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Treatment Foster Care: Addressing the Needs of Children With Disabilities
By Robert Basler, MSW, LCSW-C

According to a 2001 position paper by the American Association of Pediatrics, 80% of youths in foster care have some form of chronic medical condition and 30% have three or more conditions. In 1997, the Child Welfare League of America estimated that 30% to 40% of foster youths have physical health problems and that 20% of foster youth have been diagnosed with intellectual disabilities or some other developmental disability.

These results warrant questions about whether youths with developmental and medical conditions in foster care are receiving appropriate intervention and treatment.

Youths with disabilities are in foster care longer, have more placement changes while in care, and are less likely to be placed with a relative or reunited with parents.

Being the caretaker of a youth with disabilities is challenging. Caregivers often report adverse effects related to the care they provide, including their own health concerns, the psychosocial impact of providing such care, and a lack of practical and emotional support, all of which can impact care to the children. Support that foster parents report as helpful include the following:

• coordination of services;
• emotional support;
• respite;
• in-home care;
• effective equipment supply; and
• travel assistance.

This list forms the backbone of what an effective program must include to meet the needs of a foster child and his or her family.

Treatment Foster Care
Although treatment foster care (TFC) has generally been used with youths diagnosed with emotional or behavioral disorders, it is also an ideal setting to meet the complex needs of children with medical and developmental needs, providing the treatment they need while integrating them into their community.

A developmental disability is defined by the Developmental Disabilities Assistance and Bill of Rights Act as follows:

• a mental and/or physical impairment that manifests before an individual reaches the age of 22;
• is likely to continue indefinitely;
• results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive living, and economic self-sufficiency;
• and reflects an individual's need for a combination and sequence of special, interdisciplinary, or generic services; individualized support; or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

Some of the most common disabilities seen in Maryland’s Kennedy Krieger Institute therapeutic foster care are intellectual disabilities, cerebral palsy, attention-deficit/hyperactivity disorder, autism spectrum disorders, receptive or expressive language, and feeding disorders. Roughly one-half of these children have a mental health condition in addition to the abuse and neglect that generally precipitate their entry into foster care. As a result, the children have complicated, long-term treatment needs that also directly impact how to approach treatment parent training, permanency and transition planning, and clinical work with the children.

It is not uncommon for a child to require large treatment teams, with care being provided by multiple specialists over an extended period of time, as well as needs for accommodations at home, in school, and in the community. As a result, youths are usually served by multiple systems with divergent funding sources.

In Maryland, foster care is funded through the state Department of Human Resources, while medical care, including mental health care, is funded through the Department of Health and Mental Hygiene. In addition, most youths in the program qualify for services through the Developmental Disability Administration and special education services. This requires a treatment parent to understand not only the child welfare system but also the medical systems their child uses, the developmental disability system, and the specific medical, developmental, and technological needs of their child.

Foster Parent Recruitment
To prepare treatment parents for this challenge, a multitiered training approach is needed that includes general training for all parents, child-specific training based on their child’s identified needs, and parent support groups that encourage parent-to-parent training and mentoring.

Social workers should have training in the specific needs of the children they serve and attend all specialist appointments along with the treatment parents to provide a high level of support and continuity. Social workers should also be knowledgeable about relevant legislation (e.g., the Individuals With Disabilities Education Act, the Developmental Disabilities Act, the Americans With Disabilities Act) that is critical to the provision of effective case management and advocacy for appropriate health, school, and community services.

Characteristics of Interventions
Social workers need to work closely with treatment families in assisting them with managing the stress and grief that often accompanies working with children with disabilities while assisting the children in working through their separation from their families and trauma of abuse or neglect. This work can differ widely depending on the age, developmental level, communication ability, and history of each child. Clinical interventions, whether done by social workers, treatment parents, or specialists, need to be tailored to each youth’s specific developmental, cognitive, physical, and emotional strengths and limitations. The types of interventions used will vary from case to case, based on the assessments of the treatment team, but should keep the long-term goals of safety, community integration, and self-determinism in mind.

Achieving Permanency
With any child in TFC, permanency planning is integral. Social workers need to work closely with local social service departments to integrate children’s birth parents into treatment whenever appropriate. It is important to not only assess a family member’s aptitude for parenting but to ensure that he or she has the understanding, ability, and support to successfully and safely parent a child with complex needs.

Adoptive families also require specific screening and support. Because adoption can result in a reduction of the formal support a family receives though the child welfare system, it is vital to help a family develop a support system that understands their child’s needs as well as to ensure an adoptive family understands what formal supports they are entitled to once they adopt. Ideally the TFC program should be available to provide support postadoption as well.

When developmentally delayed youths cannot be returned home or adopted, there are special considerations for the transition into adulthood. Some may be able to live independently, but many will require some degree of support as adults. It is important to assess what degree of support will be needed and to ensure that these young adults maintain their fundamental rights of being involved in decision making, having their health and safety needs met, and having their property and finances protected.

It is important to ensure that a treatment team begins to plan for the transition to adulthood as early as possible and that they coordinate with the state’s adult developmental disability service providers to match youths to appropriate services. These can include job training, day programs, transportation services, and social supports as well as residential services in a variety of restrictiveness levels.

There can be a wide range of possible services depending on an individual’s developmental level, medical needs, the community in which he or she resides, and the support required. It is important to make sure that needed medical services are covered by insurance and that a young person has as broad a support network as possible. This can include treatment parents, birth family, or others important to an individual as well as professionals involved in a young person’s life.

Finally, it is important to address an individual’s financial needs. For example, if he or she is eligible for supplemental security income, make sure it is applied for prior to an individual ages out of the child welfare system and that, if needed, there is someone to assist with the management and protection of these funds. There are financial management firms that understand the laws governing asset management for individuals with developmental disabilities.

— Robert Basler, MSW, LCSW-C, is director of therapeutic foster care at the Kennedy Krieger Institute in Baltimore.