Evaluating Risk Factors in Foster Care Adoption

Are you considering adopting from foster care or becoming a foster parent? Join us to discuss this topic with Dr. Lindsay Terrell, a pediatrician and Assistant Professor in the Department of Pediatrics at Duke University Medical Center, as well as the Clinical Director of their Foster Care Clinic. She and her husband are licensed foster parents.

In this episode, we discuss:

• The common risk factors that foster parents and those wanting to adopt from foster care need to be aware of include physical, emotional, developmental, educational, and behavioral problems rooted in childhood adversity and trauma. 
• What types of trauma are foster kids exposed to? 
• What percentage of children in foster care have been exposed to drugs or alcohol prenatally? Creating a Family’s Prenatal Substance Exposure Workshop for Parents
• Impact of trauma on physical health.
  • Foster parents and caseworkers often have little information about prior health history.
• Other common physical health issues that are common in kids in foster care that are not necessarily connected to trauma.
• Impact of trauma on mental health.
  • Those areas of the brain most affected by trauma, especially early trauma, are those involved in stress response, emotional regulation, attention, cognition, executive function, and memory. 
  • What types of behaviors are common as a result of trauma?
• Medication and over-medication of foster children and youth.
  • Research has found that the average number of psychiatric diagnoses and psychotropic medications prescribed were significantly greater for youth and children in foster care.
  • Children in foster care are likely to be kept on them longer than other Medicaid-enrolled children who are not in foster care.
  • What are psychotropic drugs, and why are they so often prescribed for children in foster care?
• Who has the authority to make healthcare decisions for foster children and youth?
• Sleep issues common to children in foster care.
• Food issues common to children in foster care. 
• Impact of trauma on a foster child’s education.
  • Children in foster care need educational advocates.
• Risk factors to consider for children already in the home. 
• Children can heal, and foster parents can make a difference!

Transcript

Please pardon any errors, this is an automated transcript.
Dawn Davenport  0:00  
This is Creating a Family. Talk about foster, adoptive and kinship care. Welcome back to our regulars. We wouldn't be here without you. But also a special shout out. Welcome to our newbies. We're glad you're here. I'm Dawn Davenport. I am the host of this show, as well as the director of the nonprofit creating a family.org Today we're going to be talking about how to evaluate risk factors in foster care. We will be talking with Dr Lindsay Terrell. She is a pediatrician and Assistant Professor in the Department of Pediatrics at Duke University Medical Center, and the clinical director of their foster care clinic. And perhaps most important, she and her husband are licensed foster parents. Welcome, Dr Terrell, we are so glad to have

Lindsay Terrell  0:47  
you here. Thanks. Don happy to be here

Dawn Davenport  0:49  
for people who are considering fostering or are considering adopting from foster care, it's important for them to go in with their eyes open and understand what are the risk factors that they may face. So the common risk factors that foster parents and those wanting to adopt from foster care, they what they need to be aware of, and that would include physical, emotional, developmental, educational and behavioral problems that could be rooted in childhood adversity and trauma. So let's start with that. What type of trauma are foster kids exposed to?

Lindsay Terrell  1:22  
That's such a great question, and there's such a wide range of different things children could be exposed to. And also, I think there's a really interesting just maybe an expectation, or people have assumptions of what kinds of trauma kids could be exposed to. And I think many people assume that kids in foster care have experienced physical abuse or sexual abuse, and that may be true, but what we actually know, and when I look at data from our own clinic and my professional experience, what we know is the majority of children who are entering into foster care the type of maltreatment that They experience is is really in this neglect category, and that can encompass substance abuse within the family, domestic violence, improper medical care, missing school, not improper supervision, this word dependency, where for some reason it's just too hard for that caregiver to care for that child. So neglect is the big category, and then the smaller subcategories are really physical abuse and sexual abuse. So those are the big types of risk factors of trauma. But I think what I've learned from my job is that sometimes the biggest trauma is still happening, right? It's that separation from a family, and social services is in charge of making that decision, right? So this is not during no part of today's talk. Do I want to sound not positive about social services, because they have a very hard job, but they're in charge of making that decision, once that separation occurs, that child, for the most part, still loves that mom or dad or caregiver. In their minds, that's what they've grown up with as their, you know, permanent support person, and so now they're in this new family. It might be great and lovely and beautiful, but there's still that really hard separation that includes, usually weekly visits or bi weekly visits, and all of that's just so hard. So I think for me, when I see these kids in our care, there's the initial trauma that brought them in, but there's this ongoing trauma that everybody's trying to do their best to lower the impact of but it's still there too in a big part of these children's lives.

