CCPR: One of the things that we can do is refer to a skills trainer, and it sounds like that might be something that should be considered for new placements very soon in the process.
Dr. Berrick: Yes. Whether the child is moving into a kinship home or a non-kinship home, they are moving into a new household, and that movement in and of itself can be an unsettling process. Add to that the child’s experience coming from a traumatic situation. So providing that assistance early on, before behaviors are established, and before parenting practices that are ineffective have become routinized and regularized, is very important.
CCPR: Please tell us about reunification.
Dr. Berrick: We have a strongly held philosophical belief in the United States that children should be raised by their birth parents, and that parents have a right to raise those children as long as they are doing that safely.
CCPR: Do they, in fact, do better raised by their birth parents?
Dr. Berrick: That is a difficult question for the research community to answer, mostly because we cannot randomize children. We can’t take 100 children who are being severely maltreated and randomly assign some of them to foster care and randomly assign some of them to stay with their parents. Similarly, we can’t randomly send some home, and keep others in care. So until we develop better research skills, we are going to be a little bit challenged to answer that question. Nevertheless, we do have a couple of studies we can point to that seem to show that when children are reunited with their birth parents, we are typically reunifying them with caregivers who are extraordinarily vulnerable themselves. These parents typically have multiple problems in multiple domains. They might have issues relating to homelessness, mental illness, substance abuse, and physical disabilities.
CCPR: Is the system designed to ensure that parents have resolved these problems before children return to them?
Dr. Berrick: Although we like to think that the children who are reunified are returning to parents who have addressed many of those issues, we know that many of these parents’ recovery or rehabilitation is fragile. And the child welfare system in the United States is not a rich service system where, when children are reunified, a variety of saturated services follow them home. So many of those children are reunified to homes where the birth parents need to attend to their children’s upbringing largely without a great deal of government support. And children who return to their birth parents often do struggle. One study found that some children who reunified actually were more likely to engage in risk-taking behaviors and had more internalized problems, according to a standardized rating scale, than those who stayed in long-term foster care (Tuassig HN et al, Pediatrics 2001;108(1):E10).
CCPR: How can we as the children’s psychiatrists best support a longer term reunification plan?
Dr. Berrick: By using the exact same strategies that we use with kin and foster parents. Birth parents need just as much coaching as foster parents. So it is the same issue of coaching, thoughtful feedback, and opportunities to practice new parenting skills over and over again until the parenting practices get regularized and parents have more natural inclinations to parent effectively, rather than falling back on old routines that were probably less effective.
CCPR: How is policy structured to balance the right of a child to live in a safe home with the rights of parents to raise their children?
Dr. Berrick: That is the 6 million dollar question. How in the world do we craft family policies that are fair and appropriate to children, given their vulnerabilities and their limited rights? Then you put that up in sharp relief against parents who want to parent their kids, and who have some constitutional rights to do so. That’s the fascinating intellectual terrain of child welfare. Figuring out how to balance the rights and needs of parents and children is very tricky business.
One of the things that we are learning about foster care is that it is malleable to coaching.
~ Jill Duerr Berrick, PhD
CCPR: How can we as doctors best advocate on a public policy front for children to be protected enough, when it seems like there is no agreement on what “enough” is?
Dr. Berrick: I feel pretty optimistic in that regard. At the same time you have these political winds that push the conversation toward a parent’s rights perspective, there is also a developing understanding of child development and child psychiatry. Your field is at the forefront of this growing understanding of the neuro-biobehavioral connection between child maltreatment, child trauma, and effects on children that are both physiological and psychological, and that are both short-term and long-term. The more we can unpack those components to better understand what maltreatment’s effects can be on children, the less tolerance we as a society will have for maltreatment. And I think that that will help to propel additional prevention services and treatment services, it will help average Americans parent all children more thoughtfully, and it will help to change the conversation to center it on children and their rights to a safe childhood.
CCPR: Thank you, Dr. Berrick.