Last Wednesday morning, the movers arrived at the office we had occupied for five years. By Friday afternoon, we were more-or-less settled into our new space. In all respects, the move from one end of San Francisco to the other went seamlessly—nothing was lost or broken; all of the furniture fit, as expected; and we were cut off from the electronic connections that we have come rely on for only a short time.

Psychologically, it was also a seamless move. We had ample warning from our landlady that she needed the space to house her own growing non-profit. Although we quickly found another office in a new neighborhood, we had time to think about what we would be leaving behind and to visit our favorite restaurants and take out spots one last time. We had a chance to say “goodbye” to all of the people who had been our companions in the building we shared.

Sorting through all of the files and “stuff” we had accumulated prompted us to reflect on our growth over the last five years. More often than not, the files at the back of a drawer made us remember that we don’t easily discard things, even when they have long outlived their usefulness. Memories of staff who had moved on were stirred by the unexpected discovery of a signature on a post-it or a long-forgotten reminder to return a phone call.

By the time the movers began delivering boxes and furniture, we had already begun exploring the new neighborhood, excited by the discoveries of different restaurants and the ease of walking to stores and public transportation. We noticed the differences in the light, the feel of the air, and the sounds of this part of the city. Although we had not initiated this move, we quickly welcomed it as the beginning of an adventure into the next stage of growth.

How different our moving experience is from that of many foster children. The most obvious difference is that we are adults who work together and return home each evening to our families, not children being moved from one family to another.

The circumstance that prompted the need for us to move is not uncommon for foster children. The space that we had occupied temporarily was needed for those who truly belonged there. We had been welcomed and well treated, but we were never truly part of the “family,” and, as the organization that had taken us in grew around us, we knew that our days there were numbered.

Photo Courtesy of “Svacher”

Unlike foster children who often have little warning or time to prepare for a move, we had time to reflect on what we were leaving behind and to bid a fond farewell to people who had become a part of our daily lives. We also had each other to share in the physical and emotional work of the transition. Because we weren’t rushed, we could give thought to the recurring decisions about what to leave behind and what to take with us. Sorting through the accumulation of books and papers and files also led us to sift through ideas and values and practices and to talk about what was serving us well and what might be improved. The move created an opportunity to make conscious choices about what routines we enjoyed and supported our work and which should be left behind.

Foster children don’t have this choice. When a foster child is moved from one family to another, he often loses important things that belong to him. He also loses the familiar sites and sounds of his home and his neighborhood, without a chance to say “goodbye.” More importantly, he leaves behind the daily routines and rituals that have organized his life. Because foster children cannot carry enough of what is familiar with them, each move has the potential to become a step into a terrifying unknown rather than the beginning of an adventure.

For foster children seeing a therapist through A Home Within, the picture may be a little brighter. If geography and the collective will of the responsible adults allow it, the child can continue with the same therapist through two, three, or even ten changes in foster homes and/or caseworkers. The therapist can help the child hold memories and mourn losses. The stability of this relationship can provide the ballast the child needs to hold her emotional ground. The continuing presence of this one, familiar, caring adult can transform a potentially terrifying experience into one that can be mastered. Children need adults to depend on, especially in frightening times. We owe this to all children, especially those who are the most vulnerable.

By Toni Heineman

Much in the child welfare system calls for swift action — children who are in dangerous or neglectful situations must be removed quickly. But other situations, such as the implementation of policies that will affect thousands of children for many years, call for deliberation and reflection. Angie Schwartz makes a compelling case for taking time to carefully consider the impact of “realignment” on California’s foster youth in this guest blog for the John Burton Foundation for Children Without Homes, re-posted below.

TIME TO PRESS THE PAUSE BUTTON ON REALIGNING CHILDREN’S MENTAL HEALTH

By guest blogger Angie Schwartz, Alliance for Children’s Rights California is in the midst of a grand experiment regarding the funding structure of programs designed to protect vulnerable children.  In July 2011, the California Legislature adopted “realignment,” a fiscal policy that shifts a portion of the state sales tax, along with seven functions from the state level to the county level, including the core programs of California’s child welfare system.  These core programs include Foster Care, Child Welfare Services, Adoptions and Adoptions Assistance, and Early Periodic Screening, Diagnosis and Treatment (EPSDT) mental health program. While realignment of programs aimed at providing support and protection to vulnerable children is problematic, the realignment of EPSDT is particularly troubling and will likely result in lasting harm to our state’s most fragile citizens.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is part of the federal Medicaid program, known as Medi-Cal in California. EPSDT provides comprehensive medical benefits, including mental health services, for low-income children from birth and up until age 21.  The mental health services that are required under EPSDT are especially critical for children in foster care. Research has shown that up to 80% of youth involved with the child welfare system experience emotional and behavioral problems that indicate a need for mental health treatment.

