Addressing medical traumatic stress for children in the child welfare system doesn’t have to be complicated, and you don’t have to be a physician or psychologist to help children feel more comfortable with medical care. Most trauma informed interventions fit into activities that child welfare caseworkers and other team members do on a routine basis. The key is to understand how the circumstances of children in foster care (e.g., removal from their biological parents, past histories of abuse or neglect, or moving among multiple foster homes) may affect how they cope with medical treatment. The information that follows highlights key intervention points for addressing medical trauma among children in foster care and provides tips for helping at each point in time.
Key Points for Trauma Informed Care Interventions in Child Welfare
Note: The information offered below is for a mixed audience of professionals in both healthcare and child welfare, including resource parents
Other sections of this web site address intervening to prevent or diminish medical traumatic stress among all children who are facing health challenges or medical events (see When and How to Make a Difference,D-E-F Protocol for Trauma-Informed Pediatric Care, Key Intervention Points in Medical Care, and When and How to Refer for Mental Health Care). That information also applies to children in the child welfare system. At the same time, several unique considerations arise for these children at each of the following intervention points:
The period immediately following removal from their birth families is a particularly vulnerable time for children in foster care. Removal from biological caregivers can be traumatic for children, even if they were mistreated by those caregivers. Keep in mind that many children who enter foster care are moved suddenly from their biological homes, with little warning or explanation of the move. They are separated from all that has been familiar to them, including extended family and friends, and unsure what to expect from their new caregivers and surroundings. In short, removal from the home can be a frightening experience. As a result, children who require medical attention during this period may already be anxious and scared. Experiences that prompted removal, such as physical or sexual abuse, may also affect children’s ability to trust adults---even medical providers. Try the following strategies to help diminish or prevent medical traumatic stress among children in foster care:
- Learn as much as possible about the child’s previous life experiences prior to or during the medical visit (the child welfare social worker can help with this). Tailor the medical care approach using this information. For example, a child who has been sexually abused may need additional support and explanation during a physical examination.
- If the child is old enough, acknowledge the child’s recent removal from the home. Say that other children in this situation have felt scared or worried, and ask the child how s/he is feeling and what might help him or her.
- Use the Download the Medical Trauma Assessment and Action Form for Child Welfare Professionals to help determine whether the child is at risk for traumatic stress related to medical care
- Explain your role in the child’s life and how often s/he can expect to see you.
- Allow the child to ask questions and to control some aspects of the medical visit (for example, choosing a medicine flavor or holding a stethoscope to his or her own chest). This is particularly important for children in foster care, who often have very little control over what happens in their lives. Small gestures such as these can build trust.
- Explain possible impacts medical trauma may have on children in child welfare to the foster parent(s), increasing the ability of the foster parent to support the child’s current and ongoing needs.
Children in the child welfare system often move among foster homes, group homes, inpatient facilities, and adoptive homes. Sometimes these moves take children to entirely different neighborhoods, counties, or even states. Frequent movement can threaten the continuity of medical care and, in turn, have negative effects on the child’s ability to cope with medical issues. Here are some things to keep in mind when children change placements:
- Whenever possible, maintain the same primary care physician (PCP) throughout a child’s stay in the system. This is consistent with the “medical home model” proposed by the American Academy of Pediatrics Maintaining the same PCP allows a child to bond to that physician and the practice’s personnel, facilitates communication with the child welfare team, and prevents critical health information from being lost in a transfer to a new physician.
- If it’s not possible to keep the same PCP, identify a new physician before the child is moved and ensure that medical information is communicated to that physician.
- Meet in person or by phone with the child’s health care team and child welfare team prior to the child’s move. Be sure that all understand how to address the child’s medical needs during the transition.
- Designate a member of the child welfare team to be responsible for ensuring continuity of care and completion of follow-up appointments.
- Encourage the child to express his or her concerns about changing placements and how this may affect medical care. Give the child as much information as possible about what to expect from the move related to health care.
A child’s return to his or her birth parents or to the home of a loving relative or adoptive parent is a good thing. At the same time, exiting the system represents yet another transition that may disrupt the continuity of medical care. As with other transitions, make a plan:
- Be sure that the permanent caregiver is thoroughly familiar with the child’s medical history and needs and has demonstrated commitment to attending to those needs.
- Be sure the permanent caregiver is educated on medical trauma, including experiences and responses to medical events.
- Ensure family-centered and trauma informed interventions are in place in the permanent home to increase the child’s adaptation and also the parent’s ability to support the child’s process.
- Provide training for the permanent caregiver about the child’s medical needs. Explain and demonstrate all necessary home procedures and any medical equipment that is involved.
