiting manual; (2) the training needs of foster parents from the perspectives of foster parents, caseworkers, and therapists; (3) the amount and type of support foster parents received from caseworkers and therapists at the agency; (4) the types of mental health problems that children in the program have; and (5) how foster parents, caseworkers, and therapists currently interacted with the children’s schools. The principal investigator led the focus groups with a doctoral student and at least one masters level research assistant, with the exception of one of the psychotherapist groups, which was led by a doctoral student and a masters level research assistant.

Sample Characteristics

Of the 9 foster parents, 7 (77.8%) were African American, 1 (11.1%) was Asian, and 1 (11.1%) was mixed race. Ages ranged from 35–63. Two (22.2%) caseworkers were male and seven (77.7%) were female. Of the 8 caseworkers, 5 (62.5%) were Caucasian, 2 (25%) were African American, and 1 (12.5%) was Asian. Three (37.5%) were male and 5 (62.5%) were female. Their ages ranged from 29–58. The psychotherapist groups included 7 (53.8%) Caucasian, 3 (23.1%) Asian, 2 (15.4%) African American, and 1 (7.7%) Latino participants. Therapist ages ranged from 25–62 and all were female.

Data Analysis

All four groups were recorded and transcribed verbatim into word documents and imported into Atlas-ti as primary documents in a single hermeneutic unit. Researchers used open coding procedures, meaning opinions, events, and discussions that were found to be conceptually similar were grouped into categories that led to the identification of central themes or core concepts. Line-by-line analysis was used in order to generate codes for quotations that represented these themes or concepts. Each code was then defined and agreed upon so all coders were applying the same meaning to the codes. Multiple codes were used when two codes were indicated in the line-by-line analysis. As suggested by Miles and Huberman (1994), data were sorted into sub-codes that indicated causal conditions, phenomena, context, intervening conditions, actions/ strategies, and consequences during the axial coding phase. Coders included masters and doctoral level research assistants who met in pairs initially to discuss coding issues and to assign codes until consensus was met. Each focus group was then coded using the agreed upon codes. A third coder reviewed final documents and final codes were decided upon by consensus.

Results

The five predominant themes in the focus groups included (1) The need for parents to be trained in behavior management strategies (foster parents; therapists); (2) Concern that foster parents would not follow through with the proposed intervention (caseworkers); (3) Role conflict and lack of role clarity, leading to difficulty with providing foster parents with support (caseworkers; therapists; foster parents); (4) Difficulty with communication with the teacher (caseworkers); and (5) Need for greater resources and sensitivity in schools (therapists; foster parents). These themes are related to each of the research questions.

The Content of the Proposed Intervention and the Needs of Foster Parents and Their Children Need for Training in Behavior Management Strategies

Foster Parents

Foster parents described the challenges of raising children with behavioral problems. They frequently juggled multiple responsibilities with work, school, and childcare and at times felt overwhelmed with the behavioral needs of their children. In particular, foster parents thought that training in how to address behavior problems and in time management would help them better meet their children’s needs.

What [foster parents] will want to do is the right thing if we have enough options. If we are trained well enough to deal with certain issues, certain problems that arise, and I think a lot of times a lot of us are not equipped and this is why we get bogged down with our own situations of how to deal with it.

…Maybe if they [foster parents] could get some organization skills. You know, time management skills you have to be taught sometimes. And I think if we got that, we could really make a big impact on kids with behavioral problems.

Overall, the issues and needs that foster parents described were compatible with the proposed intervention, and foster parents had few suggestions of topics that should be added that were not already included in the intervention.

Therapists

Therapists thought foster parents needed training in how to address children’s behavior problems using positive reinforcement rather than punishment. Therapists viewed the proposed intervention as a good complement to their individual work with the child and unanimously thought that it had the potential to meet the needs of many of the agency’s foster parents. In particular, they thought that structured training and home visits would support use of positive reinforcement and other behavioral strategies.