Dawn Davenport  3:46  
You know, what we often hear parents say is they look at the child's file and they see that the child is been removed from neglect. And as you say, that's the vast majority of the kids who enter foster care. Some form of neglect is what brings them in. And it's easy to say from a parent standpoint, well, it's just neglect. It's not abuse. So you know, it's it's just neglect, which is discounting the impacts of neglect. So let's talk about that. What are some of the impacts that you see in kids, both physical and emotional and behavioral, from having not been parented, have not been parented? Well,

Lindsay Terrell  4:25  
good question too. You know, I think it's easier to see the impact of what we consider the more harsher forms of maltreatment. So physical abuse and sexual abuse, we kind of expect challenges to come from those. This neglect category is so large and vague that, yeah, that you know you might, you might hear someone say, well, it's just neglect. But really, there might be a lot more going on with that neglect than we really know of at the start. Yeah.

Dawn Davenport  4:59  
Exactly, and you might not know, and it's got to be severe enough for a childhood been removed, we at least hope that's the case, right?

Lindsay Terrell  5:07  
Yeah, we see plenty of kids who come in for a concern of neglect, but then later we find out there was physical abuse, or there was sexual abuse, or there were other medical diagnoses that we don't know of. So there's that initial call or information that you get about that child is is just what's there at the time. So I think you have to take that for what it is, but then I think the long term consequences of neglect, we really have to look at research of children who, you know, attachment is this big topic nowadays, and you can have a child that's neglected but still has great attachment, right? You can have a child that has that's not neglected at all, actually from a social services standpoint, but has very poor attachment, just based on how parenting has gone. So when I think about ongoing, lifelong challenges for children who experience neglect, that attachment is a big piece of it. Have they been able to establish somewhat of a secure attachment to a caregiver during their lifetime? The earlier the better. Studies show that if you, if you don't have that secure attachment early on, modeled to you that you may have trouble later on in life, securing solid, healthy attachments in life, and then you get into these other categories of neglect, you know, food insecurity. You might see a child who really struggles with ongoing how they eat and how they think about food. The trouble that starts when you're younger can go on and become bigger, if not addressed early on in life. So I think about, I kind of have to look at it as like, what was that neglect category? But I think healthy emotional attachment, how kids think about food, how kids think about hygiene, the ongoing what's also counted and neglect, I probably should have said this early on, is this exposure to domestic violence. And so what does this look like for a child who has experienced violence all around them, or pieces of stories of violence all around them growing up? So what does that do to their brain long term, this constant elevation of stress, and we know that long term that actually impacts the makeup of a child's brain, right? That child then has, for the rest of, you could say, for the rest of their lives, but with appropriate treatment, you can help this, but this constant ability to go to fight or flight at a rate more frequently than the person who's not exposed to that violence. And so that's why, typically, you hear about kids who have been in foster care, are in foster care who might get in trouble at school or might have outbursts at home, right? I often think about, what is it that they've been exposed to at home that's either modeled things like that or that's caused them to constantly be in this fight or fight mode,

Dawn Davenport  8:04  
all right, what percentage of children in your experience in foster care have been exposed to drugs or alcohol prenatally?

Lindsay Terrell  8:13  
That's a great question. I'm saying all your questions are great because they are and I could talk about this for a long time, but what we know locally is that about 17% currently in my local area has been exposed. The reason they're coming into care is because of substance abuse in the home that's within our larger group within North Carolina. When I'm looking specifically at our clinic, more than half of the kids coming in for concern, for neglect, have had some sort of substance abuse in the home. So it is definitely out there. I can say anecdotally, over the past couple of years, the majority of our infants coming into care have been exposed to substances in utero.

Dawn Davenport  8:57  
And that tracks with national statistics. The one we give is about 75% of children, but many doctors and parents would say it is higher than that, but have been exposed prenatally to alcohol and drugs, and this is not a factor for infants as much as it is for I mean, obviously infants could be exposed, but the symptoms of the exposure often do not show until the child is older. That is a misconception that this is a problem that affects infants, and in fact, depending on the exposure that substance exposed to and the amount of exposure, it is a lifelong impact. So I throw that out there right? Let me pause here to tell you about our weekend wisdom podcast, but I want to remind you to make sure you hang around after this little break, because we'll be discussing the impact of trauma on physical health and some of the physical health issues that are common in kiddos and. Foster care. But for now, weekend wisdom, we have two podcasts. We have this one that you're listening to now, we also have the weekend wisdom podcast, where we answer your questions. Audience members send in questions, and we devote about five to 10 minutes to answering that question. Send us your questions at info, at creating a family.org and now back to the show. All right, I want now to talk about the impact of trauma, and I'm using trauma as a more general term now, which would encompass neglect, abuse, witnessing violence, constant stress, having parents who are struggling with substance abuse disorder and things such as that. What are some of the impacts of trauma on physical health of a child?

