Psychologists work to support children and parents in the child welfare system, but more is needed

Nearly 400,000 children and teens are living in limbo within the U.S. child welfare system—waiting to be adopted, return to their family of origin, or find some other permanent home (The AFCARS Report, No. 29, U.S. Department of Health and Human Services, Administration for Children and Families, 2022)opens in new window.

By definition, they have virtually all experienced some form of trauma or neglect, with up to 80% meeting criteria for a significant mental health issue (Rosen, D. S., et al., Pediatrics, Vol. 136, No. 4, 2015opens in new window). Many kids also face trauma within the system, including separation from caregivers, court involvement, moving from one foster home to the next, and even further abuse or neglect.

Despite these extraordinary challenges, kids in foster care can thrive and lead healthy lives with the right help at crucial junctures—and mental health providers play a key role in that healing. Though services vary by state and county, many focus on repairing attachment and relationships, often with the goal of reuniting children with their biological parents or getting them settled with an adoptive family.

“All children need protective, supportive, and emotionally responsive relationships in order to thrive. That seems simple, but those relational components should be at the center of the help we provide to children in foster care,” said Michael Lawler, PhD, president of Pacific Northwest University of Health Sciences in Yakima, Washington, who has worked in the child welfare system as a service provider, researcher, and policy developer.

Mental health professionals also support other crucial players in children’s lives: biological parents, many of whom are coping with addiction or mental health issues of their own, and foster parents, who may struggle to manage the behaviors and needs of the kids they take in. The interdisciplinary field includes everyone from psychologists, social workers, and educators to occupational therapists and pediatricians.

“These kids are among the most vulnerable in our society,” said psychologist Audra Langley, PhD, a professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles (UCLA) and the director of UCLA Treatment, Intervention, Education, and Services (TIES) for Families,opens in new window an interdisciplinary program that serves children in foster care in Los Angeles and their families. “Giving them access to psychologists who really understand trauma, development, identity, and culture is critical.”

Most children enter foster care because they have faced severe abuse or neglect by a parent or guardian, with a large number removed from homes because of parental drug use (Meinhofer, A., & Angleró-Díaz, Y., JAMA Pediatrics, Vol. 173, No. 9, 2019opens in new window). About 80% move into a foster family home with either a relative (“kinship care”) or a nonrelative (“foster parenting” or “resource parenting”). Others live in a group home or, for some older adolescents, in supervised independent housing. In the majority of cases, the aim is to reunify with one or more biological parents or primary caregivers. For about one third of cases, adoption is the ultimate goal (The AFCARS Report, No. 29, U.S. Department of Health and Human Services, Administration for Children and Families, 2022opens in new window).

A lot is at stake for kids in foster care. Young children who miss out on early social interaction often have cognitive delays, impulse control issues, and trouble communicating. Those developmental setbacks can eventually multiply and hinder learning and achievement at school. Neglect and abuse also disrupt the stress response and may lead to chronic stress, which can cause mental health problems such as anxiety and depression and increase risk for long-term cardiovascular, metabolic, and other physical health issues (Mental and Behavioral Needs of Children in Foster Care, American Academy of Pediatrics, 2021opens in new window).

Some services focus on the prevention end of the spectrum, aiming to support positive development in foster kids before significant emotional, behavioral, or developmental problems arise. In Colorado, Fostering Healthy Futures (FHF)opens in new window provides weekly skills training, led by psychologists and social workers, and one-on-one mentorship to children, ages 9 to 14.

The 30-week intervention, directed and developed by Heather Taussig, PhD, helps kids work through the challenges of foster care while forming a close bond with an adult mentor. For example, one week’s skills training might teach kids about coping with change and loss, while their mentor helps them explore how grief shows up at school and practice applying their new skills. Mentors also plan fun activities—a game of basketball, a trip to the movies—and help their mentees create a “life book” that chronicles their past and hopes for the future.