Prior to realignment, counties paid a small portion of the cost of EPSDT mental health services, just 5%. The rest was paid by the federal government (50%) and the state (45%).  Under realignment, the amount paid by counties will now increase from 5% to a full 50%; the federal government will continue to pay its 50%; the state will pay nothing.

Photo Courtesy of “MadamPsych”

Even before increasing the county share of cost tenfold, California was doing a bad job of providing medically necessary mental health services to children in foster care.  According to a report, from the state’s own California Department of Health Care Services, just 60% of youth who required mental health services received them. That’s right – only 60%!  Why?  Because that relatively small share of cost was still a cost to counties – and one they felt they could contain by controlling the services offered and access to those services.

Realignment will exacerbate the problem of access to critical mental health services by creating a greater fiscal incentive for counties to reduce or curtail access to medically necessary mental health services for children.  Under realignment, counties will be responsible for a full 50% of the cost of EPSDT services, with no guarantee that the level of realigned revenues will be adequate.

What is a predictable response for a county in this position? Manage costs by controlling caseload. This notion that caseloads can – or should – be controlled is completely contrary to the legislative intent and mandate of EPSDT.  EPSDT is not intended to be limited or capped based on arbitrary fiscal allocations.  Rather, it is supposed to provide each child the care he or she needs to thrive.

In addition, the capped allocation makes little sense given pending policy changes that will greatly expand the population of youth eligible for EPSDT.  Over the next couple of years, an additional 878,000 new children will enter the Medi-Cal program due to the elimination of the Healthy Families program. In addition, thousands more children will be newly covered by Medi-Cal due to implementation of the federal Affordable Care Act.  Finally, the recent settlement in Katie A. v. Bonta will require that specialized clusters of EPSDT mental health services be provided for youth at risk of group home placement.

However, the legislature is in the process of establishing the fiscal base line for EPSDT when we have no idea how much counties will require to serve these newly eligible children. The combination of these three policy changes create a perfect storm that, without careful deliberation and planning, will likely leave many needy children without critical care and supports.

The Governor’s approach to realignment of EPSDT should be reconsidered. The Legislature should slow down the process and ensure that adequate time and attention is paid to ensuring that our EPSDT mental health system will meet the needs of children and families. Rather then proceeding full steam ahead with all of these changes at once, I believe the Legislature should establish a statewide working group tasked with developing a plan to improve the service delivery system, ensure equity of access between counties, increase accountability, develop outcome measures, determine if EPSDT should be realigned ongoing, and if so, ensure adequate funding for the program in the realigned system.

This Thursday, April 12th, the Senate Budget Subcommittee will hold a hearing on EPSDT realignment starting at 9:30 a.m. in Room 4203. Please join me in encouraging the legislature to press the pause button on the realignment of EPSDT to provide more time for careful deliberation and planning. Yes, the state budget is in a crisis. That is no excuse for proceeding recklessly with the lives of abused and neglected children.

By Toni Heineman

Two articles crossed my desk recently that underscore the vulnerability of children in the foster care system. Individually, they each warrant attention; taken together they should prompt us to action. Preliminary research coming out of Purdue University suggests that adoptive mothers are vulnerable to depression following adoption. The fatigue, worry, and isolation that contribute to post-partum depression may also be contributing factors to depression in the wake of adoption.

From Rise magazine comes a report of a twenty-year study of the number of childhood deaths resulting from abuse and neglect annually in Sacramento, California that demonstrates a direct correlation between decreases in preventive services and increases in death rates.

One of the goals of the child welfare system is to provide permanency for children. When children cannot be reunified with their biological parents, adoption offers foster children the chance to have a “forever family.” But adoption is a complex process for both parents and children.

