Dr. Toni Heineman

Clinicians who offer pro bono therapy through A Home Within bring not only their skills, but also their hearts to their work. Because they understand the crucial importance of stable, lasting, loving relationships, they very frequently find creative ways of maintaining the connection to a child they see in therapy. Nora’s therapist reached out to us when Nora was in danger of losing not only her family, but her therapist, too.*

It seemed that nine-year-old Nora had finally found a family, and she had a formal family portrait to prove it. But then the parents who had planned to adopt her decided that she just wasn’t quite the child they had in mind. This was the fourth family Nora had lost. First she lost her mother to drugs and the streets. Then she lost the relatives she had been living with when they couldn’t adequately care for her. After a brief time in emergency foster care, Nora thought she had found a family that would be hers forever.

Sadly, Nora’s therapist was planning to leave the clinic where she had been seeing her at about the same time Nora would move to a new family. Then a colleague told her about A Home Within. “I was so relieved and pleased when I learned that I didn’t have to transfer her to a new therapist in the clinic, but could continue to work with her through A Home Within.”

Nora is now settled into a new adoptive home. Instead of losing her therapist and feeling rejected by yet another person, Nora has had her therapist’s help through this very difficult transition. Nora and her new adoptive parents are still getting to know each other, but the family dog has become her constant companion. She continues to work to make friends in her new school. Her teachers are working with her therapist to help Nora control her temper and learn better ways of approaching people.

Nora has been able to work with the same therapist for over three years. Without this continuing support, her feelings of rejection and anger might have put too much strain on the relationship with her new foster parents, leading to yet another loss.

Happily, this is not an unusual story. The clinicians who are part of the network of A Home Within give their all for the child they agree to see “for as long as it takes.”  Valentine’s Day is a fitting time to honor these clincians and the love that they infuse in their work. They are truly the heart of A Home Within. If you would like to volunteer, please contact us at www.ahomewithin.org or call 888-898-2249.

* Identifying information has been changed.

Envisioning a brighter future for children and youth in foster care does not require much imagination. The current system of care allows so many youth to leave care facing years of hardship that are likely to include unemployment or underemployment, homelessness, poverty and multiple brushes with law enforcement that it’s easy to identify room for improvement. However, it takes not only imagination, but thoughtful analysis of pertinent research and current policies to envision the changes that should and can be implemented to transform foster care into a system that could promote the physical, social, cognitive, and emotional well-being of children and youth touched by the foster care system.

Bryan Samuels, Commissioner of the US Department of Health and Human Services’ Administration of Children Youth and Families has that vision. The flight home from the Summit on Healthy Adolescent Development and Well-Being convened by the Center for the Study of Social Policy and the Jim Casey Youth Opportunities Initiative gives me time to try to absorb both the enormity of the changes Commissioner Samuels imagines for the child welfare system and to relish the thought that he just might make them happen.

The primary charge of the child welfare system has been to ensure the physical safety of the children in its care with more recent attention to the reduction of risk. Fortunately, Commissioner Samuels is not alone in his insistence that this is not good enough for foster children, or for any children, for that matter. There is a large and growing chorus of voices demanding that our policies and programs must integrate those approaches known to protect and promote the well-being of all children and youth, but most particularly, those who are the most vulnerable.

There are many risk factors that can impair or impede children’s healthy development – among them, poor nutrition, poverty, lack of medical care and inadequate education. But if we don’t ensure that all children have a good relationship with an adult who loves and cares for them we deprive them of the single most robust predictor of healthy development.

Most parents and substitute caregivers do their best to make sure that their children have access to medical care, educational opportunities, and community support. For many complex reasons, not all adults can provide this for the children in their care. But their love for the child and their continuing care through adversity offers the child protection from the overwhelming emotions that impede development. A relationship with a caring adult creates the psychological space children need for healthy development.

As Bryan Samuels attests: “resilience is not good fortune arising from chance encounters with a supportive friend, peer or partner.” Resilience grows from ongoing relationships – this is the gift children most need from the adults who care for them.

“I just wanted to talk to someone.”