“For many of these children, it’s the first time somebody has asked them to tell their story in a way that’s not diagnostic,” said Lindsey Weiler, PhD, LMFT, an associate professor in the Department of Family and Social Science at the University of Minnesota who has conducted research on FHF. Two randomized controlled trials have shown that participation in the program reduces both trauma symptoms and juvenile justice involvement (Taussig, H. N., et al., American Journal of Community Psychology, Vol. 64, No. 3–4, 2019opens in new window; Prevention Science, Vol. 22, 2021opens in new window).

While in foster care, most kids are required to attend therapy, but those services are not always sufficient to meet their needs, said Saralyn Ruff, PhD, LMFT, an associate professor and director of the Foster Care Research Group at the University of San Francisco.

“When they were 16, therapy was mandated. Now that they’re 21, they may want it but don’t know how to access it or no services are available,” she said.

Ruff is a research consultant for A Home Within,opens in new window a nationwide organization that offers free weekly one-on-one psychotherapy to current and former foster youth “for as long as it takes” to heal. She and her colleague Deanna Linville, PhD, LMFT, are conducting a community-based needs assessment on the effectiveness of therapy in child welfare settings, which has been submitted for publication in 2023. They interviewed current and former foster youth, foster parents, case managers, therapists, and clinical directors (Children and Youth Services, Vol. 143, 2022opens in new window).

One major takeaway: Current outcome measures used to evaluate the effectiveness of mental health services—typically a decrease in service use—may not fully capture kids’ experiences. In contrast, increased help-seeking may be a better indicator of progress, said Ruff. Maintaining healthy relationships (with family members, friends, partners, and therapists) is another important measure of success in this population.

Foster youth also reported that when they first entered therapy, they often weren’t ready to open up about trauma. Many were still navigating the foster care system and major daily challenges such as food and housing insecurity.

“When you’re on the streets and you’re trying to figure out where you’re going to sleep that night, therapy is not what’s most important,” said Linville, the executive and clinical research director at the Center for Transformative Healing in Eugene, Oregon.

In contrast to often rigid state-mandated therapy, foster youth also want more of a say in setting goals that matter to them and access to therapeutic approaches that feel relevant, including somatic therapies such as eye movement desensitization and reprocessing and brainspotting. Foster youth also want the opportunity to choose or match with a therapist who has a shared identity or lived experience with the child welfare system, the researchers found.

The need to heal attachment and relationships leads many service providers to deliver therapies that treat both foster children and parents, biological or otherwise (Lawler, M. J., et al., Children and Youth Services Review, Vol. 33, No. 3, 2011opens in new window).

In Dallas, the Rees-Jones Center for Foster Care Excellenceopens in new window at Children’s Health uses an integrated care model to weave trauma-informed psychoeducation, parenting skills training, and other mental health care supports into primary-care visits. They also offer specialized care, including psychological assessment and trauma-informed treatments (Lamminen, L. M., et al., Practice Innovations, Vol. 5, No. 1, 2020opens in new window).

For foster kids and teens, adjusting to a new home with different rules and routines is nearly always difficult. Meanwhile, situations and behaviors that can be common in a chaotic household—staying up late, lack of structure, hoarding food—can present challenges for foster parents. They may need help understanding such behaviors as adaptive and learning how to respond.

To support this transition, the Rees-Jones Center uses a variety of interventions, including parent-child interaction therapy (PCIT), a pair-based intervention for parents and children, ages 2 to 6, which aims to decrease challenging behaviors and improve attachment and bonding. While the parent and child interact, a therapist coaches the parent on how to respond to various behaviors.

“When you’re in the thick of it, acclimating to this new setting, you’re going to see more behavioral outbursts. It’s exhausting for our caregivers, so an intervention like this can really help,” said Laura Lamminen, PhD, ABPP, a pediatric psychologist and associate professor who leads behavioral health program development at the Rees-Jones Center.

PCIT, as well as other dyadic treatments such as child-parent psychotherapy, can also help reestablish a secure bond between children and their biological parents. In some cases, those treatments are required by child welfare agencies as part of the family reunification process.

“Parents of children in foster care often themselves come from disrupted attachment relationships,” Lawler said. “Working with a child and parent together allows us to help both generations heal.”

