Dr. Berrick: Good foster care looks a lot like good parenting, and more. We know a lot about strong, effective parenting from a large body of literature over many decades. We know that children do well when they are raised by parents who are intentional in their parenting, who are proactive, provide prosocial role models for their children, and who are nurturing, loving, responsive, and sensitive. And we know that those same characteristics that lead to better outcomes for children in the general population also are extremely important for children in foster care.
CCPR: But the average child in foster care may be very different than the average child being raised by their parents.
Dr. Berrick: Yes, the average child in foster care is very different than the average American child by a couple of important characteristics. They are more likely than children in the general population to have experienced significant physical abuse, sexual abuse, or neglect (Stambaugh LF et al, Adverse childhood experiences in NSCAW. OPRE Report #2013-26. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families; 2013). These are deeply traumatic experiences, because children experience these harms from the people who they see as their primary love objects, as their principal caregivers, and as their physical protectors.
CCPR: And does this result in a greater incidence of mental health problems in these children?
Dr. Berrick: Yes, this can result in emotional difficulties, instability, and mental health issues that can go the spectrum from mild to severe. We also know that children in foster care exhibit both internalizing and externalizing problems at much higher rates than we see in the general population. In addition to these emotional and mental health concerns, you also typically see health problems from chronic to acute conditions at rates that are much higher than what you would see in the general population, and foster children are more likely to have developmental delays compared to an average American child population (Vandivere S et al. Children in foster homes: How are they faring? Research Brief, Publication #2003-23. Washington, DC: Child Trends).
CCPR: So all of these concerns mean foster parents have to be able to deal with even more than the average parent.
Dr. Berrick: This accumulation of vulnerabilities makes the parenting challenges associated with these children that much more difficult. It means that you are looking for caregivers who not only have the capacity to parent just as any typical American parent would, but you are also looking for caregivers who have the capacity to parent children effectively who have mental health conditions, sometimes coupled with physical health conditions, sometimes coupled with developmental conditions.
CCPR: Tell us about kinship care. Is this the ideal?
Dr. Berrick: The pros of kinship are that the caregiver is related to the child, and they probably feel a sense of family obligation to care for the child. They are probably known to that child, so moving to that household may not be a traumatic experience. In addition, the child may have already spent a good portion of their life in that household. It means the children get to carry with them their language, their heritage, and their family story. And we know that those are really critical scaffolding for children to use as they grow up and understand who they are in the world.
CCPR: What are the particular challenges to kinship care?
Dr. Berrick: On average, kinship caregivers are more socially disadvantaged than the typical American household (Ehrle J & Geen R, Child Youth Serv Rev 2002:24(1-2):15-35). They may not have a strong educational background and may be very low income. Whereas kin provide children with what we call “social bonding”—meaning they create opportunities for children to have connectivity with their family and with their identity—some kin may not be able to provide children with “social bridging.” This is related to caregivers providing the opportunity point that children need to move into the world with a greater degree of social capital. Kinship caregivers can be very effective, but sometimes they need a lot of additional support from social service providers who can help develop some of those skills and talents that kin may not necessarily have in their existing parenting repertoire.
CCPR: This is where child psychiatrists may come in. Is more parenting coaching and education the best way for us to support kinship care placements?
Dr. Berrick: Absolutely. One of the things that we are learning about foster care is that it is malleable to coaching. I use the word coaching instead of training or education because those look a lot like sitting in a room and listening to somebody. Coaching is one-on-one assistance in the micro-moments of parenting. So the psychiatry community may be able to do coaching in the clinical setting. This can be done by posing parenting challenges and opportunities to caregivers and their children in vivo. And giving coaching opportunities and recommendations in the moment that then caregivers can practice until they develop a new repertoire of skills.
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.