We hear this time and again from young people in the foster care system. These children and adolescents have a lot on their minds. For whatever reason, their parents were unable to care for them. That fact alone contributes to the unusually high levels of depression and anxiety in this population. Add to that the frequent changes among those charged with their care. Change and uncertainty are a way of life for foster children as caseworkers come and go and they move from one foster home to another — often without warning or explanation. They want to make connections — to have someone to hear about what is making them so unhappy that it is difficult for them to think and learn, to make friends, and to enjoy life. However, as the New York Times reports, when these children want someone to lend an ear, they are often given pills instead. And the drugs they are given, even at a very young age, are powerful psychotropic drugs, formulated to treat the most serious of mental illnesses.

Researchers from the University of Maryland, Johns Hopkins University, and the University of Pennsylvania analyzed the distribution of psychotropic medication among nearly 17,000 Medicaid-enrolled youth in one mid-Atlantic state. Among three groups — youth in foster care, disabled youth receiving Supplemental Security Income (SSI), and those receiving Temporary Assistance for Needy Families (TANF) — foster youth were more likely to be prescribed more than one psychiatric medication and to be maintained on those medications for longer than youth in the other two groups.

The findings of this study are extremely disturbing. First and foremost, as the authors note, “concomitant antipsychotic use is not empirically supported.” While the evidence does not suggest that youth will benefit from a regime that includes two or more of these powerful drugs, the evidence does demonstrate that even one of these “atypical antipsychotics” can produce dangerous and lasting side effects. For example, metabolic changes induced by these drugs can lead to obesity, high cholesterol levels, and diabetes and patients taking these medications should be carefully monitored.

The need for ongoing medical supervision points another concern arising from this study. Life in foster care is notoriously unstable. When children move from one foster family to another, there is no guarantee that they will remain in the same community or that there will be continuity in their medical care. Indeed, “Medical Passports” were created to address the need for foster children to carry their records with them because of the great likelihood that they would receive medical care in different places and from different people. In attempting to understand the results of their study, the authors posit a number of possible clinical explanations and suggest that some “might lack a reasonable clinical rationale.” These explanations might be directly related to larger systemic issues. For example, it may be that as a result of multiple changes and the lack of a consistent adult, foster youth remain on medications longer than other children because they simply didn’t have consistent follow-up appointments.

No doubt, there are many possible clinical, systemic, and other ways of explaining the outcomes of this study. One issue that must be kept in mind is role of the parent or caregiver throughout the medication process. Parents are called on to describe the child’s symptoms, participate in the decision making-process, administer medications, monitor effects and side effects, and maintain communication with physicians and other professionals involved in the child’s care. This is a complex and lengthy process that depends on the parent or parent substitute knowing a child well enough to detect behavioral and affective changes over time and in different context. Most parents can offer this to their children. When they can’t, we owe children long-lasting relationships with other adults who can.

Being a parent is hard.
Being a single parent is harder.
Being a teen parent is even harder still.
Being a single teen parent who grew up in foster care is nearly impossible.

And yet some of these young parents – overwhelmingly mothers – manage to raise physically and emotionally healthy children, while simultaneously finding their way through the developmental tasks of adolescence. The odds are not in their favor.

Parents who grew up in foster care are six times more likely than others to lose their children to the foster care system. Why do some succeed when so many fail? We explored that question this past week at two conferences focused on working with adolescent parents: ‘Caregiving Orientations’ in Dallas, Texas and ‘Nurturing Adolescents’ in Denver, Colorado.

Clearly, inherent individual differences contribute to success in parenting, as in other aspects of a teenager’s life. However, beyond that, the single most important factor may be the teen parent’s contact with caring, supportive adults who can help her navigate the complex and often conflicting developmental tasks of adolescence and parenting. Sometimes teens have the support of parents and extended family, particularly if they have grown up in a culture that readily accepts early parenting.

However, teen parents in foster care rarely have the support of their families. In fact, many of those who become pregnant while in care will lose their foster families as a result. These young people are ill-equipped for independence, either as individuals, still in the throes of development, or as parents, attempting to promote the healthy development of another.

Fortunately, some of them have access to programs like “How to Read Your Baby” or “Reaching HOPE,” that recognize that consistent relationships are the key to helping teenagers do the best they can for themselves and their children. Successful programs are built on the realization that the adults who work with these young parents must find ways of keepinghope alive for themselves and their clients.