Psychologists not only deliver trauma-informed treatments, they also help train parents to see children’s behavior as adaptive strengths rather than simply problematic, Langley said. At UCLA TIES for Families, the Preplacement Education and Preparation (PREP) program trains prospective foster parents from a culturally competent, trauma- and healing-informed perspective. PREP covers topics such as understanding trauma and addiction as a way to build empathy for birth parents, answering children’s difficult questions in a developmentally appropriate way, temperament and attachment, common medical issues, and grief and loss.

“When a child joins a family’s care, it can be a time of vulnerability,” Langley said. “We also see it as a time of opportunity to understand children’s behaviors and reactions in the context of their experiences.”

For children who cannot reunify with their families of origin, UCLA TIES for Families partners with the Los Angeles Department of Children and Family Services to offer a preplacement multidisciplinary consultation that can help inform child welfare placement decisions. The assessment includes a thorough review of psychological health, medical records, developmental history, and educational outcomes, creating a comprehensive picture of a child’s strengths, challenges, and needs.

Because of the unique challenges of foster parenting, family-to-family support also holds tremendous power. Most of the staff and board of Formed Families Forward (FFF),opens in new window a Virginia nonprofit that supports foster, kinship, and adoptive families raising children with special needs, have lived experience in foster care and other public systems.

FFF offers a combination of peer support, parenting classes, family events, and educational consultations to families of children with mental health issues and other disabilities. Last year, more than 1,000 parents and professionals attended training sessions led by clinical psychologists and other experts. Topics include navigating special education services at school, helping students with disabilities transition from high school to higher education, how to care for children with fetal alcohol spectrum disorders, and more. FFF also offers a peer support group for parents and caregivers—one of their most popular offerings.

“Every foster care, adoptive, or kinship situation is different, but all cope with the impact of loss, grief, and broken family connections,” said Kelly Henderson, PhD, FFF’s executive director.

Among foster kids, children who are Black or Native American are significantly overrepresented, leading growing numbers of researchers, practitioners, and activists to regard the child welfare system as racially biased and overly punitive. For that reason, some experts are shifting their focus to the structural factors—including poverty—fueling the cycle.

“A lot of kids are caught in this system, not necessarily because their parents have abused them, but because their parents were deemed by the system as too poor [to care for them],” said Abigail Williams-Butler, PhD, an assistant professor in the School of Social Work at Rutgers University in New Jersey. Williams-Butler, a developmental psychologist and social worker, studies how the intersection of race, gender, and class affects Black children and families involved with the child welfare system. “If we provide better support to biological parents, maybe we don’t need to take so many kids away.”

Some community leaders aim to abolish the child welfare system and reinvest its economic resources in biological families. In New York, Just Making a Change for Familiesopens in new window is campaigning to end the system in its current form. Others are pushing for change within the existing model, including by recruiting and supporting foster families of color. To bolster those efforts, AdoptUSKids,opens in new window part of the Adoption Exchange Association, recommends hiring diverse foster parent recruiters, improving communication with prospective foster families, and connecting with foster parents through social media.

“Much like nearly every institution, we don’t properly represent the communities we serve,” Lawler said. “We need more psychologists, social workers, and foster parents who look like the children in foster care.”

Psychologists, social workers, and other helping professionals can help reduce inequities in foster care by documenting and calling attention to the system’s inherent bias, Williams-Butler said. There’s also plenty of room for psychologists with varied expertise—clinical, community, developmental—to create and adapt assessments and interventions, evaluate outcomes, and aid in the prevention and treatment of mental health issues among children in foster care, said Langley. High-quality training programs that allow psychologists and other professionals to specialize in child welfare are an important piece of the puzzle, Lamminen said.

A greater investment in this population would be a boon to the field, helping psychologists fulfill their professional commitment to aid those in society with the greatest need.

“It’s important for us to think about how we can develop future psychologists who are part of child welfare prevention and intervention,” Langley said, “both because we have something to add, but also because we have something to gain.”