Lindsay Terrell  10:50  
Yeah, so there's a very well known study done out on the west coast called the Adverse Childhood Experiences Study, and they looked at all these different adverse childhood experiences that people reported and then follow their health kind of long term, and they didn't track all the adverse experiences that you and I have been talking about today, but I think we can count. We can probably assume that a lot of the adverse experiences that we see for children who are entering foster care are the same or worse than some of the ones that they describe in that study. But what we know is that long term kids who are exposed to adverse experiences, the higher that number, number of adverse experiences, the more likely they are to have long term adult consequences in their health. And so you think about and it's really interesting things you know, mental health problems. They talk about suicide risk or attempts of suicide. They talk about sexualized behavior, or kind of hyper sexualized behavior, or having sexually transmitted infections and that kind of thing. But then they also talk about things like cancers and obesity and these things that I think for a long time we've assumed couldn't be related to your emotional health as a younger child, but but actually are that this constant stress or higher adverse experiences that you have actually do put you at higher risk of certain cancers, diabetes, obesity, these long term, bigger, high cost adult health outcomes, and so that's the long term concern for children who are entering foster care. The short term, what we know, as I said before, is that when you have this high stress on your brain all the time, scientists have shown that your brain actually changes in how it's made up and what's getting blood flow and what hormones are being released, and if you don't try to address that with appropriate mental health therapies, and I should say trauma informed, well studied therapies, then you the concern is that you'll see long term repercussions of that as well. That's staying in that fight or flight mode, and even with appropriate therapies. You know, that still may be something that that person or child struggles with for a lifetime. We hope not, but you know, like any disease, some are really treatable and some are harder to treat.

Dawn Davenport  13:23  
Are there other common physical or health issues that are common in kids in foster care that are not necessarily connected to trauma? One that comes to mind that we have seen are dental issues. So what? What are some of the other physical issues that you see that that aren't necessarily connected to trauma? Yeah,

Lindsay Terrell  13:44  
that's a great question. Dental issues are definitely one that we see. There was a dental student here last year, the year before, I think it was, she interviewed local foster parents, and I think 50% or more of the kids in foster care had some type of significant dental caries or a cavity that needed, you know, significant work. So I think along that same category are just things that you know, kids who haven't gotten all of the well child care that would be recommended by the American Academy of Pediatrics. So sometimes we see infants who have trouble gaining weight. Sometimes we see infants that are significantly overweight because they've been, you know, bottle fed, maybe not in the way that a pediatrician would have recommended. Our

Dawn Davenport  14:33  
bottle fed materials that are not particularly

Lindsay Terrell  14:38  
healthy. Sometimes we see this lack of of just overall well child care, right? And the goal of those Well Child appointments is to make sure that now going to my parents side, that as a parent, I'm doing what's best for that kid, and thinking about the small things that could add up to be a big thing. So I. Are things that we see that are, you know, physical and are there and not related to trauma, that we kind of have seasons of life where we know we need to be on the lookout for lice and scabies and, you know, those kind of creepy crawly things that pass from person to person. We see some skin, things like eczema, just super dry skin, or skin that needs a steroid cream, we go on it that if you're not getting good well child care, that might be something that just isn't a high priority. Or maybe life is just so hard that that's not a high priority at that time. And then I think, I think diet is a big one too. Just Kids who are either, I said this about infants, but either kids who are struggling with obesity or are underweight just based on the diet that they're receiving at the time. And I want to be careful when I say this that I'm not generalizing to every kid who's entering foster care, right? Every kid who comes in foster care enters for different reasons, and some may be related to different things than what I'm talking about. And so I hope that everyone listening won't assume that like every kid who comes in. I'm not saying every kid's gonna come in with life, or every kid's gonna come in with this problem, but just the things that we see, that's kind of the typical gamut of things that we see. And

Dawn Davenport  16:16  
if adopting through foster care, if the child has already been in foster care for a while. At that point, they will have been receiving medical care while they were in foster care. So you wouldn't necessarily see some of these issues, an issue that's worth raising with both well foster care parents, resource parents or adoptive parents or case workers often have very little information about prior health history. How does that come into play? And is what's a parent to do about that? Yeah, that's so

Lindsay Terrell  16:49  
tricky. You know? I think oftentimes I'll hear people say, Well, you know, social services just to give us no information about this job, but, but typically, at the time that a child comes into custody, there really isn't a lot of information. And so sometimes it's no one's fault. It's just how things are. Yeah,

Dawn Davenport  17:08  
child's been removed there. You know that these families are probably not going to have a file sitting right there of all the pediatrician visits and notes,