The internal and external challenges facing any one of these young parents are daunting. Staff members must often hear one story after another with seemingly no way to get to a happy ending. Every day they are asked to hold the hope in the face of situations that appear hopeless. Sometimes even a glimmer of hope is hard to find, but sometimes that is enough.

Programs that maintain hopefulness in their staff also support hope for the young parents and children they serve. Sometimes a sense that things might be better tomorrow – even if just a little better – is enough to get through the day. And sometimes, just getting through the day creates a sense that things just might be better the next day.

This week’s settlement marks the end of a hard-fought battle to improve mental health services for California’s foster youth. We should applaud the work of the advocates and state agencies that struggled for over nine years to craft an agreement designed to improve the emotional well being of foster children and youth. CLICK HERE to read coverage of the story, published by the Center for Investigative Reporting’s California Watch.

I am always inclined to greet news like this with cautious optimism, ever hopeful that good intentions will result in more and better services for these vulnerable young people. Cautious because, however difficult it might be to arrive at far-reaching plans and programs, implementing them will be even tougher.

Children who are already in or in danger of entering the foster care system have led hard lives. Most have been neglected by parents who have been unable to care for them adequately because of mental illness or substance abuse. Some have been physically or sexually abused. Many have been in the care of a number of different friends or relatives before they enter care. Once in care, they may cycle through multiple foster homes, caseworkers, pediatricians, and therapists.

Extreme instability in a child’s life creates a psychological instability that presents daunting challenges for even the most experienced and well trained mental health professionals. If the state of California is going to deliver on the promises of this settlement, it will need the support and expertise of professionals from both the public and private sectors.

One of the simple reasons that foster children don’t get adequate mental health services is that there are not enough resources in the public sector to meet the very substantial need. Unfortunately, legal settlements and legislation don’t create more professionals with the education and experience required to meet the complex needs of these children and families.

We know from personal experience that clinicians in the private sector are willing and able to do their part to help address this issue. Through A Home Within, mental health professionals in twelve communities across California volunteer their time so that foster children can have weekly pro bono psychotherapy with a consistent therapist “for as long as it takes.”

Our organization is not alone in mobilizing private sector resources to meet a public need. For example, through Give An Hour, therapists provide free sessions of psychotherapy to returning veterans and their families. And in clinics and offices across the country doctors and nurses, attorneys and accountants donate professional time to help meet the needs of those who depend on public services.

If we can create more opportunities for professionals in the private sector to work with our public agencies, we will all benefit. In addition to the direct advantages this gives the individuals involved, increased contact between these groups can help to narrow the gap between our public and private sectors and help California realistically to provide the quality care this settlement mandates.

We live in hope.

This Labor Day weekend I’m reminded that those who shoulder the responsibility for managing the care of foster children get even less attention than those in their care. With state budgets shrinking the burdens on these workers will only increase.

When positions are cut, caseloads increase. The Child Welfare League of America recommends that child welfare workers have responsibility in the range of twelve to fifteen ongoing cases. It’s important to remember that managing “a case” does not mean simply monthly visits with a child in foster care. It often means that the caseworker has contact with biological and foster parents, with siblings, grandparents and other members of the child’s extended family. It may also mean conferences with teachers, physicians, mental health specialists, and attorneys. Of course, these people are not in one easily reachable place and are often difficult to contact. Dropping even one more case on a worker’s desk dramatically increases her workload.

And it is likely to be “her” workload. Approximately 70% of child welfare caseworkers are women who earn in the range of $25,000 to $30,000 annually. According to one online site, salaries posted for caseworkers are 23% lower than all job postings nationally. Not surprisingly, turnover in this population is high; over 30% of caseworkers leave their posts every year.

We are used to thinking about the impact of repeated and unexpected losses on foster children, but the chronic loss of coworkers and colleagues also depletes the morale of the caseworkers who are left behind. Of course, low morale affects job performance. Caseworkers enter the child welfare workforce because they want to do well by children; when they are not able to do their jobs as well as they would like, their self-esteem suffers even more.

Caseworkers have really, really hard jobs. On a daily basis, they see children who have been abused and neglected. They meet with parents who are distraught over losing their children. They encounter family members and attorneys who are in pitched battles over what is best for a given child. And when that part of their work is done, they sit in front of a computer to complete seemingly endless forms to document their work.