I think it’s so easy for foster parents to focus on the negative especially with kids with behavior problems. It’s one thing after the next and it’s really frustrating … Feeling overwhelmed, it’s really easy for them [foster parents] to just focus on the negatives.

I think a lot of foster parents operate on the very concrete level, which is why I think also this is going to be great hopefully …I think something that they can use makes sense.

I talked to one of my foster parents about giving him sort of incentives and then I had one or two foster parents actually do it. So, I think you know going into the homes and having someone who’s specifically doing that, it would be helpful because there’s more sort of accountability there…

Concern that Foster Parents Would Not Follow Through

Caseworkers

Caseworkers, however, questioned whether foster parents would participate. They agreed that their foster parents could use some of the proposed skills, but most thought that foster parents were either overburdened, reluctant to change, or inconsistent.

It’s pulling teeth already to get them to go to doctors and … stuff, so putting this on them, I don’t see it, but maybe I’d be surprised.

If foster parents are setting a good, structured environment and showing good examples etc., things will change and stuff. But a lot of it is a problem with the foster parents not wanting to change the old ways that they’re doing things. … change their mindset to, you know, realize that maybe you do need to do some of these more elementary things with these kids… even though you didn’t have to do it with your own children.

Given their concerns about the extent that foster parents would participate and learn from the intervention, caseworkers were clearly less positive than either foster parents or therapists about the extent that the proposed intervention would meet foster parents’ needs.

Caseworkers and Agency Therapists as Sources of Support for Foster Parents Lack of Clarity, Conflict, and Difficulty with Providing Foster Parents with Support

Although we did not directly ask participants about their roles, when we asked about interactions between foster parents and agency staff, themes emerged related to perceptions of caseworker, therapist, and foster parent roles and lack of role clarity. Caseworkers described conflicts in the multiple roles they had professionally. They also believed that foster parents had a lack of clarity about the expectations of their role as providers of care to children with special needs. Therapists experienced conflict in their primary role as the child’s therapist and the foster parents’ need for support. For both caseworkers and therapists, a result of these role conflicts was a reduced focus on their supportive role with foster parents. Foster parents also had concerns related to agency limits on their role that partly mirrored and partly contrasted these perspectives.

Caseworkers

Caseworkers saw their responsibility to maintain child safety as their primary role. This creates tension about being in a supportive role to foster parents, whom they monitor to ensure that the child is receiving appropriate care. Although caseworkers viewed foster parent support as one component of their job, their primary focus was spending time with the child and ensuring that foster parents followed through with agency requirements. Caseworkers did not feel responsible for training foster parents. They commonly used an authoritarian role to ensure parent compliance, which consequently distanced the foster parents.

It depends on the foster parent, what their need is, but … My role is to make sure that everything she tells me is true, which it usually is when I come out there, and that’s one of the homes I spend most of [the] time with the kids.

A lot of foster parents are also guarded about what they are saying, because of the reporting aspect of it, and coming back and then, well I just saw my caseworker now all of a sudden, licensing’s coming out to talk to me about this and that and so they [foster parents] get a little more withdrawn. So that also gets thrown into that mix.

Consistent with their focus on monitoring whether foster parents were following agency requirements, some caseworkers thought that a review of agency expectations would be an important focus for the foster parent training.

I think a big part of the problem that I have with foster parents is that our expectations of what we need them to do, and their expectations of what we’re gonna do is so far, you know, apart from each other. Sometimes nobody has ever really sat down and told them everything that’s involved [with being a foster parent]or if they have, the foster parents have not really heard it. So it would be interesting to see … in a group meeting kind of format, so that they would have a better understanding of what is expected of them, and what we’re willing and able to do as an agency.

Therapists

Therapists also described tension in their role as the child’s therapist and the need to provide support and information to the foster parent. They appeared to respond to this tension primarily by limiting contact with foster parents; in fact, therapists rarely saw the foster parent and only a few described talking with the foster parent by phone consistently. Foster parents may have wanted more contact with the therapist, but therapists did not want to compromise the child’s trust. At the same time, they knew that foster parents played an important role in the child’s wellbeing, and did not want to isolate them.