Creating a family is not easy, under even the most ideal circumstances. Parents and infants must get to know each other—they must learn to send and receive cues and to respond sensitively. Parents must reconcile their conscious and unconscious expectations with the baby who is actually before them—whether they have a girl when they had hoped for a boy, or whether they have an active baby when the baby of their dreams had been easy-going and mellow.

Add to this the emotional complexities contributed by infants and children who have been separated from their parents and are very likely to be wary of new relationships because of the maltreatment they suffered. And, just like biological parents, adoptive parents must relinquish their fantasies about the child or children with whom they would create a “forever family” in order to fully embrace those who have actually been placed in their care.

Photo Courtesy of “ZeRoSKiLL”

New parents need a lot of support. They need help with the additional work that children bring. They need emotional support as they try to manage the inevitable anxieties and responsibilities of parenthood. Common sense would tell us that parents adopting from the foster care system would need even more support because of the inherent vulnerability of the child they are bringing into their lives.

While parents adopting from the foster care system can certainly benefit from the support of family and friends, professional help is often called for. They need to have the counsel of social workers and specialists who understand and can help them meet the emotional needs of children who have been traumatized and subjected to multiple losses. Yet, these are exactly the kinds of services that are cut when budgets decline.

When we think about preventive services we, understandably, think first of programs that will keep children with their biological parents and out of the foster care system. However, it is also important to attend to programs that will ensure that when children are adopted from the system that their parents have the support they need to keep their promise of creating a “forever family.”

Through A Home Within, children leaving the foster care system and their adoptive parents can have pro bono support from an experienced therapist who can help them with the challenges of building a family together.

Watch this video to hear what Lorry, a parent who adopted a foster child, has to say about the help her daughter received from A Home Within – http://youtu.be/kxSNMN-cAbc.

By Toni Heineman

We know that lasting relationships are vital for children to thrive, but sometimes we forget. Sometimes we think we can take shortcuts. We think that children need only a little of our time or that we can give them just enough to get by. Sometimes we forget that children need to be loved with every ounce of our hearts and souls. This story offers a lovely window into the difference a stable relationship can make in the lives of a foster child and the adults who come to love her.

If you didn’t see this article in Sunday’s New York Times, I hope you will take
time to read it now.

At the age of seventeen, transgendered Christina lands on the couch of one of her former teachers. Cris, who had been taken with Christina’s intelligence and fierceness, discovers a ferocity in herself as she moves in to protect this child from a child welfare system that is unable to protect and care for her. Thirteen years later, they are off to celebrate Christina’s birthday, in the tradition of the “messy family” that they have made together.

Photo courtesy of lanier67.

Sadly, the stories of many of the adolescents in foster care don’t end so happily, nor do they always end well for the adults who reach out to try to give them the support of a positive relationship. But, as they did for Christina and Cris, sometimes when people really believe in the power of unconditional love and care, things do turn out well.

Their story reminds us that lasting, positive relationships help to heal the trauma that hides in the dark corners of our minds and propel us into the light of shared joys.

School is just around the corner for most children. For both children and parents, that usually means a mixture of excitement and anxiety—along with sadness about the end of the lazy days of summer and relief that school will bring some more structure to family life. But for foster children and teens and their caregivers worry may dominate the days before school begins, particularly if the foster placement is a new one. Even if the children will be attending the same school as last year, they will be going from a new home.

Parents and other caregivers can help to smooth the transition back to school for all students, but particularly for those entering a new school. A visit to the school can help to orient new students, but even if buildings are open a few days before instruction begins, it’s a good idea to call ahead to make sure that visitors are welcome. If it’s not possible to visit, tracing the route the student will travel to school–whether walking, taking public transportation, or riding with parents or other families—will help the student begin to get oriented.

It’s also helpful to establish mealtime and other routines before school opens. What time are kids expected to be at the breakfast table? Are they supposed to dress before or after they eat? Will they have breakfast at school? If they take lunch or a snack from home, do they help prepare it? Do they have input into what they take? This kind of information helps to alleviate uncertainty and confusion. Some children benefit greatly from having a checklist to help them remember to brush teeth and hair, what they are supposed to put in a backpack, and whether they are supposed to make their bed before they leave for school.

Photo courtesy of  Gioia De Antoniis.

