Psychiatric needs of children in foster care


Our foster care system is in dire straits. According to the Department of Health and Human Services, in the United States alone, over 400,000 children are currently in care and over 100,000 of those children are waiting for permanent adoptive homes. While the numbers are staggering, so are the long term and lasting psychiatric and mental health concerns that often follow these children through the system. One of the most common consequences of early trauma and a journey through the foster care system is often misdiagnosed or underdiagnosed posttraumatic stress disorder (PTSD) and anxiety.

Typically we think of PTSD as associated with veterans or those who have lived through war, but we often forget the complex, interpersonal trauma that is often experienced by children within the foster care system. Trauma such as separation and loss, as well as various forms of abuse or witnessing violence, can lead to PTSD. Unfortunately, children who have survived trauma often are left without the appropriate coping mechanism to battle their inner distress. As such, these hurting children often display behaviors that are linked to diagnosis of ADHD, conduct disorder and oppositional defiance disorder as opposed to PTSD or even anxiety.

As a nurse who has practiced in the fields of mental health and public health, I’ve seen my fair share of children on psychotropic medication to battle the behavioral issues they may be displaying. Children in foster care have an even higher incidence of medication usage, even in those who are preschool age or younger. I would challenge that in many circumstances these children are not in fact battling ADHD, but are instead working through inappropriate coping mechanisms to situational distress, loss and fear. As healthcare professionals we know that children process stressful situations differently than an adult. Big situations lead to big feelings in little bodies who don’t know how to verbalize their distress. I’ve seen this time and time again not only in children that I’ve worked with, but in children I parent.

Nearly 10 years ago my husband and I opened our home to children in foster care. Since then we’ve adopted four children. Our children arrived at our doorstep having lived through trauma, loss, and multiple placements. We’ve worked through reactive attachment disorder, PTSD, anxiety and a whole host of other behavioral concerns directly related to our children’s past. As a mom, I’ve watched my children struggle with relationships and self-esteem. I’ve seen impulsivity directly related to anxiety and taken my child to neuropsych evaluations and testing. We’ve sat through therapy sessions and inpatient intakes. One of the hardest things I’ve ever done was to leave my child in the care of other nurses and staff on a pediatric mental health unit. But harder still have been the battles to have my child seen for who he is as opposed to a diagnosis or a potential candidate for psychotropics.

I’ve had many a teacher tell me to put my son on medication. I’m sad to admit that in the hopes of finding a solution, I’ve done just that. But what we’ve learned as a family and what I’ve learned as a nurse is that medication isn’t necessarily the best or only option. Psychotropics don’t cure anxiety. They don’t help calm PTSD. But recognizing that my child has difficulty with stimuli and managing the big feelings in his small body does.

I said earlier that our foster care system is in trouble. The system itself is broken, the workers overburdened and the children are left hanging in the balance. As nurses, parents, siblings, and members of society I urge you to make a change. Recognize that the kiddos you see in practice may be calling out for help in the only way they know how. See each child for who they are, not as a behavior to be managed. Educate parents and foster parents on ways to teach their child appropriate coping skills. Encourage the moms and dads who are fatigued and feel discouraged. Look for alternatives beyond a pill bottle. But most importantly, be the change.

Marcy Hanson is a nursing instructor at Montana State University.


Selected references

Ai A, Foster L, Pecora P, Delaney N, Rodriguez W. Reshaping child welfare’s response to trauma: Assessment, evidence-based intervention, and new research perspectives. Res Social Work Pract. 2013;23:651-668.

DosReis S, Ming-Hui T, Goffman D, Lynch S, Reeves G, Shaw T. Age-related trends in psychotropic medication use among very young children in foster care. Psychiatric Services. 2014;65:1452-1457.

U.S. Department of Health and Human Services, Administration for Children and Families. 2015. The AFCARS report. Retrieved from

The views and opinions expressed by Perspectives contributors are those of the author and do not necessarily reflect the opinions or recommendations of the American Nurses Association, the Editorial Advisory Board members, or the Publisher, Editors and staff of American Nurse Journal. These are opinion pieces and are not peer reviewed.

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