Lindsay Terrell  17:16  
right? Right? And you know, I hope as a pediatric field, where we're improving in how we share information about these children within our own clinic, it's very important for us to make sure that any foster family, foster child resource plan, anyone coming through our clinic, even biological parents, are fully aware of the acute or urgent medical concerns of that child. And so it's a constant balance of some information needs to stay private, right? And some information really does need to be shared from a medical perspective. And so we are trying to balance that. But I, I do think, I think one of my favorite things now that I do that, I've been in this job professionally, and then my family had its own experience with fostering and adopting. Is I love now having friends in my community who are entering into this foster or adopted journey, and I'm just a phone a friend, so when they say, Hey, we got this call about, you know, this type of placement, or this type of child, and I think it's important to read a little bit between the lines. You know, it's important to if, if social services is saying there's a behavior concern, there is likely a behavior concern, don't try to minimize that. Take it for what it is. Know, it may be way worse or way harder than what you think, right? If Social Services says we don't have a lot of information about a child, that doesn't mean that there's not going to be more that comes, I think about accepting a placement for foster or adoption in the same way that I would. I hope someday get advice to my own children about marriage, like whatever you seeing when you're dating that's hard or difficult, or maybe little just things that pop up and you're like, that's a little tricky. It would be naive to think that those are going to get better when you get married on their own, right? So I think this, the same is true for those of us who are thinking about fostering and adopting, that those little things that you read about, you should really take to heart and think to yourself, Is this something I want to manage for a year, two years? Do I have the capacity to do that? Do I have the support system that I need to do that, and

Dawn Davenport  19:41  
through adoption, it's for life. Yes, right,

Lindsay Terrell  19:43  
right, yeah, definitely. That is definitely. You should be fully aware of how hard those things will be over time just because they're in a loving family. It is not the solution to many of these problems. It's. It is for a lot, for a good bit of them, but there are other things that need help, too, and even for fostering. You know, the average time for a kid to be in foster care is at least a year. But really lately, after COVID and things, what we're seeing is longer than that. And each transition that a kid goes through, you know, if one foster family takes them and then says, Oh, this is a little too hard. That's another trauma. It really is, and I don't want to guilt anybody, but, but that's something we should all be thinking about when we accept a placement. Is long term? Is this something I can do, that we as a family can commit to long term.

Dawn Davenport  20:41  
We often say that that one of the most important things that we as an as an organization can do, which we're a training and support organization for foster, adoptive and kinship families, one of the most important things we can do is help families set realistic expectations, because if they have realistic expectations going in, that increases the stability or the placement, and a stable and loving home can go a long way to helping children heal. But you also have to have realistic expectations that love alone is not going to take care of all issues it that's just not how it works.

Lindsay Terrell  21:26  
Yeah, so true, and I think that's so important for agencies like yours who are doing this training, or even the agencies that are making the phone calls, right that can be a highly pressured situation where you want to help and you want to do good things, but you also have to have these realistic expectations of what it is that you as a family can do. And that's an okay thing to do. That's an okay thing to establish is there, yes, there's a shortage of foster families. And yes, it would be great if there were more, but we all have to be able to see what it is that we can handle. And I'm always surprised, you know, we've had a couple of placements in our family, and each time we have a placement, I'm so surprised at the amount of work in those first few months. I, you know, kind of gotten to the point where I got to the point where I was like, we can do, we can do. We've done this before. We can do it. And each time, I think I forgot how it's kind of, you know, it's like having a newborn again. You're like, Oh, I forgot that was kind of hard the first go round. And so I think there are a lot of other things that come along, not just the child, but meetings and social services meetings and gal meetings and visits that all cloud that and make it harder to

Dawn Davenport  22:45  
that suck your time, Right exactly? And foster kids do have a lot of appointments for all the reasons we've just been talking about catching up on their physical hair, digital appointments, therapy, visitations. So all of these are just part and parcel of trauma on physical health. Let me pause here for a sec to remind you that we have 15 free courses thanks to the support of the jockey being Family Foundation, in the past, we've only had 12. Now, through their support, we are offering you 15. These are wonderful courses that are directly relevant to parenting, you can get more information about them at Bitly, slash J B F support. That's B, I T, dot, l, y, slash J B F support. And now I want to move to talking about the impact of trauma on mental health. And we've been alluding to that all along, that trauma impacts our stress response, your fight and flight and flight, our fawn response, but also things like emotional regulation, just the ability to self regulate their emotions and attention. Just across the board, do you see that in your practice, that children who have experienced the trauma as we no child is who is entering foster care, who has not experienced trauma. If things are going hunky dory, these kids are not being removed. So something has gone wrong in this child's life for them to be removed. So what are the more common mental health issues you see in the kids coming in? You've mentioned attachment as one of them. What are some of the others? Let

Lindsay Terrell  24:23  
me, let me preface by saying some children come into custody and I'm amazed at their resiliency. Good point. It's truly like what I maybe love the most about my job is to see that somehow children can just be so resilient in their ability to cope with things that are hard.