Knowing the afternoon routines can help avoid struggles. For
example, adults may assume that kids know where to put their backpacks or that they are supposed to change out of school clothes. If those weren’t the rules in a previous foster home, it’s likely that they will revert to the patterns they followed there. Having a quick snack available also helps to reduce the
grouchiness that comes from low blood sugar! Sitting with students while they eat also offers an opportunity to hear about the events of the day and review expectations for the rest of the afternoon and evening—homework, dinner, and any other activities that will come before bedtime.

Some children will be so exhausted at the beginning of school that they will fall asleep quickly and sleep soundly. Others will be so anxious or excited that they will have trouble falling asleep and sleep fitfully. We can easily forget that interacting with teachers and peers for several hours during a school day is tiring. It can also be stressful to have to follow a predetermined schedule without the opportunity to rest when you want to or to have to sit quietly at your desk when you want to be talking to your neighbor.

All of this is harder if you are the new kid. All children need a little extra TLC at the beginning of school, but particularly those who are new to the school and the routines of the family.

By Toni Heineman

“I just wanted to talk to someone and they gave me pills.” This lament, which we have heard repeatedly from those who have spent time in foster care, is becoming increasingly common in all factions of the population. Brandon Gaudiano, professor of psychiatry at Brown University, in a recent New York Times Op Ed, suggested that among the reasons for the decline in psychotherapy as a treatment of choice for emotional distress is that psychotherapy has an “image problem.”

Psychotherapy is often perceived by consumers and medical professionals alike as being costly, time-consuming and ineffectual, while psychotropic medications are perceived as inexpensive, fast-acting, and effective. As in so many cases, the truth is not so simple.

Psychoactive medications help some people some of the time, as does psychotherapy. Answering the question of which is the better choice for any individual at any given time is not nearly as easy as advertisements for anti-depressants and anti-anxiety medications would have us believe. And, as Gaudiano points out, pharmaceutical companies have enormous budgets to create and promote the positive image of their products, while advocates for psychotherapy lack those financial resources and the will to develop practice guidelines that would aid mental health professionals and consumers alike.

Image courtesy of Curtis Perry.

There is abundant evidence that relationships are a powerful agent of therapeutic change, yet, too often, we deprive those in emotional distress of the chance to develop a relationship with a skilled and experienced mental health professional. Psychotherapy can help relieve suffering without risking the physical and psychological side-effects of medications. When we medicate too quickly we also deprive people of the chance to enjoy the longer lasting effects of psychotherapy.

It takes more time to build a therapeutic relationship than it does to take a pill, but the benefits last longer because people who are medicated passively ingest the thing that promises to cure them, while those who undertake psychotherapy must actively engage in the process of building or reestablishing their mental health. Through the clinical process they have the opportunity to internalize the knowledge and experience the therapist offers. Unlike a prescription, it will not have to be refilled endlessly to remain effective.

When people turn to us for help we need to remember that there is no medication that can cure the sense of abandonment when a child is removed from her parents and no pill that can create trust in the face of repeated losses and disappointments. Those who have suffered the trauma of chronic loss, the mind-numbing effects of poverty, or the brutality of discrimination need us to end a hand before handing out drugs.

By Toni Heineman

Shortly after she began meeting with her therapist, Maggie, seven-year-old Wanda* began referring to their weekly sessions as “Maggie time.”
As a child she used her time to play and draw as she chattered. Wanda is now fourteen and the play has fallen by the wayside and the chatter has turned into more thoughtful conversation. Her therapist explains that “Maggie time” is just part of Wanda’s regular routine.

Wanda was placed with her great aunt following her mother’s suicide attempt. Although her aunt’s health has declined over the years, she and Wanda have recently been called upon to help care for an aging uncle. This has necessitated a move from a rural area into a small apartment in a town near Wanda’s biological mother. Wanda’s mother also suffers from serious health problems and does not adequately care for herself. Nevertheless, Wanda is determined to “give her a chance.”

Despite having to spend significant after-school time to care for her caretakers, Wanda maintains good grades with every intention of attending college. Maggie describes her as a talented musician who practices diligently and takes great pride in her performances.

Like most teenagers, Wanda values the time she spends with her friends. She explains to Maggie that having friends of different ethnic backgrounds is important, as she explores issues arising from having parents of different races. With Maggie, she thoughtfully considers where she fits in and tries to understand what makes her feel comfortable in some groups or with some people and not with others.

