In this issue of CCPR we focus on the treatment of children in foster care systems. Nearly one in three of these children have significant psychiatric problems during their time in foster care—especially those related to trauma and neglect that brought them into the system (McMillen JC et al, J Am Acad Child Adolesc Psychiatry 2005;44(1):88– 95). Recently, psychiatrists working with foster kids have been under fire for allegedly overusing medications, especially antipsychotics.
The articles in this issue will help practitioners answer questions such as: When do we use medications, and why, and what other options for treatment exist? In this introductory article, I’ll provide you with a brief primer on how foster care works, and how psychiatrists get involved.
What is Foster Care?
When children are in a tough home situation—whether involving abuse, neglect, or other circumstances—it’s not a given that they will end up in foster care. At least 25% go into what’s called “kinship care” (www.childwelfare.gov/topics/outofhome/kinship/; Winokur, M. Cochran Database System Review 2014 (1)). This means that the child goes to live with a relative or a family friend for a while, often in an informal arrangement that does not involve the courts or legal action. This is not foster care, because the child is not a “ward of the state.”
Foster care typically enters the picture when an untenable home situation comes to the attention of the police or a state agency such as child protective services (Schor EL Pediatr Clin North Am 1988;35(6):1241–1252). Sometimes, the parents call the authorities because they are concerned for their child’s well-being. Other times, someone else such as a teacher, physician, mental health worker, or neighbor reports concerns. When the situation is dire, police respond to a complaint and are dispatched to the home, often with a social worker. The child may then be taken into temporary protective custody with an organization such as a state’s department of social services or children’s shelter care system for 48–72 hours. After this, there is a confusing set of hearings that will vary from state to state. During these hearings, the child might be living with a temporary foster family or in a group home.
There are various reasons psychiatrists might need to know about this process. First, as a mandated reporter, you may be the one who contacts child protective services because of concerns about a child’s safety. Second, you may be asked to do an evaluation over the course of the hearings to determine whether placement outside the home is in the best interest of the child. If it is decided that the child should be returned to the current home environment, you may be asked to complete a reunification readiness assessment. Third, if you end up treating the child, some of the first records you review will be reports detailing the outcomes of the hearings.