Dawn Davenport  24:43  
Let me pause here. I love the you probably are very familiar with the Budapest study out of Harvard. They followed kids that were adopted from Romania. They're continuing to follow these kids. They're not kids. They're adults now. They were starting in the early 1990s and these kids ex. Experience some of the most horrific abuse and trauma that you could imagine. It's It was unbelievable what these kids went through, and they were adopted here. And I believe his name is Chuck Nelson. I believe doctor he I think he's the one who is the head of the study. I may be wrong on that, but I loved his expression. We interviewed him on the show, and he said, but he's also written this, and my percentages may be off, but it was something like about 20% of the kids were really struggling. 10 years later, and then about 50% of the kids were, well, probably more. Probably about 60% of the kids are doing okay, you know, they are definitely showing the impacts of the trauma, but they're, they're functioning. And then he said there were about 20% of the kids, and he called them the resilient rascals. And he said, these little rascals, they couldn't necessarily tell from the the experiences that the kids had, but these kids, these little resilient rascals, he said, they're thriving and and there's, you know, was it temperament? Was it things that they that were not reflected in the record, even though they were from the same institution? It's hard to know. But anyway, I love that expression, and so we, we would expect the same with children adopted through Yes, yeah,

Lindsay Terrell  26:19  
I think that's true. And I would say the same thing. I can't really predict who's going to be that. Yeah, but typically, in that first meet, we see kids when they enter foster care, and then about a month later, from my professional standpoint, and so you can typically get a good idea of, like, man, that kid has been through a lot, but the level of conversation and ability to talk through things is really amazing. Okay, so, so that's there are some really amazing resilient kids. And I think just as you said in that study, there's some kids who maybe aren't as resilient, but they they overcome a lot during that process as they kind of grow up. So and then from there, I have to think about it in age group. So for our youngest, like infant babies, typically, what we see are, you know, as I said, the majority of those children are coming in having been exposed in uterus substances. So we see a lot of fussiness, irritability, colic, waking up more at night, trouble, feeding. So that's kind of the typical category that we hear about and see with infants. As we get into that toddler age, especially depending on when they come into care, sleep is a big issue. And sleep can just crush a caregiver. You can think you have it all together, and then you take away sleep and like it is gone, your ability during the day is gone. And so I'd say for toddlers, we often hear about sleep, pickiness with food, not wanting to eat, and then it's this kind of body ability to regulate. You know, hear a lot about tantrums, and typically you'll hear like tantrums are better or worse after visits. I think I think I want to be careful when I say that. It's not that the visit itself is bad, it's just that's a lot for a kid to manage. And so in that toddler category, we think a lot about sleep, tantrums, behavior. Can they stay in a daycare? Right? If they need daycare, some kids have trouble adjusting to that or staying in a daycare if their tantrums are really bad. We think a lot in that category. And I, I think it's important for people to think about occupational therapy as really great support for those younger children PCIT or parent child. Interactive therapy is also great, very caregiver heavy and so ideally biological mom and dad are participating in that with the foster parent. But occupational therapy is one. They talk a lot about body regulation and being in the green zone or the red zone and and trying to let out some of that energy in a way that's not all emotional and physical, but regulating it. So I'm thinking about occupational therapy in a gym, not in a school, right? One, where you go to the facility, and you're engaging with an occupational therapist in a gym, learning boundaries, having to take turns, share all of those. Those are great things for toddlers to be involved in. Then you get into elementary school age. Kids, oh, I think sleep can still be a concern. Kids staying up late, wanting to watch TV, be on a phone, right setting, good boundaries and sleep habits is still important for that age, you really start getting into more of the heavier mental health concerns in that category. So thinking about that attachment, but also looking for things like anxiety, depression, often, one can look like the other. We also see, I don't like to call it ADHD, because trauma can look a lot like ADHD, but it's that. It's that hyperactive, inattentive kind of child, and so again, having difficulty in school. School, maybe getting into fights at school, throwing tantrums at home, still in that elementary school age category, and for those kids, parent child, interactive therapy is great. That's a good age group because they can I think it goes up to maybe seven or eight, so it's that lower age. But occupational therapy is still great for that kid, if that kid really struggling with their day to day, making it through the day in school without having these high elevations of emotions. Then we really start looking at, could medication be helpful? That's outside of my scope. I mean, I'm I very rarely will prescribe any kind of mental health medication for a child, but we have a great support system of pediatric psychiatrists here who will really think about medication to help bridge some time to support that child. The goal is not long term, forever medication, but is there some support that we can offer to allow this child to attend school, go through daily activities while they're learning these other strategies. And then as we move into teenage kids, oh, all the things I mean, all teenagers I feel like are struggling with these things, but especially in this population, depression, anxiety, you have to think about substance abuse disorders, eating disorders and just being on an electronic device for a very long time. Frankly, that's not a disorder yet, but it might be someday.

