Technology and the Developmental Needs of Adolescents (Updated! 7/29/11)
Welcome to Session 4! Meeting Developmental Needs: Loss.
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Transcript of Welcome to Session 4! Meeting Developmental Needs: Loss.
Remember the Core Competencies of PRIDE:
1. Protecting and Nurturing Children
2. Meeting Children’s Developmental Needs and Addressing Developmental Delays
3. Supporting Relationships Between Children and Their Families
4. Connecting Children to Safe, Nurturing Relationships Intended to Last a Lifetime
5. Working as a Member of a Professional Team
The Child Health Program
• Partnership between the UMDNJ School of Nursing (Francois-Xavier Bagnoud Center) and DCF/DYFS, established in 2008
• The purpose of the Child Health Program (CHP) is to support DCF/DYFS to ensure that the medical/dental/mental health needs of children in out-of-home placement are met
• The CHP develops child-specific health care plans• The CHP adheres to recommendations of the American
Academy of Pediatrics (AAP)
The Child Health Program
“Health Care Management is the responsibility the of the child welfare agency, but it is a function that requires
medical expertise.” 1
• Numerous studies indicate that children and adolescents in foster care have multiple physical, emotional and developmental needs
• Health Care Management is provided by the CHP to overcome barriers to ensure that children & adolescents receive high-quality, comprehensive and coordinated health care
1 Fostering Health: 2nd Edition, Task Force on Health Care for Children in Foster Care, AAP, 2005
• Responsible for managing the health care needs of children in out-of-home placement through Health Care Case Management
• Ongoing interaction with DYFS staff regarding health and medical needs of children in placement
• Provide nursing summary and Individualized Health Care Plan for children
The Child Health Program
Components of Health Care Services
• The American Academy of Pediatrics indicates there are four primary components to health care services: 1. An initial health screening (pre-placement exam) within 24
hours of placement
2. A comprehensive medical and dental assessment (CHEC or CME) within 30 days of placement
3. A developmental and mental health evaluation (part of CHEC)
4. Ongoing primary care and monitoring with the child’s Medical Home
• Continuity of care for children in out-of-home placement is paramount!
• Pre-placement or re-placement physicals are completed within 24 hours of placement/re-placement
• Physicals are to be completed by CHU nurse, Urgent Care Center or Medical Home
• DYFS policy prohibits pre-placement and re-placement physicals in hospital emergency rooms unless deemed necessary by the Local Office Manager
Initial Health Screening
• Comprehensive Health Examination for Children (CHEC) includes a mental health assessment (detailed interview and evaluation)
• Comprehensive Medical Examination (CME) includes a mental health screening (just a few general questions)
• CHU Staff Assistant will coordinate and schedule – must be completed within 30 days of placement
Comprehensive Medical Exam
• If during CHEC/CME needs are identified, CHU will follow up to assure that appropriate follow-up is obtained
• Children under age 3 should have an evaluation by the Early Intervention Program (EIP)
Developmental & Mental Health Evaluation
• Medical Home refers to child’s primary care physician• Medicaid HMO must be selected• Continue with prior Medical Home when feasible
(continuity of care)• Early Periodic Screening, Diagnosis and Treatment
(EPSDT) exams at specified intervals as per Bright Futures/AAP
• Immunizations per Centers for Disease Control (CDC)• Routine dental exam and care every 6 months, starting
at age 3*.
Ongoing Primary Care and Monitoring with Medical Home
How It Works: The Child Health Unit
• Group of child health care staff (nurses and assistants), dedicated to serving DYFS children in a given area: – Ensure that children receive their immunizations, dental and
medical appointments according to the American Academy of Pediatrics and Bright FuturesTM
– Access immunizations records– Obtain medical records and medical information– Assist Resource Parents with advocating for a child’s health
care needs– Manage the health care needs of children in out of home
placement
How It Works: The Child Health Unit
• Group of child health care staff (nurses and assistants), dedicated to serving DYFS children in a given area: – Health care resources, support, and education for Resource
Families– A “bridge” to the healthcare community– Communicates with those involved in care of child, keeping
them informed of child’s health status and participating in key case conferences concerning the child
– May attend regional placement conferences, family team meetings, court hearings, etc.
The Child Health Unit
Ensuring That A Child’s Health Care Needs Are Met
• Physical Health Needs– Children receive Early and Periodic Screening Diagnostic and
Treatment (EPSDT) examinations in accordance with the periodicity schedule
– Children receive timely immunizations – Children receive appropriate follow-up care to address their
health needs (includes follow-up of the recommendations of health care providers)
The Child Health Unit
Ensuring That A Child’s Health Care Needs Are Met
• Mental Health Needs– Children receive mental health assessments– Child Health Unit will work with DYFS to ensure referrals that
service are in place
• Dental Health Needs– Children 3 years and older receive semi-annual dental
examinations- unless indicated otherwise. New recommendations began screening at age 1.
The Child Health Unit
Communication is KEY!• In-Person Contact:
– The Child Health Nurse will contact Resource Parents and make a home visit within 2-3 weeks of placement and visit about every 2-4 months depending on the child’s healthcare needs.
• Phone Contact:– Resource Parents are expected to contact their child health
nurse to inform them of any changes in health care status of the children in their care, doctor visits, new medications, etc.