The stories of the caseworkers who do their jobs well day after day do not make front page news. When negligence or overwork or a perfect storm of factors results in the injury or death of a foster child, headlines often demonize the caseworker because it’s easier than addressing the contributing complexities of the foster care system.

Labor Day is an annual opportunity to honor those whose work often goes unnoticed and unsung. I speak for the board, the staff, and the volunteers of A Home Within across the country in saying “thank you” to all the caseworkers who willingly take on the extraordinary responsibility of caring for foster children and youth.

Too often we hear bad news from the research on foster youth. In striking contrast, the latest research from the Foster Care Research Group,  based at the University of San Francisco that evaluates the programs of A Home Within, demonstrates that the emotional well-being of foster youth seen by our therapists improves substantially over the time they are in therapy.

In particular, recent analyses of symptom reduction over the course of long-term treatment demonstrates clinically and statistically significant declines in depression, anxiety, dissociative symptoms, suicidal thoughts, sleep difficulties, learning problems, and self-injurious behavior. The quality of life improves as these symptoms lessen because they interfere with social interactions, learning, and the overall capacity to manage the ups and downs of everyday life. In short, long-term therapy is improving the chances for these foster youth to lead productive and personally satisfying lives.

Not surprisingly, establishing and maintaining relationships is hard for youth who have experienced multiple unexpected and inexplicable losses. With good reason, they do not trust easily. It typically takes several months for foster youth to feel safe enough to begin to share their feelings with a therapist. The fact that this data comes from interviews with therapists who, on average, have worked with their clients for over three years is a testament to the needs and hopes of the youth and the skill and hopes of our therapists.

The work of the Foster Care Research Group, headed by Dr. June Madsen Clausen in the Department of Psychology at USF, is an invaluable resource for A Home Within. Under her guidance, for the last eight years, undergraduate research assistants have conducted telephone interviews with therapists at the beginning of treatment and annually thereafter until an “exit interview” when the therapist reports that the treatment has come to a close. Over that time, they have been gradually expanding the number of chapters included in this first phase of the research, and this fall will include all chapters. We are especially excited to learn that the research group will now be moving into the long-planned second phase of the research, which will involve collecting data from the caseworkers that are responsible for the foster youth referred to A Home Within. This will supply additional data points, helping us to better understand what we do well and what we can do better.

The data supports what we all know — relationships DO make a difference!

A policy mandating that children coming into foster care may not be held in offices for more than eight hours certainly seems reasonable. These children are scared, confused, and reeling from the process of being removed from their caregivers. We want them to get settled into a comfortable home quickly—someplace where there are adults to feed, bathe, and comfort them.

We do not want them sitting an office waiting room or shuffled from one office to the next. We don’t want them to visit the nearest McDonalds for a Happy Meal after seven hours and fifty-nine minutes only to start the clock running again when they return thirty minutes later.

However, according to a recent article in the Los Angeles Times,  this is what caseworkers have resorted to when they have been unable to locate foster homes for children — particularly for infants and older teenagers, who are among the most difficult to place. The Department of Children and Family services contends that only a small number of children have spent extended time in their offices awaiting more stable placement.

If the alleged events have happened to even one child, there’s a problem. In these situations there is a tendency to try to affix blame, which only detracts from finding solutions. Caseworkers who have to meet a deadline for removing children from holding areas may feel as if they have no choice but to find clever ways of meeting the letter of the law when they have no chance of meeting the spirit of the law. What are they to do with children who have no place to go when they have no place to send them?

An abundance, or at least a reasonable supply, of foster homes could solve the problem. But increasing the number of foster homes requires time and money, both of which are in short supply in the child welfare system, even in the best of times. As the country’s economic woes are increasingly felt at the state level, we are likely to see more and more imaginative approaches to insoluble problems.

It is difficult to legislate truly creative solutions. Laws and rules rarely include the feedback loops necessary to address unintended consequences.  Innovative and imaginative solutions arise from discussions that recognize that everyone at the child welfare table is well-intentioned with different and valuable ideas and multiple and conflicting constraints. Unless we can begin more open and vigorous conversations, we may find ourselves looking back on running out the clock at McDonald’s as a very benign way of managing an impossible situation. In the meantime, maybe the realities facing caseworkers dictate that there should, at the very least, be warm blankets and healthy snacks available when there simply is no safe alternative to an overnight in an office waiting room.