Dawn Davenport  31:28  
It's a problem, regardless of whether it's it's under the DMS, but yes, yeah, yeah,

Lindsay Terrell  31:33  
for all of us, but, and I think it's important to recognize that some mental health problems that kids have may be related to their trauma, right? And because certain parts of their childhood, whether it was in coming into custody or separating from parents or what they experienced before, that, they're having long term consequences of that and mental health challenges because of that, we also have to acknowledge that mental health disorders or parents with mental health problems is another reason of kids that are in custody, and so we have to be aware, and again, this is as we're thinking about accepting a placement, that it would be naive to think that these children are not at higher Risk of maybe acquiring a more genetic DNA family type pattern of a mental health problem that maybe they were going to grow into despite all their other things that were going on. So we do see some kids as they kind of age through that they need more mental health support, or they struggle more with substance abuse, or they struggle more with anxiety, depression, or later on, get a diagnosis of bipolar or something like that, that may be more related to other things besides just their trauma. Your

Dawn Davenport  32:52  
point so well taken that often the problems that are within the home are the result of a condition that our disorder that the parents are having, and perhaps even the substance abuse disorders, are parents who are self medicating to cope with mental health disorder. Depending on the mental health disorder, there is a genetic connection, and so it would be our children who are in foster care may have a greater propensity to develop mental health disorders if there, if there is a genetic connection, such a good point, right? I am loving this interview, so I hate to interrupt it, but I do want you to know about one of our long term sponsors, Vista Del Mar has supported both creating a family and this show for many years. Vista Del Mar is a licensed non profit adoption agency with over 65 years of experience helping to create families. They offer a home study only service as well as a full service infant adoption program, and they can also do international home studies and post adoption support. They do have a foster to adopt program which is directly relevant to this show. You can find them online at Vista Del Mar that's all one words, all pushed together.org/adoptions, and now back to the interview. I'm glad that you raised the issue of medication and of foster children and youth. And I wanted to talk about medication as well as over medication, the research has found that the average number of psychiatric diagnoses and psychotropic medications prescribes were significantly greater for youth and children in foster care, and we hear that anecdotally from the parents we serve kids coming in with a Ziploc bag full of medication, and research also says that kids and youth in foster care are likely to be kept on these drugs longer, and they were also comparing that this particular study compared them to other Medicaid enroll. Old kids, so kids of a similar and economic so they were ruling that out, but kids in foster care are on the drugs longer. Let's start by talking about what are psychotropic drugs, and then talk about why they are prescribed, and why they are prescribed as often as they are for kids in foster care, right?

Lindsay Terrell  35:18  
So I, I passed by psychotropic drugs. This is drugs to help regulate mood and emotions. And some of those drugs are, you have to be careful how you prescribe them, you know, things like Concerta, methylphenidate, all of those ADHD meds are, you know, highly regulated. Some of them aren't as much. But so when I think about psychotropic meds, I really think about meds that a psychiatrist would be prescribing, and the reason for prescribing those would be for concerns about behavior, mood, depression, anxiety, bipolar, these heavy hitting, hard mental health whether there's like an adjustment time or an actual mental health diagnosis. But, yeah, that's that's how I think about psychotropic meds and the reasons that someone would prescribe

Dawn Davenport  36:06  
them. And why do you think that children and youth in foster care often have so many of these prescribed you

