Foster Care Info Sheet Aota

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Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth

Foster Care
OCCUPATIONAL PERFORMANCE OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children
How might time in foster care influence and youth participate in what they need and/or want to do in order to promote physical and
occupational participation?
mental health and well-being. Practitioners focus on participation in the following areas:
While each individual will demonstrate their own unique
strengths and needs, living in a home that is deemed “un- education, play and leisure, social activities, activities of daily living (ADLs; e.g., eating,
safe” creates an atmosphere for adversity and stress dur- dressing, hygiene), instrumental ADLs (e.g., meal preparation, shopping), sleep and rest,
ing critical developmental periods. Children in foster care
and work. These are the usual occupations of childhood and young adulthood. Task analysis
may be challenged in the following areas of occupation.
Social Participation
is used to identify factors (e.g., sensory, motor, social–emotional, cognitive) that may limit
• Difficulty expressing emotions in a healthy way successful participation in these areas across various settings, such as school, home, and
• Social cognition limitations, including difficulty under- community. Activities and accommodations are used in intervention to promote successful
standing perspectives, and analyzing and responding
to different social situations
performance in these settings.
• Difficulty self-regulating and controlling inhibitions (Lewis,
Dozier, Ackerman, & Sepulveda-Kozakowski, 2007) WHAT IS FOSTER CARE? PROCESS, PREVALENCE, AND EMERGING OT ROLE
• Inappropriate boundaries with respect to personal space According to Title IV-E of the Social Security Act, foster care provides safe and stable
• Difficulty forming healthy attachments with family,
teachers, and peers out-of-home care for children until the children are safely returned home, the children
Activities of Daily Living (ADLs) are placed permanently with adoptive families, planned arrangements for permanency
• Limited independence in ADLs, skills are often not are made, or the children age out of foster care (Child Welfare Information Gateway, n.d.;
commensurate with age
• Delayed hygiene awareness
Social Security, n.d.). While year-end statistics indicate that more than 400,000 children
• Sensory processing impairments that impact engage- reside in America’s foster system, more children than this enter and exit foster care at some
ment in ADLs point during the year. For example, 640,000 children resided in foster care at some point in
• Difficulty accepting ADLs training from “new” caregivers
2012 (Child Welfare Information Gateway, n.d.). On September 30, 2015, 35% of children
Education
• Increased risk of absenteeism from school (Zorc et
in foster care had been there for 6 to 17 months, and 36% of children had been in foster
al., 2013) care for longer than that. If a permanent home is not found, a child will age out of the
• Varying impact of birth family visits on academics foster care system between 18 and 21 years, depending on the state. Meanwhile, it is impor-
(Fawley-Kinga, Traska, Zhang, & Aarons, 2017)
• Increased rates of grade retention and high school
tant to consider the approximately 205,000 children who do not remain permanently in
dropout (Scherr, 2007) foster care but were removed from a home that was deemed “unsafe” (U.S. Department of
Instrumental ADLs (IADLs) Health and Human Services, 2016).
• Age-inappropriate IADLs (e.g., children becoming the Children enter foster care because of caregivers’ inability to meet the child’s basic living
primary caregiver for younger siblings)
• Lack of modeling and teaching in higher-level house- and health needs. A precipitating factor may include caregiver abuse (e.g., sexual or physical);
hold management tasks unsafe living conditions (e.g., illegal drugs and alcohol abuse by caregivers); and caregiver
• Decreased knowledge and skills for independent living neglect (e.g., physical, psychological, emotional, and medical) or abandonment. Many of these
concepts of money earning and money management,
health care management and maintenance, and proper children may also experience prenatal exposure to toxins, thus compounding their vulnerability
safety procedures and emergency management with a combination of prenatal stress and early childhood abuse and neglect (Charil, Laplante,
Play/Leisure Vaillancourt, & King, 2012). After separation from their biological family, children tend to
• Lack of play modeling and engagement prior to the
child entering care
experience multiple foster placements (Newton, Litrownik, & Landsverk, 2000). Continual
• Lack of time and opportunity to play due to constraints of disruption of living situations results not only in a change of family and home environment,
meetings, counseling, and birth-family visits but also changes in school, community, worship, and daycare environments. Such instability
• Fear of being outside or in play environments because
of past experiences; some children experience “sea-
in placement may adversely impact social emotional development (Rubin, O’Reilly, Luan, &
sonal” avoidance of play and leisure activities due to Localio, 2007). Any child who is removed from a home and placed, even briefly, into the foster
the trauma triggers associated with seasonal changes care system is at risk for limitations in typical daily living opportunities of childhood, which
• Decreased opportunity to engage in extra-curricular
activities
may impact lifelong health and occupational well-being. For any child experiencing foster care
• Little exposure to, and often ensuing hesitancy to even a single time, issues including caregiver incompetency, diminished child capacity, and
participate in, healthy leisure system inefficiencies reduce the potential for occupational justice (Cross, Koh, Rolock, & Eblen-
Sleep/Rest Manning, 2013). The impact of early adversity, trauma, and disruption to living situations
• Bed wetting and incontinence
• Challenges with sleep onset latency (due to sensory
experienced by these children negatively impacts their overall health and well-being (Anda
problems, fear and anxiety, etc.) and overnight sleep et al, 2006; Nelson, 2012). The impact of occupational injustice, early adversity, and chronic
disruption (due to nightmares and night terrors) trauma on youth in foster care may create impairments in areas including cognition, social
• Sensory processing difficulties limiting ability to
self-regulate and to tolerate the sensory aspects of
skills, self-regulation, and emotional and physical well being, leaving these adults ill equipped
co-regulation to prepare for sleep
Continued on page 2.