Please visit www.ahomewithin.org to learn about how A Home Within helps foster youth to build relationships and meet their seemingly-impossible challenges.

Over two hundred retired generals and admirals have banded together to call attention to the alarming consequences of our failure to care adequately for this nation’s children. Mission: Readiness reports that 75% of the young adults who, in the past, have been the most likely to join the military are “unfit to serve” because of poor education, obesity, or a criminal record. Given the high numbers of foster youth who fail to graduate from high school, spend time in jail, and suffer multiple serious health problems, including obesity, it is sadly safe to assume that they are overrepresented in the group of those who are not eligible for military service.

We should all be concerned about the implications for the individuals who make up this sobering statistic. As taxpayers, we should be alarmed that our failure to invest in our children’s health and education has not only jeopardized these lives, but also our national defense. As citizens, we should be ashamed that the children we have promised to care for when their parents can’t are among those who are unable to serve their country. This is not an argument that our armed services should be staffed by those who grow up in the foster care system. It is an argument that when we step in as surrogate parents we make an implicit promise to give foster children basic health care and education. We owe them care that prepares them for a full range of adult choices.

When foster youth are unable to serve in the military they are cut off from one avenue of educational opportunities. They also forego the opportunity to benefit from the intangible skills — such as leadership, teamwork, and resource management — that are integral to military life and can translate into success in civilian life. When foster children are unable to serve in the military, they are deprived of one important choice of citizenship — a chance to serve and defend their county.

Over 20,000 youth age out of foster care each year. If only 5,000 of them can meet the minimum requirements for military service, we have deprived 15,000 citizens of important opportunities and our country of a substantial pool of young adults who might want to pursue the military option. By implication, we have also deprived our country of many other contributions from youth who want to enhance our economy and our culture in significant and satisfying ways but are unequipped to do so.

The retired military leaders who are leading the readiness cause have a long view of what is at stake and what it takes to develop well-prepared armed services. We should heed their wisdom; they have studied war and fought to bring us peace. They tell us that we must not delay in addressing the shortage of military personnel and that we must do this today by meeting the immediate health and educational needs of very young children if we want them to be prepared to serve in the future.

Preparing children for the future begins today.

Most children who enter the child welfare system have been neglected by their
parents—some have also suffered physical or sexual abuse—but, by and large,
foster children simply have not received the care they need from their parents
or other relatives. Their most basic physical needs have not been met and their
emotional needs have received even less attention. Sometimes we behave as if
we simply can’t bear to see the pain in their lives.

While there may be a single event that calls attention to their plight, these
children have spent most of their lives in an environment defined by “toxic
stress”–chronic, unrelenting stress stemming from some combination of poverty, community and/or domestic violence, inadequate medical care, and poor educational opportunities for them or their caregivers. One or both parents may suffer from mental illness, have a history of substance abuse, or incarceration.

In short, children in foster care have not had an easy start in life and, as a result,
they are generally not easy-going children. With good reason, they are angry,
scared, distrustful, and short on the emotional and social skills crucial for forming
and sustaining relationships.

Parenting is never easy; parenting mistreated children is just plain hard. Keeping
the Promise, http://www.adoptioninstitute.org/research/2010_10_promises.php
summarizes findings from the Donaldson Adoption Institute’s study of adoptive
families, which indicates a significant need for and lack of services and support to
help adoptive families succeed. The findings of this study are not surprising; what
is surprising is that we need a study to detail what common sense should tell us.
When you ask people to do something hard, if you want the job done right, you
must give them the tools they need and teach them how to use them.

In many ways the needs of adoptive parents and foster children are very
straightforward—they need help in forming and maintaining relationships. The
particular form of the support each family needs will vary, depending on the
strengths and challenges the children and parents bring to the mix. What does
not change is the need to focus on family relationships.

With 130,000 foster children waiting to be adopted, this is an issue we cannot
afford to ignore. The emotional needs of mistreated children will not disappear
just because we choose not to see them. The inherent challenges of parenting
mistreated children will not go away if we choose to ignore them. These parents
and children face very real and difficult challenges in the process of creating a
family. They need our help and we cannot help until we recognize that need.

It’s time to get our heads out of the sand.