Working Systemically with Children In Foster Care

Initial interview with Ken

Ken, a 14 year old, was removed from his home by the Department of Children and Family Services (DCFS).

Systemic clinician: Hello… (introduce names, roles and purpose of today’s session). As you know, DCFS has contacted me and asked if I would meet with you to talk about DCFS’s involvement in your family. What I would like to do in the next hour is to get a clear picture of how they became involved in your family, in your own words. I would like to know what it’s like to be in your situation. Is that all right with you? Do you have any questions of me before we start?

(Reply as necessary.)

From what I’ve read, you tried to harm your mother and younger brother. In addition, your mother has terminated her rights to be your parent. Could you tell me what happened?

Ken: She made me mad, so I hit her. My brother tried to block my punch, so I hit him, too.

Foster care overview

According to the 2020 data from the Adoption and Foster Care Analysis and Reporting System, 407,493 children were in the system. The number who exited the system during the same year were 224,396. Exiting means that the children were reunited with their family of origin. States differ with respect to age limits with 18 years old being the mean. The mean stay in foster care is 8.4 years as of September 30, 2020 (The Administration for Children and Families, 2022).

Based on preliminary data, on an average day, there were approximately 7,700 children and young adults in foster care. Fewer children were in foster care during 2021, including 2% fewer children entering care and 7% fewer children experiencing care at all compared to 2020 (The Administration for Children and Families, 2022).

What the children have in common is that every attempt is made to reunite children with their families of origin. What may differ is the number of placements before reunification. The nature of the placements can mean foster care home or residential treatment facilities. And, in certain cases, whether, in fact, reunification is deemed by the state to be in the best interest of the child. State agencies are often referred to as Departments of Children and Family Services.

Ways to think about foster care children are the following themes taken from the writer’s experience as a Guardian ad Litem, what vexes them or impacts their ability to function fully at home, in school, and in their community:

• I must be perfect because if I’m not, my foster parent will send me to another home.
• I must please others because, if I don’t, my foster parent will send me to another home.
• Adults can’t be trusted, because when I trust them, they leave me just as my parents did.
• Nobody should like me because I’m a bad kid. I’m just not good enough.
• I keep my distance from others because that’s what they do to me.
• It doesn’t matter whether I’m good or bad. I’m not in control of anything in my life, including what I eat, where I sleep, whom I play with.

Most interventions have not been evaluated in community-based settings with children in foster care (Hambrick, Oppenheim-Weller, N’zi, & Taussig, 2016). This article explores working with foster care children and their families using a systemic clinician lens, how to screen and assess children and their families in foster care, how to work with them in treatment, and highlights some of the benefits of systemically treating children. We shall explore how a systemic clinician can add foster care to existing specializations.

Screening and assessing children and families in the foster care system

Sarah Fay (2022), in her book, Pathological: The True Story of Six Misdiagnoses, offers a critique of the flaws of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) with a conclusion that the DSM is based largely in fiction (Fay, 2022). Despite her critique and those of others, a court/DCFS does not mandate providing ongoing therapy without seeing some evidence that the issues it finds to be problematic are being addressed.

At a macro level, systemic clinicians need to consider court/Department of Children and Family, and Licensing Board requirements when selecting assessment tools in the state where they plan to work with foster children and their families. In addition, consideration should be given to reliability and validity of instruments used. At a micro level, the concern is for the development of an appropriate treatment plan that can in part account for the outcomes or lack thereof for the children and their families they plan to serve. The court/Department of Children and Family ask for accountability. They want an answer to the question: “How will your work improve children and family functioning at home, in school, in the workplace and in the relationships they form as members of their community?”

Interview with Ken at the completion of the initial assessment.

Systemic clinician: Ken, I appreciate your patience in filling out all the questionnaires that I ask you to complete. As you might expect, I asked your mother to complete some, too. In addition, I consulted with the staff at XYZ home for boys and they completed some, too. What did you think when you finished completing the questionnaires? What stood out for you?

Ken: I’m guessing that my inability to control my anger was one of my biggest issues. Is that true?

Treatment of caregivers and children in foster care

In some cases, the court/Department of Children and Family Services mandate who will receive therapy. For example, client(s) may include the biological parents, foster care parents, or staff members from a state-supported residential foster care home who have been charged with caring for children who have been removed from their home because of abuse or neglect. Systemic clinicians may find themselves serving intergenerational clients, that is, adult children who have had their children removed from their home just as they themselves were removed from their home when they were younger. Further, clinicians may find themselves treating a toddler now, and then as a young adult more than a decade later; i.e., foster care work across the lifespan.