Developed by Amy Lynch, PhD, OTR/L; Rachel Ashcraft, MS,


OTR/L; Amy Paul-Ward, PhD, MS, OT; Lisa Tekell, OTD, OTR/L;
Arezou Salamat, MOT, OTD, OTR/L; and Sandra Schefkind, OTD,
OTR/L, FAOTA, of AOTA’s School Mental Health Workgroup.

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx


Occupational Therapy’s Role in the Foster Care System

for employment, maintaining a household, managing finances and healthcare, and sustaining relationships (Child Welfare Information Gateway,
n.d.). The occupational injustice experienced translates across generations, as youth in foster care are three times more likely than their peers to
become pregnant and attempt to find redemption in parenting their own offspring, despite their lowered parental readiness and skill (Dworskey
& Courtney, 2010). Occupational therapy practitioners are emerging in the field of early adversity and foster care as much needed providers,
offering a distinct approach to promoting permanency and stability for youth who have experienced foster care (Lynch, 2016; Schefkind, Newell,
Ashcraft, & McCown-Lucas, 2015).

OCCUPATIONAL THERAPY’S ROLE IN THE FOSTER CARE SYSTEM


The distinct value of occupational therapy within the context of foster care is to promote everyday participation in meaningful occupations at
the universal, targeted, or intensive levels of intervention (Paul-Ward & Lambdin-Pattavina, 2016).
Occupational therapy practitioners can support both the physical and mental health needs of children in the foster care system. They are
key team collaborators, supporting and remediating the development of motor, social, cognitive, self-regulation, and sensory skills. Practitioners
can advocate for system and individual programming to support the needs of children impacted by unsafe homes in early life, and to develop
programs to prevent the scaffolding effects of long-term foster care. A client-centered occupational therapy approach that focuses on motivation,
fun, and engagement supports these children in developing skills for independence in ADLs and IADLs, play, leisure, and overall wellness and
satisfaction in independent living.