It’s a delicate balance, I’ve found. Cause like she was saying you don’t want to have the child perceive you as you know being on the foster parents’ side you know if there are issues between the two of them, but you also do want to lend support to the foster parent because if that situation is happening it’s usually a pretty tough situation. Um, so it’s hard, it’s really hard… in some cases I’ve had to just really reassure the client, the child, that I’m not taking sides you know it’s important to hear foster parents’ perspective too and then in listening to what they had to say as well and just doing some kind of education.

Therapists believed that offering foster parent groups was an important part of the proposed intervention. They thought that foster parents could offer each other support in a way that caseworkers or therapists could not.

I just think you know getting support from a therapist or caseworker is very different from getting support from other foster parents who are going through the same thing. Um cause I know foster parents can feel like yeah, well you’re telling me to do this, but you’re not the one every day with these kids while they’re acting out or doing this or doing that and it’s real easy for you to come in and say do this and do that, but so I think the support from other people who are going through similar things that they are would be pretty key.

Foster parents

From the foster parent’s perspective, tensions in their role as the primary caregiver to the child and the agency’s role as the child’s protector and decision maker at times interfered with their care of the child. Some foster parents stated that the agency did not include them in important decisions concerning the child. They thought that the agency assumed that it knew what was best for the child, even when it was not in agreement with their perspective. At times, foster parents felt unappreciated for their role as caregiver to their children. They wanted to be included more in the process of planning for the child, and to work more collaboratively with caseworkers and therapists. Notably, they did not appear to expect to receive support from the caseworker. When foster parents were directly asked about what type of support the caseworker provided, none of them described emotional support or support related to dealing with a child’s behavior problems. Instead, foster parents described wanting to be given more complete information about the child, a role in decision-making, and more empathy and support.

I think the main thing that you look at is that you are a team player and they not treating you like a team player. And if you don’t know everything that’s going on, how can you deal with it?

Sometimes they don’t want to keep you as part of the equation. “Well this is between me and the child and the caseworker,” it’s like, well all right, [but] the caseworker isn’t here at night when the kid’s hitting the window.

But, if she’s [foster mother] getting paid to do a job, let her do her job. And not, um, cause her problems while she do her job. Because while you causing these foster parent all these problems, that child is going to circle from that home to the next home, to the next home. So how are you going to be able to say which home is the better home for the child?

Caseworker and Therapist Contacts with Schools and Openness to Working in Schools Difficulty Communicating with the Teacher

Caseworkers

In Illinois, the state child welfare agency mandates that a meeting between the caseworker and the teacher occur three times a year. Consistent with this policy, caseworkers reported regular contact with schools, but they also reported significant barriers to communication. The amount of contact varied, depending on the school, the teacher, and the foster parent. Caseworkers thought that schools preferred to talk to foster parents, and reported that although a few schools were open to caseworker visits, from their perspective, others were reluctant.

It’s very hard, it’s very hard [to talk to the teacher]. Sometimes you just have to make, try to get there before school starts before the students are actually in, [that’s] usually a better time. Or call and find out when their prep period is cause a lot of times [if] it’s other than that, they really don’t want to see you. Depending on the principal, they don’t want to see your face at that school unless you have an appointment already setup.

When you have a foster parent who’s really on top of school stuff and they actually go and go to parent-teacher conferences, and be like I want to know if Johnny is doing good or not ... those are the homes you go in, you see on the refrigerator, Johnny did good on this date… but I think most of the time it’s because their foster parent has demanded that this, you know, that I need this. Cause I feel like the schools, most schools, not all schools, but most schools, prefer to deal with the foster parent rather than the agency.

Most caseworkers did not actively work on school-related problems at the child’s school, instead appearing to receive information from teachers only when the child had significant behavior problems. One caseworker reported actively working with the school to address behavior problems, although she also described varied levels of openness and access to the schools that she worked with.