- Provide guidance to the caregiver until they demonstrate competency with procedures and medical equipment.
- Encourage staying with the child’s current PCP, if possible. If this is not possible, identify a new one and make an appointment before the child leaves care.
- Encourage staying with child’s medical specialists for continuity of specialty care.
- Communicate clearly to the child that the new caregiver is prepared to help them with any medical needs. Allow the child to ask questions and express concerns about leaving the child welfare system.
- Be especially mindful that older teens with medical needs or disabilities who are “aging out” of the system, or transitioning to independence without permanent caregivers, may need intensive planning around medical needs well in advance of their exit from the system. Two websites offer helpful information:
Whether it is a well-child check up or an appointment to care for an acute or chronic health issue, outpatient medical appointments with primary care providers and medical specialists can be stressful for children in foster care. For newly placed children, they may be attending appointments with unfamiliar physicians and foster parents they do not yet know well. Children in foster care may not have a regular primary care “medical home”, and may have received outpatient care in the Emergency Department. Try these suggestions for helping children cope during outpatient medical visits:
- Before the visit, talk with the child about his or her questions or concerns related to the visit, and ask what would help the child cope. If concerns are about a procedure, sometimes having a favorite stuffed animal in hand or listening to music during a procedure can help kids remain calm.
- Child welfare professionals and resource parents can talk with the health care provider about the child’s worries in advance of the appointment, and plan strategies for reducing the child’s stress.
- Plan foster parent attendance at medical appointments. It is critical for children in foster care to have a consistent, warm, supportive adult accompany them to medical appointments.
- If the foster parent cannot attend, work to identify someone else whom the child knows and trusts.
For children in foster care, coping with admission to the hospital can be especially challenging. When children are admitted directly from their biological home, there may be a Court order preventing their biological parents from visiting them and they may not yet have a foster family assigned to them. These children lack a consistent, nurturing caregiver to provide support for them while they are in the hospital. For children admitted during their stays with foster families the situation is more variable. Some foster parents may be unable to take time off work or may have other childcare obligations. Consequently, children in foster care may spend long periods of time alone while in the hospital. They may have to endure painful procedures without trusted caregivers present. All of these things may increase the child’s vulnerability to medical traumatic stress. The following strategies may help during hospital stays:
- Identify someone consistent in the child’s life who can be present at the hospital and during procedures. The child may be able to help identify this person. This could be a family member, a foster parent, a social worker, a teacher, etc.
- Assist the identified caregiver in locating services to address any barriers to their presence at the hospital. This may include transportation services, child care arrangements, etc.
- When possible, make concerted efforts to include biological parents and extended family members. When permitted by the Court to have contact with their children, biological parents can be sources of support. They can also provide medical history and will need to understand the child’s medical issues if the child is to return home. A favorite aunt, a grandfather, or some other extended family member may also be a good source of support for a child in the hospital.
Leaving the hospital can be as frightening for children in foster care as being admitted to the hospital. Children who were admitted immediately after removal from their biological homes may not know with whom they will live when discharged. They may be meeting a foster family for the first time, or they may be headed to a group living facility. As if this weren’t stressful enough, these children may also worry that their new caregivers will not understand their medical needs. They have no way of knowing whether they can trust their new caregivers to attend to their medical care. Even for children who are leaving the hospital for familiar foster families or other caregivers, several important considerations remain. A transition plan is critical. Here are some suggestions for diminishing stress associated with leaving the hospital:
- If possible, work with the child welfare social worker to identify where the child will go when discharged from the hospital. If the child will be released to a new foster family, advocate for the foster family to visit the child and begin building a relationship while the child is still in the hospital.
- Talk with the child about any concerns s/he may have about leaving the hospital. Provide as much information as possible about what to expect related to medical care after discharge from the hospital.
- Prior to discharge, provide training for caregivers on the child’s diagnosis, medical needs, and medical equipment. Caregivers should demonstrate clear understanding of this information and demonstrate competence with equipment.
- Provide caregivers with concrete connections to and clear instructions for follow-up care. If possible, make appointments for follow-up care before the child is released from the hospital.
- Before the child leaves the hospital, arrange a meeting involving the child welfare social worker, the child advocate attorney, other service providers (e.g., mental health, medical specialists, etc.), and the caregivers to ensure that all have a shared understanding of the child’s medical needs and next steps.
- Next steps should include the integration of family-centered and trauma informed interventions that will help to reduce the child’s distress as well as foster parents ability to support the child and cope with possible ongoing stressors (in child and foster parent).
Learn more about working with child welfare professionals and earn continuing education credit by completing For Health Care Professionals: Pediatric Medical Traumatic Stress (PMTS) and Working with the Child Welfare System (1.0 CEU)