Universal — This level of intervention includes partnering with child welfare agencies, fam-
ily safety preservation systems, schools, and residential treatment facilities. At this level, occu-
pational therapists may consult with agencies and systems; meet with administrators; develop Learn more about occupational
screening resources for occupational engagement; and develop programming and environmental therapists’ role within an
modifications that match the needs of a child from foster care to promote access to developmen- interdisciplinary trauma-informed-
tal, academic, life skills, and leisure opportunities within the community. care approach to treatment
https://www.aota.org/~/media/
Targeted — At this level, strategies may focus on developing programs and services for children
in the foster care system or who are at risk for disruption within their biological family. An occupa- schoolmhtoolkit/childhood-trauma.pdf
tional therapy focus may include training and providing in-services to places such as schools, places
of worship, clinics, and welfare agencies demonstrating the distinct value of occupational therapy;
along with clinics or community-based screenings for children in foster care to identify those who Did you know? “Nearly 25% of
may need additional evaluation by an occupational therapist. Practitioners may partner with child children in foster care experience
welfare agencies to provide training and education parenting classes for both birth families seek- post-traumatic stress disorder
ing to regain custody of their child and foster families working to understand the unique needs of (PTSD). This is double the rate of
PTSD experienced by individuals
foster children and strategies to help these children succeed in their homes. Additionally, practitio-
active in military deployments, and
ners can be instrumental in the planning, delivering, and evaluating occupation-based transitional more than six times the rate of the
programs in which youth transitioning out of foster care become successful by doing (Paul-Ward general public” (Deutsch et al., 2015,
& Lambdin-Pattavina, 2016). Practitioners can implement attachment-based, trauma-informed p. 293).
program principles to build healthy relationships. In so doing, a stronger therapeutic alliance foun-
dation develops, thus ensuring that children engage in meaningful occupations so they feel safe and
supported (Purvis, Cross, Dansereau, & Parris, 2013). Occupational therapy practitioners can col-
CHECK THIS OUT!
laborate with others, developing community programming that promotes opportunities for social U.S. Department of Health and Human
activities, play, and leisure interactions to reduce the impact of foster care on lifelong maladaptive Services
activity choices, such as drugs and alcohol use (Pears, Kim, & Fisher, 2016). Targeted interventions www.mentalhealth.gov/
improve placement stability and overall long-term well-being for children and youth in foster care
National Institute of Mental Health
(Fisher, Kim, & Pears, 2009).
https://www.nimh.nih.gov/index.shtml

Intensive — Individualized occupational therapy services for children in care from birth through National Alliance on Mental Health
https://www.nami.org/
ages 18 to 21 may occur within various environments, including the foster home, home environ-
mentalhealthmonth
ment pre- and post-reunification, daycare, school, welfare agency, or other natural environments
for the individual. Practitioners advocate for individual children’s needs at individualized education Substance Abuse and Mental Health
program (IEP) meetings to ensure the school understands that the potential impact of trauma and Services Administration
https://www.samhsa.gov/children
Continued on page 3.

Developed by Amy Lynch, PhD, OTR/L; Rachel Ashcraft, MS,


OTR/L; Amy Paul-Ward, PhD, MS, OT; Lisa Tekell, OTD, OTR/L;
Arezou Salamat, MOT, OTD, OTR/L; and Sandra Schefkind, OTD,
OTR/L, FAOTA, of AOTA’s School Mental Health Workgroup.

Copyright © 2017 by The American Occupational Therapy Association, Inc.


Occupational Therapy’s Role in the Foster Care System

foster care on the child’s performance warrant special supports in school, including individualized occupational therapy services. Individu-
alized services may also relate to developing parenting skills for birth parents hoping to re-gain or maintain custody of their children, or
extended birth family members seeking temporary or permanent custody of children. Individual services for infants, toddlers, and elemen-
tary aged children include: training in and development of age-appropriate skills for completing ADLs, participating in education, devel-
oping skills for engaging in social groups in the school, improving motor skills, and learning self-regulation skills to support participation
in school and community activities (e.g., sports and recreation programs). Occupational therapy practitioners can also collaborate directly
with teachers to help teachers better understand the unique relationship challenges for children in foster care and the impact of positive
relationships on academic performance. Practitioners can develop individualized learning and social strategies to improve the student’s
performance in the classroom. Therapists can develop social groups to promote play (Fabrizi, Ito, & Winston, 2016) and engagement with
caregivers, peers, and teachers. Individual services for adolescents aging out of foster care or emancipated may include evaluation (includ-
ing conducting a thorough occupational profile), and occupation based interventions in the areas of managing finances; managing and
maintaining one’s health; parenting; establishing and managing a home; preparing meals and cleaning up; creating safety and emergency
plans; shopping; pursuing an education; identifying employment interests and pursuits; as well as seeking, acquiring, and maintaining
employment. Occupational therapy practitioners can assist in training individuals on work skills to increase their employment potential
(Pecora et al., 2006). They can also assist youth transitioning out of foster care to develop future goals and skills needed to achieve them
(Paul-Ward & Lambdin-Pattavina, 2016).

Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Lewis, E., Dozier, M., Ackerman, J., & Sepulveda-Koza- behavioral well being for children in foster care.
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