Some schools are really good, and they work really well with the caseworkers and those are the schools I find that the kids get the Special Ed services that they need … And they actually kind of do well in school. But then, there’s some schools that they don’t care who you are, they’re working with the kids and they don’t want any other outside people working with them and they give you such are hard time that sometimes the caseworkers just don’t even fight it….

Need for Greater Resources and Sensitivity in Schools

Foster parents

Due to time constraints, the foster parents did not comment directly about the amount of contact they had with schools. They did report that schools and teachers ranged in their abilities to accommodate children with specialized needs, and some foster parents described interactions with teachers who were inconsiderate of foster children’s special needs.

Well I had to kind of explain some things to the teacher when I moved the child into a new school, the teacher said to me in front of the child was, “What did you do with her this summer? She doesn’t know how to write her name full.” So I had to take her to the side... I told the teacher, “If you ever have a problem, you call me or pull me to the side.”

Additionally, they believed that some schools were not following through with the child’s Individual Education Plan (IEP).

(The school) has a whole specification page per that child. And a lot of times the teachers aren’t following that. So you’ve got the IEP and it looks like a great IEP but if it’s not being followed, you still can have the kid not doing the book report, or in the library while everybody else is doing math.

Therapists

Most therapists had minimal contact with schools and preferred to see the child out of school, where he would not be singled out in front of his or her peers. Therapists also noted that most schools lacked the resources to accommodate foster children’s needs, and that teachers may have been hesitant to recommend special services because not all schools could afford to provide the needed services.

I really try at least for my own clients to give em some sense of autonomy … Kind of like school to be like that one place where the therapist is not popping up and I’m here, unless it’s really, really severe and I’ll work with the school social worker. But I really try to let them have that peace and let them talk about it on their own, during our therapeutic process. But I don’t do much work with the school.

I think in IEP meetings, teachers tend to downplay the behavior issues. Um… they would call saying you know this child’s really acting up and we’re having all these issues and then you get in an IEP meeting and the teacher’s just you know “oh, he’s doing fine” you know, and you’re like wait? Um, it’s all money and politics basically (laughter). You know, I mean they can only have a certain amount of kids on IEPs and so they’re trying to finagle a way out of it, and teachers can’t really speak up at those meetings.

One therapist did report working with children at school specifically because of behavior problems at school, and thought that having a presence in the school was helpful.

I think if the kids are having these kind of behaviors at school that the teacher would tend to sometimes, you know, [want] to get him out. So I had a few kids who would be consistently suspended, and so if I was at the school once a week, that decreased the suspensions, cause they felt like somebody was there and cared and was working with the child.

Overall, however, most of the therapists had limited contact with the schools and teachers.

Discussion

Development of a context-specific mental health service model for foster children will require a reallocation of the resources of the child welfare system so that parenting support and training becomes a central target for intervention and evidence-based services are delivered in homes, schools, and other community settings. The findings from our planning groups point to both support for this type of model and challenges to its implementation. Identified themes clearly support the need for foster parent training. Foster parents thought that their needs for more parenting and organizational skills could be addressed by the proposed intervention, and therapists thought that foster parents’ need for a greater focus on encouragement of children and support could be addressed. However, caseworkers suggested that the same characteristics described by foster parents, such as their need for more organizational skills, along with resistance to changing their behavior, would limit the extent that foster parents would follow through with the intervention.

Unfortunately, few foster parents viewed caseworkers or therapists as sources of support when it came to dealing with behavioral problems that they were having with their foster children. Instead, the foster parents described them as at times unhelpful and intrusive. They agreed with caseworkers that the role of the caseworker involved overseeing their homes to ensure child safety, and they believed that this role could limit their ability to function as the primary caregiver of the child. Similarly, the therapists’ focus on the child meant that the therapist did not function as a support to the foster parent. Overall, the participants did not describe collaborative relationships between foster parents and agency staff.