Lindsay Terrell  36:18  
know, our the studies that we've done here show that so it's everywhere, and maybe it'd be best to just give kind of an anecdotal this isn't a real patient, but it's this common thing that we see where a child enters CSS custody, comes into a foster home or into a kinship home, and is adjusting right. Life is hard, whether it's from previous trauma or just being in a new environment, starting a new school, having all these people visit, right and then begins to have behaviors, or maybe is already having behaviors, but but in this new home, begins that behavior, so throws tantrums, maybe tries to run away in a parking lot, or maybe picks up a knife, you know, things that are scary for anyone to experience. And so let's say that that family tries to get support through local mental health support. And what we know nationally is there are prolonged wait times for good mental health therapy and support pretty much everywhere we have pretty good connections with places around us here, where we can try to get some kids in faster, depending on their behavior, but frequently it's hard when those behaviors escalate. If you are not on a wait list, it's really hard to get it right when you need it. And so now let's say this child is experiencing these behaviors, but the wait list for good mental health support is two or three months, and so that family says this is too much, right? Which is okay to say that sometimes happens. So that child gets moved either to another home or to a group home or to depending on the level the severity, so now they're in the new home, and their behaviors don't get better, right? When I think about it, a kid is a kid, right? They they just pitched a fit in one home and it moved them. So now I think you could assume that that's now a learn. Could be a learned behavior. If they continue acting like that, they might get to be in a different home or and, you know, all of the challenges that can come along with that. So now you've got this child that isn't in a stable placement, or it's hard to find a stable placement, they finally get into mental health therapy, and that person, that physician or psychiatrist is like, we need to put this child on some medication to try to help lower these behaviors. But now let's say that child moves to a new home, so you have a new set of eyes on the kid, and maybe the behaviors are different, or maybe they're the same, or they look different, and they go to the psychiatrist and say, Well, I'm seeing this or maybe that kid had to move to a different county, so maybe they're seeing a new psychiatrist, and that psychiatrist says, well, we'll, we'll add on this medicine too. Well, maybe it gets to the point where that child is actually hospitalized for mental health concerns, right, which is a very sad place when it gets to that point, but it does sometimes get to that point, and then that mental health hospital who isn't necessarily talking to these other psychiatrists sometimes they are, and that's great. Well, maybe add on a different set of meds or change up that regimen. And so what I think about for these kids, right? If, if, if my own kid had a mental health concern and needed therapy, I I'd stick with that child for the whole time, right? There isn't the option to say, Oh, I can't do it. Which foster care is unique in the way they can say that, and sometimes you need to say that. Hear me say that. But so I think some of the trouble with these children is that they don't have one person who's consistently following them, who's able to accurately report concerns. So if the foster parents are changing, and we know that the turnover of Social Services social workers is high, that's a really hard and demanding job, so that's also changing. And we know that even gals or CASAS can also change over as well. But if you don't have that set person, and the kids moving from county to county or place to place, so they don't even have the medical following as well. Things just get kind of added on, and that's typically what we see. These kids with challenging behaviors who have a hard time keeping a placement, bounce around to different places, maybe go in and out of mental health hospitals, end up on a lot of meds, a lot, and so it's really important for that child to find a pediatric psychiatrist, someone who specializes in pediatric psychiatry that is not a child that I would recommend being treated by a physician who doesn't specialize in pediatric psychiatry. They're just so many complicating pieces to that. And really that's what that person is board certified in. And so I think that's the best thing that we can do for that child. And then encourage that pediatric psychiatrist make sure they're aware of these studies that these kids are usually, are typically on a high number of meds. And is there a way we can think about titrating some of them off, or is the kid on two meds that are actually doing the same thing right? And a good pediatric psychiatrist will be able to do that right away and come up with a really good plan to safely address the number of medications that that child is

Dawn Davenport  41:43  
on. And you know, one of the things that strikes me is that, you know, why are these kids also kept longer on these drugs and and why are these kids being prescribed these drugs by doctors who are not pediatric psychiatrists? And you know, every child needs an advocate. They need a person who is invested exclusively in them. And their birth family might have had that person, but then they or might not. But even if there was a person in their birth family who was advocating for this child, they've now been removed from that and some foster parents are absolutely going to say, I am going to be the advocate for this child. I would hope that all those who are adopting would be doing that, because they're making a permanent commitment to this child. But as a parent, we would certainly say, Okay, wait a minute. If we're going to take if we're going to be adding a drug, should we be taking this other drug off? We would be asking questions. We would be advocating. And oftentimes what happens is kids who are in foster care don't have that advocate, right? And so it's easier to just not fight to find because they're hard to find pediatric psychiatrist, so you go to the pediatrician, or you go to someone else who says, Well, let's try this. And because there's not the long term investment there. It's easy to say, Okay, well, let's just give it a try.

Lindsay Terrell  43:05  
Yeah, it's so true. And, and, you know, I think the lack of an advocate isn't because people aren't trying, you know, right? I agree. Services tries foster parents try

Dawn Davenport  43:14  
and case workers who are with these kids often long time they care desperately, but there's such turnover,

Lindsay Terrell  43:21  
right, right? And, yeah, they're just really tricky, hard situations. And I would say, for foster families out there, tread carefully as you enter into that, right? You might hear what I'm saying right now and be like, I'm going to take in the teen and I'm going to wean them off all of their psychotropic meds. But you know, some of those might be needed too, and so try to find a balance of trusting everyone who's involved in and asking questions first, advocating

Dawn Davenport  43:49  
means asking questions, right? Not that raises a really good question, who has authority to make healthcare decisions for a foster child and youth? Obviously, if you have adopted the child are an adoption placement, you would have that authority after the adoption, but we're talking about with foster children, who has the authority to make those healthcare decisions, whether it's talking psychotropic drugs or whether we're talking dental care or anything else. Yeah,

Lindsay Terrell  44:15  
so I should preface to say I am not a legal expert, but my understanding of of all of those rules is that social services has the authority to make decisions about routine and emergent medical care. Anything that falls outside of that, which includes vaccinations, can be tricky, so that's a whole nother podcast, probably. But and mental health medications do not fall under that typically, and so even though there's a child in foster care that bio family, bio mom and dad still have typically, usually, unless the court decides to get a court order, but has the medical decision making authority when it comes to the. Thinking about things like psychotropic medication, thinking through vaccine schedules, or if they have a religious objection to vaccines, or thinking through things like non routine medical decisions, things like circumcision, ear piercing, you know, those kind of things that aren't necessarily medically necessary and that can be really hard. That can be a reason why kids may be delayed in getting some of the care that they need if they enter care and someone's recommending a psychotropic medication, but bio mom or dad may not agree or may not understand or may be hard to get in contact with. And so, you know, there are many barriers to these kids receiving care, but that that can be one of them, too.