Treatment goals in foster care cases are not unlike those used in other family therapy cases. For example, the systemic clinician may consider:

• Reducing the effect of a child’s misbehavior on other family members
• Learning new methods to help families achieve harmony and balance
• Helping parents feel empowered to take control of the family and react positively to children who are acting out (Dattilio & Jongsma, 2000)

Most interventions have yet to report a high level of evidence regarding what models/approaches work best with foster children.

High level means interventions that are tested in community-based settings with children in foster care (Hambrick, 2016). With this finding in mind, this writer relied on his background as a systemic clinician with 20 plus years of experience to identify and select the following models/approaches as being representative of the kind of approaches a systemic clinician may want to consider using.

For the adult population, at least three problems may need to be addressed: parenting/relational skills, domestic violence, and substance use.

Three examples of parenting skills courses include The Incredible Years Parenting Program and Parenting Choice and Parenting Inside Out (n.d.). One study found that The Incredible Years Parenting Program improved parent’s ability to decrease behavioral problems in children once reunification is underway (Bergstrom et al., 2019). Parenting Choice is another example of an evidence- based parenting program that is approved by both Department of Children and Family Services, and courts in several states (Weir et al., 2013). Results of a longitudinal randomized controlled trial of the effectiveness of Parenting Inside Out showed reduced recidivism, better parental participation, better attitude, and reduced substance abuse (Weir et al., 2013). If one of the goals in treatment is to improve the parent-child relationship, then a parenting education program is beneficial.

Parents arrested for partner violence are typically mandated to complete a course of treatment by the court. Several studies show that treatment contributes to a 5% reduction in recidivistic violence above and beyond arrest and court monitoring (Hamel, 2019).

It is generally accepted that the focus on substance use alone does not result in decreased substance use. Instead, a focus on the interdependent nature of relationships and how these benefit the individual and improve other relationships for good or ill can be effective. Extensive literature supports family-based models and the effectiveness of treatments based on family dysfunction, family systems, and behavioral family models (McGrady & Epstein, 1996). A more recent study concludes the model of choice depends on the presenting problem. For example, if the problem is centered in the marriage, then behavioral couples therapy is better. If the situation involves a family that is centered around substance use, then a family systems approach may be superior (Walitzer, Dermen, & Connors, 1999). A more recent study concluded that substance use disorder treatment practitioners should offer couple and family therapies as a standard of care option (Hogue, Schumm, MacLean, & Bobek, 2021).

Telehealth delivery

Since COVID, delivery by telehealth has expanded, and evidence to support the feasibility and effectiveness is substantial (Mucic & Hilty, 2019). Telehealth usage jumped 10% nationally in January 2022, making up 5.4% of all medical claims (Melchionna, 2022). Therapists report using a combination of in-person and online treatment of their foster care clients to this author. Such treatment may decrease client no-show rates and increase completion of goals established at the onset of treatment (PBS, 2021).

Treating foster care preschoolers and early elementary schoolers

An Adlerian Play Therapy approach with activities focusing on the expressive arts, music, kinesthetic activities, and storytelling/narrative therapy encourages foster care children to connect, and feel affirmed, in a nonpathologizing way (Eller, 2018). In an article about integrating family system theory and Theraplay  (another play therapy approach) the findings indicate that Theraplay may lead to statistically significant benefits regarding family communication, adults’ interpersonal relationships, and children’s overall behavioral functioning (Weir et al., 2013). Another study found Theraplay effective in supporting families who have experienced violence in the home (Bennett, Shiner, & Ryan, 2006). Still another study concludes that feelings of helplessness inherent in traumatic experiences tend to take precedence over safety issues in the home (Myrick & Green, 2014). A skilled systemic clinician can address presenting concerns while building healthy interpersonal skills, including boundary-setting essential in homes where safety issues exist.

Treating foster care elementary school children

Behavioral Therapy. In some states, DFCS and school districts use behavioral specialists as a starting point to deal with disruptive behavior. Used since the 1960s with children on the autism spectrum, Applied Behavior Analysis (ABA; Austim Speaks, n.d.) programs have expanded to improve social skills, decrease problem behaviors and other factors affecting a child’s functioning at school, at home, and in the community. The challenge for the systemic clinician is how to exert change on the entire caregiving system in which the child is placed. Therefore, beyond asking the “What is happening” question, the systemic clinician also asks who within the caregiving system maintains the status quo, keeping in mind the recent conclusion that treatments utilizing behavioral therapy with parents and families have strong support (Sheidow, McCart, & Drazowski, 2021).

Tweens/teens

Cognitive Behavioral Therapy (CBT) adds an understanding of cognitive distortions to the treatment of tweens/teens in foster care. This approach makes sense since many foster care children experience stressful events or situations before and perhaps during their foster care experience. CBT is a safe and effective intervention for both acute and chronic PTSD that affects the experience of children throughout their lifetime (Kar, 2011).