These findings are similar to findings from other studies of foster parents’ perspectives on fostering and support, which suggest that foster parents often feel inadequately supported by their caseworkers (Brown & Calder, 2000; Hudson & Levasseur, 2002; Rhodes, Orme, & Buehler, 2001). In a qualitative study that included 54 Canadian foster parents (MacGregor et al., 2006) dimensions of support that included emotional support, trust, recognition of their competence with their children, and inclusion in decision making about the child. Emotional support was closely related to positive, open communication and worker availability. They found that most foster parents did not think that caseworkers adequately respected foster parents’ abilities and the work that they did with their children, similar to the perspectives shared in our study. What our study adds to these findings is the extent that the primary roles assumed by caseworkers and therapists (i.e., child protection and individual treatment) might contribute to interaction patterns that foster parents perceive as unsupportive.

The themes related to involvement in the children’s schools are both encouraging and suggestive of the challenges of engaging teachers in a context specific model, in which a key environment to provide services is the school (Lynn, McKay, Atkins, 2003). Teachers were viewed as difficult to access, and issues related to teachers’ perceptions of role boundaries were also raised, particularly in terms of the caseworkers’ role in the schools. It is encouraging, however, that a caseworker who had independently pursued working with children at school thought that this could be accomplished in some cases. Additionally, foster parents reported some success in advocating for their children, and most saw their role as including protection of the child from the insensitivity of the school’s personnel. These actions on behalf of the child suggest that both caseworkers and foster parents acknowledge the importance of the school environment and are engaged in attempts to work with this environment to some degree already.

Previous research suggests that foster parents are generally disengaged from foster children’s school experiences (Zetlin et al., 2003). In contrast to this finding, several of the foster parents in our study appeared to be highly engaged in assisting their children at school. This might be related to the sample used in this study, which consisted of foster parents who had volunteered to be on an advisory committee to the agency. Foster parents who volunteer at the agency might be more comfortable than an average foster parent with advocating for their child and communicating with teachers. Our findings are also somewhat inconsistent with previous findings suggesting that caseworkers, who often have more direct contact with school settings than foster parents, tend to have conflictual interactions with school personnel (Altshuler, 2003). Caseworkers reported difficulty with gaining access to teachers, and at times resistance to their involvement, but conflict with school personnel did not emerge as a theme in their discussion. An important question that was not addressed by this study relates to the perceptions of school personnel about the proposed intervention and their experiences with foster children and child welfare staff. Future research focused on the perceptions of school personnel is needed to more fully understand factors potentially facilitating or hindering the implementation of an ecological service model in school settings.

Relevance of Findings to Implementing Context Specific Mental Health Services

In a context specific service model, foster parent-child interactions would become a primary target for an ongoing intervention supported by caseworker and mental health professionals. Our findings provide support for foster parent training and support, but also point to potential challenges in implementing this type of model. This model requires caseworkers to assume a supportive, educational role with foster parents, which is incompatible with their primary role as guardian of the child’s safety and enforcer of agency policy. As one caseworker noted, “A lot of foster parents are also guarded about what they are saying, because of the reporting aspect of it.” Similarly, the therapists’ primary role as the child’s individual therapist who sees the child at the agency limits the extent that therapists are available either to support and provide ongoing training to the foster parent or to work with the child’s teacher on school-related issues. Given the intensity of the services already provided to foster children, however, proposing a model that would require additional providers and additional costs rather than a shift in the roles of current providers may be unrealistic. For this type of service model to be sustainable, it will need to become integrated into existing child welfare and mental health services. However, this change would require a clearly delineated shift in the roles of caseworkers and therapists, as well as foster parent expectations of these roles, so that role incompatibility and lack of clarity do not undermine the intervention.

In a study of caseworker attitudes about implementation of evidence-based practice, Aaron and Palinkas (2007) suggested that caseworkers are more likely to utilize evidence-based practices if (1) they view the intervention as meeting the needs of their families; (2) they had some personal investment in learning it, such as enhanced competence at their jobs, or if it resonated with their own parenting experiences; (3) the information provided in the training was helpful to the work that they do; and (4) they felt that agency administrators and their supervisors supported the use of the intervention. Application of these factors to the themes that emerged in our focus groups suggests that to implement the proposed intervention successfully, we will need to focus on increasing caseworkers’ investment in the intervention and their understanding of its potential benefits. Even though they agreed that parents needed more training, their competence in fulfilling the primary roles in their work (i.e., ensuring child safety and enforcing agency policy) would not be enhanced by the training. In addition, from their perspective, foster families would be unlikely to benefit because they would be unlikely to follow through with the intervention. Although the agency administrators and supervisors believed that the intervention would be helpful, to change the types of interactions between caseworkers and foster parents will require that we directly address these issues.