Dawn Davenport  45:45  
All right, we've talked about the impact of trauma on physical health and emotional health. We won't spend much time on this, but trauma also impacts a foster child's educational, educational experience. There often has been inconsistency in attendance, there has not, oftentimes been someone who has been invested in the child's education. So it is common for these children to have educational gaps. Regardless of the grade they are in. They may not be at grade level, and so all kids coming into foster care and need an educational advocate. And that can be the foster parent, it can be the case worker, but being aware of that, I just want to being aware that just because a child's in third grade does not mean they're reading on third grade level or doing math on third grade level, right?

Lindsay Terrell  46:36  
Especially after COVID That became a well, you know when, when kids are doing a lot of school at home, and if you don't have a computer or a laptop, or when they go back to school, many kids now after that, are entering custody a little behind,

Dawn Davenport  46:52  
yeah, that makes such good sense. The last thing I want us to cover are the risk factors to consider for children already in the home. If you are bringing in a child from foster care, either through fostering or through adoption, what are the risk factors you need to consider for the children who are already in your home? Oh,

Lindsay Terrell  47:12  
that's a loaded question. I think it's so important to acknowledge the needs of your own kids, right? What are their current needs and level of needs and what are their strengths? What are they good at? You know, how do they interact around other kids? How do they share their toys? How do they just all of those questions are probably the first thing to be thinking through. I think, when you choose to adopt or foster, it's a family decision, and so you would hope that everyone, including your kids, would be on board and understanding of what that could look like for their future. I talked to a lot of families about just ages, you know, and I think that's a big as you it sounds like you all do, you know, talking to families about what is, what is within your capacity that you can do. And you know, early on with our own kids, we have two biological children, and we did a little respite, just to kind of so within foster care, you can do respite, and just we were licensed, but we're just learning and exploring from having kids just come and visit for a little while in our home, right for a weekend or a week, and we learned so much through that. And so I think that's a great way to kind of see where your own kids may do better, or where they may struggle, and if they struggle, that may be okay. But are you willing to have that and engage that, knowing it may get better and it may get worse. So for our own family, having kids that were about the same age as ours is was a challenge. And some people, some kids, do that very well, but, but we saw for our own family that was not going to be the best for for our long term ability to function. And so I think thinking through the ages is really important, and then otherwise, my only other suggestion would be just making sure that as parents, we have good supervision over our children. It's really nice to get to that point where your kids can just play in the other room by themselves for an hour while you make dinner. But I think when you're talking about fostering or adopting and there may be behaviors that we don't know of, and even our own biological kids may not be used to or familiar to certain things that having really good eyes on supervision is just really important for the safety of everyone

Dawn Davenport  49:43  
involved. Well said, and plan on that, because it is certainly more time consuming, especially if your children are at the age where you're not having to constantly supervise them, having to go back to that right is it feels like from a parental standpoint, as. Regression, and it may not be forever. It is for the period of time so that you get to know the new child, their strengths and their struggles, as well as how your own children are coping. So I think all of that,

Lindsay Terrell  50:16  
the last thing I'd say, Don is that, I think anecdotally, what we've heard. You know, when we say we're a foster family, people will say, Oh, I could never do that. It's too hard, or that'd be too hard for our own kids, or too hard to say goodbye, I wouldn't want to mess up our own family and for us personally and for the foster families that we know, it's the most challenging, hard thing we've ever done. It's also the most beautiful thing to watch our own kids accept children in and love on them in ways that even I'm amazed at, and it's encouraging for me to see the love that they pour out for them and inspiring for me, because sometimes I need that too to say, Oh, look, okay, I can take a deep breath at 5pm while I'm trying to make dinner and see the beauty that's in this moment, rather than just seeing how hard it is, really see it through the eyes of a child. So doesn't mean everything is going to be beautiful, but I think that's the I want to make sure people hear that, that I wouldn't take back anything that we've done, children

Dawn Davenport  51:21  
can heal, and foster parents can, and absolutely do make a difference. Thank you so much. Dr Lindsay Terrell for being with us today to talk about evaluating risk factors in foster care. We truly appreciate your expertise. Thanks,

Lindsay Terrell  51:40  
Don It was great to join you today. You.