Maggie recalled that one day not long ago Wanda talked about being invited to participate in a discussion group at her school. She described the conversation and her contributions. After a while Maggie commented that Wanda had done such an amazing job of articulating her thoughts and feelings. Wanda responded: “What do you expect? I’ve been seeing you for seven years!”

What an amazing “thank you.”
* The child’s name has been changed and identifying information has been eliminated.

By Toni Heineman

Did you know that you can find a new home for a child on the internet?

You can also find a new home for a pet that you can no longer keep. There are multiple sites that offer guidelines on how to re-home dogs and cats to make the transition easier for them. There are organizations that work with prospective pet owners to help them select an animal that best suits them and makes sure that pets and owner have a chance to get to know each other before making a home together.

Not always so for children, as an extensive investigation by Reuters revealed. This chilling report documents the way in which the internet has been used to find new homes for children whose adoptive parents have found them too much to manage. In most cases these children came to the United States through international adoptions, apparently with little preparation for either the children or their adoptive families.

The investigation discovered parents who delivered children to families they had never met. One woman described dropping her adoptive daughter on the doorstep of a couple she had found online. When the child didn’t show up at school the police were sent to the home and discovered a filthy “hellhole.” When the child was later discovered in another state, background checks revealed that the couple that had taken her in had lost their biological children to foster care.

Photo courtesy of Mike Blackburn.

Certainly, our child welfare system is far from perfect. However, there are policies and procedures in place that, when properly enforced and followed, do offer children protection. Foster and adoptive parents have background checks. Caseworkers make visits to ensure that homes provide for a child’s physical safety and have routine contact to ascertain that children’s basic needs are being met. When a child must be moved to another home, with careful planning and support, the child is helped to make a smooth transition.

It doesn’t always work as it should.
Anyone who has had contact with the foster care system is painfully aware of the system’s shortcomings. But when it does work, it provides a safety net for vulnerable children—there are many eyes looking to see that they are getting what they need and many ears to hear their voices. The children who are re-homed via the internet have no one watching or listening—unless the parents in the new home also find them so difficult that they get thrown out or hurt and end up in foster care.

By Toni Heineman

Diane Ackerman’s review of advances in the study of the neurochemistry of relationships * beautifully illuminates the importance of our earliest relationships on the formation of subsequent relationships. Her synthesis of research across many fields — from the lap to the therapist’s couch — reminds us that if we don’t attend to the infants’ earliest relationships, we risk subjecting them to a lifetime of physical and emotional ills.

Photo Courtesy of “Conorwithonen”

In the care of a loving parent the infant “feels felt.” Her needs are understood and met — long before she can name them or even experience them as discreet desires. It is through being known by the caregiver that the infant comes to know herself. As her needs are felt by her caregiver, the infant experiences the security of being held — not just in loving arms, but in a loving mind.

The tragic loss that we inflict on too many foster children is the repeated loss of a loving mind. We long to be kept in the mind of another. Children who are raised by “good enough” parents take for granted, as well they should, that their parents keep them in mind. Indeed, when children discover that they sometimes slip out of a parent’s mind they are incensed. For example, if the parent returns from a shopping trip having forgotten to bring home something the child requested, the upset child is bemoaning not just the missing treat, but the awareness that he is not always in the forefront of the parent’s mind.

It is one thing to learn that parents are sometimes forgetful. It is quite another thing to learn that you may be entirely forgotten by the people who are supposed to care for you. And sometimes, foster children are entirely forgotten. When caregivers cannot keep children in mind, children do not learn their own minds; they are wary of and confused by others.

When children do not know how to know the mind of another, they do not know how to form loving relationships. Yet, as research is increasingly definitely demonstrating, it is loving relationships that protect our physical and emotional health. The foster care system was designed to provide for the physical needs of children suffering from abuse or neglect by their parents.

We have mounting evidence that we cannot separate physical needs from emotional needs. Food and shelter are insufficient to meet children’s basic needs. They simply must have a consistent, loving adult to care for them. Failure to provide that vital relationship compounds and exaggerates the hurts the system is supposed to heal.

* This blog entry was written in response to Diane Ackerman’s blog post in the Sunday, March 25th edition of the New York Times Opinionator blog, which can be found online at http://opinionator.blogs.nytimes.com/2012/03/24/the-brain-on-love/