Foster parents’ descriptions of their experiences also have implications for the development and implementation of the intervention. Foster parents expressed a need for more recognition of their role as the child’s primary caregiver, consistent with the findings of previous qualitative studies (Hudson & Levasseur, 2002; MacGregor et al., 2006). The goals of a context specific service model, with its strong focus on effective parenting, is consistent with this need, suggesting compatibility between the service needs of foster parents and the proposed intervention. The identified need for more organizational skills also has relevance for the development of the intervention, since it points to a need for tools to organize tasks and schedules. These needs could be met with parent management training, which is one of the components of the intervention. Highlighting these aspects of parent management training could potentially increase foster parent engagement and caseworker investment in training.

Given both foster parents and caseworkers involvement in children’s school experiences, training them how to work conjointly with teachers to improve children’s experiences at school would be ideal. Interventions focused on targeting foster children’s school experiences have not yet been empirically validated, but available research with other populations of children suggests that children’s school behavior and academic achievement can be improved by supporting teachers’ use of behavior management techniques, increasing parental involvement in children’s school behavior and learning, and increasing positive parent-teacher communication (Atkins, McKay, Talbott, & Arvanitis, 1996; Connors & Epstein, 1995; Stone & McKay, 2000). Studies with low-income children indicate that school-home interactional problems contribute to risk for behavioral and academic problems (Connors & Epstein, 1995; Hill & Craft, 2003; Stone & McKay, 2000). Ecologically focused interventions could facilitate school-foster parent communication, address the reciprocal effects of academic achievement and behavior problems, facilitate appropriate instruction levels, and provide consultation regarding effective classroom management for children with behavior problems. However, our findings suggest that coordination and advocacy with schools at a higher level than the classroom teacher, such as the principal and school district, might be necessary to assist with opening access to the schools. If findings from future research validate the findings of our study, teachers’ apparent reluctance to talk with caseworkers might be addressed by including foster parents in the intervention process and educating teachers on the role of the caseworker to increase caseworkers’ access to the schools.

Conclusions

Several factors provide an exceptional opportunity to develop an integrated, context-specific service model in children’s homes and schools, including high expenditures in child welfare on clinical services (Brenner & Holzberg, 2000; Naylor et al., 2003), the pervasive nature of child welfare services, and recent attention on the poor conditions in foster care and children’s low academic achievement (Emerson & Lovitt, 2003; Zetlin & Weinberg, 2004). The results from our planning study also indicate that foster parents are interested in learning more effective ways to work with children with difficult behaviors.

From an ecological perspective, simply educating caregivers in how to provide positive, therapeutic parenting and behavioral interventions, however, is not adequate. Education might provide knowledge of the behavioral skills needed to address children’s needs, but it does not build the necessary structure and support for positive foster parenting and school-based interventions. Supports for the use of the skills learned need to be an integral part of service models to maintain positive care environments. Caseworkers and mental health providers play a key role in providing this reinforcement. Building their capacity to implement evidence-based interventions poses challenges that will need to be addressed for these interventions to be effective. In particular, the results of our planning study suggest that caseworker, foster parent, and therapist perceptions of their roles will need to be expanded to allow for a more collaborative relationship between foster parents and agency staff members so that more effective foster parenting and conjoint work with teachers can occur.

Acknowledgments

This research was supported by NIMH K01 MH070580. The views expressed in this paper solely reflect the views of the authors and do not reflect the views of the National Institutes of Health. We would like to thank Patricia Chamberlain, PhD, for her comments and assistance in conceptualizing the service model presented in this paper.

Footnotes

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