Gestalt Therapy (GT; Zinker, 2016) is a holistic and humanistic approach that is rooted in experience and focused on self-awareness. For tweens/teens who find talking about the past a bad experience, GT, with its focus on the present moment, can be good fit (Geralyn, 2022).

Journaling/Narrative. In many families, it is common to give the gift of a journal to a tween/teen for a special occasion. The “journal” may be a written document but could also be extended to include a camera for video story telling on a social media platform. The effects of writing have been well documented, particularly for those recovering from trauma and emotional upheaval (Pennebaker, 2013; Diamond, 2002). For example, one biological study found that writing is associated with an enhancement of the immune system (Lepore & Smyth, 2002). Psychological symptoms such as depression and general anxiety decreased in the weeks and months following journal writing (Pennebaker, 2013). Finally, a practical benefit is that students make higher grades in school following a semester of such writing (Cameron & Nicholls, 1998).

Aging out of the foster care system

Career Counseling (Brown, 2021). The world of work offers foster children a chance to experience fulfillment, meaning, and connection with others, as well as providing them with an important means of identity expression (Lent & Brown, 2013). It is obvious that foster children need help navigating the complex and ever-changing world of work, a fact which makes career counseling important. No studies provide practitioners with a detailed career counseling outline (Stevenson, 2017). Since different approaches can lead to the same benefits, systemic clinicians should at least familiarize themselves with one of three career counseling models: the self-directed search (Holland, Fritzsche, & Powell, 1994), a narrative approach (Chen, 2011) and multicultural career assessment (Flores, 2002).

Internal Family Systems (IFS), a model like others overviewed in this article, focuses on healing trauma and restoring wholeness. It assumes that as we develop, our parts form a complex system of interaction, including polarizations and alliances. Systems theory can be used to connect internal systems to external systems and vice versa (Schwartz, 2001). This approach provides foster children with a safe space to heal as they prepare themselves to transition out of foster care. IFS is based on research concluding that family based treatments seem superior to no treatment or individual-based treatments (Goger & Weersing, 2021).

Mid Treatment Feedback Session

Systemic clinician: Ken, we had six sessions since you were referred by DFCS. I’d like us to reflect on what, if anything, we have accomplished. What, if anything, we have done in our sessions have you found helpful?  

Ken: When we talked about giving myself permission to take a personal time out, I found that helpful. Now I go to my room when I’m feeling confused or upset.

Therapist: Could you tell me more about how you figured out to go to your room when you find yourself getting upset?

Ken: When I was younger I would …

Benefits of treating children in foster care

At the beginning of this article, several important beliefs were disclosed by children in foster care. As a result, using the interventions identified and described, children in relation to a “village” of caregivers will:

• Reduce their need to be a perfect child
• Decrease their need to please others
• Increase their ability to determine the difference between persons who are safe and persons to avoid
• Increase their ability to see themselves as having both positive and negative parts, and that there are no bad parts
• Decrease their need to be diffident with everyone they encounter
• Reduce their need to exercise control over each aspect of their life.

Underrepresented populations

This article did not cover the needs of LGBTQIA children, immigrant children, disabled children, and other children who find themselves in foster care. In addition, in states with indigenous people, systemic clinicians need to be mindful that this population has its own rules and regulations which need to be considered. Systemic clinicians will want to seek additional education and training if they are serving foster care children not discussed here.

Termination interview

Systemic clinician: Ken, as you know this is our final session. As you think about your plans, as a person, as a person in a relationship, as a person in the world of work, what do you see as your strengths and areas you continue to find worrisome? 

Ken: Bottom line, I am more confident about … and less worried about …

Expanding your practice to become a foster care provider

One way for systemic clinicians to break into the foster care market is to engage in foster care related activities in their community, such as attending fund raisers, providing foster care to a child, adopting a child, and becoming a Guardian ad Litem/CASA volunteer (National CASA/GAL Association for Children, (n.d.). Eligibility varies among the states and most have training program/certification that volunteers are expected to complete. In addition to providing systemic clinicians with knowledge and skills to provide care in the best interest of children, the program provides access to local Departments of Children and Family Services, court contacts, school contacts, medical contacts, and other members of the community who serve foster children. The result is a network that would support systemic clinicians who wants to expand their practice to include this deserving population.

Final thoughts

Systemic clinicians have an opportunity to make a difference in the lives of children and their families in foster care. To do so, they need to screen and assess children and their families using relationally-oriented instruments. Once assessed, systemic clinicians need to identify and select interventions that align with the needs of children and families. It is hoped that use of a systemic/relational approach will lead to improved children and family functioning at home, in school, in the workplace, and in relationships formed as members of a community.