The Child Health Unit
• In the Beginning …– Ensure pre-placement and re-placement physicals for children in
placement are completed within 24 hours of initial placement or a change in placement.
– The child health nurse will complete a DYFS form that is the child’s Health Passport. This is mailed or given to the Resource Parent.
– The nurse may be calling you to discuss significant health care issues before receipt of the Health Passport.
The Child Health Unit
• Ongoing care…– A child health care plan is developed by the Child Health Nurse
which will include their nursing plan and recommendations from health care providers and other community sources as well (e.g. School).
– The Health Care Plan is a living document and so it changes as the health care of your child changes. The Child Health Unit staff and Resource Parents will be communicating often.
Child Health: YOUR Responsibilities
• Maintenance of a “Medical Log” by the Resource Parent is expected and will be reviewed by the nurse at visits. The Medical Log should include all health care visits (well & sick), medications, illnesses, injuries, appetite.
• According to DYFS policy, if a child has a fever of 100.4°F, you must contact your child’s primary doctor.
• The Resource Parent must maintain a copy of the child’s immunization record.
• Psychotropic medications require DYFS approval• CPR Certification is recommended for all Resource
Parents and caregivers.
Definitions
• Separation is the change that occurs when there is a break up in a relationship
• Loss is the effect on people when something important is withdrawn
• Grief is the process that helps people work together through the pain of separation and loss
Challenges of Dealing with Loss
• Separation, loss and grief are painful experiences to think and talk about
• It makes us uncomfortable to be with children and adults who are sad and angry
• The grief of others can remind us of our own losses and trigger painful memories
• Our own painful experiences can either help or hinder the way we respond to other’s losses
• We often feel unsure how to help others people deal with their pain
• Dealing with painful losses can take a long time, sometimes forever
Categories and Types of Losses
• Loss of physical/mental health
• Loss of significant people
• Loss of self esteem or sense of well- being
Expected Losses
• Usually shared by all human beings• Usually a lot of support for expected losses• Usually considered “normal” and we therefore
feel normal in our need to grieve• There may be regrets, but typically no great
sense of blame or shame• Usually prepared by life for these to occur
Name Some Examples of Expected Losses
• Death of a parent or older family member• Moving to a new home, leaving friends and
community behind• Moving to a new job or retiring• Children growing up and leaving home• Loss of senses or abilities as a result of aging• Loss of certain privileges and freedoms as we
mature from children to adults
Unexpected Losses
• Usually unprepared to cope• Usually not shared equally by all humans• Sometimes there is little understanding or
support from society about the need to grieve• Often a sense of personal shame or blame• Often not regarded as “normal losses” and this
sense of being different complicates the grieving process
Name Some Examples of Unexpected Losses
• Loss of a child• Sudden loss of a job• Financial losses• Serious Illness or injury• Car accidents, fire, natural disasters• Infertility• Theft of property• Divorce
Why Do We Need To Know These Categories?
• Important to understand that the majority of significant experiences in life can involve a loss of some kind
• Some losses are not as apparent as others• The most frequent loss people suffer is loss of
self-esteem• All people who experience loss respond to it with
feelings and behaviors
Name Some Losses that Birth Families May Encounter When Children Enter Foster Care
• Loss of the child/children• Loss of home (housing assistance may be
discontinued when there are no children)• Loss of health (drug addiction, HIV, depression)• Loss of spouse/significant other• Loss of self-esteem (society looks down on
offenders of child abuse and neglect)• Loss of control/self direction (must negotiate the
return of their children with DYFS/Courts)
Name Some Losses that Resource Families May Encounter
• Loss of family stability• Loss to own children in assuming role of resource family (having to
share time with other children)• Loss of self-esteem (children who do not respond or are difficult to
manage)• Possible loss of status in the community (perception of anything
having to do with DYFS is negative)• Loss of important people (other team members when a child returns
home)• Loss to own children and extended family when a child returns
home• Loss of autonomy in parenting (need “permission” from DYFS)• Loss of privacy• Loss of health (exposure to children being placed, mental stress)
Name Some Losses that Adoptive Families May Encounter
• Loss of the family experience as they “expected” it to be if they were unable to have their own (birth) children
• Loss of exclusive parenting role in children’s lives (children are likely to be curious about their birth family)
• Loss of control in their family development (need to work with other team members to identify a child that is “right” for them)
Pathway Through the Grieving Process
• Resource families need to understand how people grieve their losses
• Grief is a healthy process that we must go through to heal the painful feelings of loss
• The “Pathway Through the Grieving Process” is described on PRIDEBook Page 136.
• The entry point into this process can be any significant loss (health, significant person or self-esteem)
Pathway Through the Grieving ProcessLoss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
This pathway illustrates responses to grief, not
necessarily stages of grief.
These responses may not occur in orderly
progression, as illustrated.
Many people may go back and forth from one
response to another …
… or they may exhibit several of these
responses at once.
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Shock Denial and Protest
• We try to stop the loss from occurring or deny that the loss has occurred.
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?
• Flat emotions, no evidence of being upset• Denial that they have been removed by
showing no reaction to the separation• Continually asking to go home• Refusal to eat, sleeping problems, being
susceptible to injuries or developing illnesses (real or imagined)
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
What Behaviors Might Be Expected of Children Experiencing Grief in Foster Care & Adoption?
• Denying that there is anything is wrong in their family
• Living in a fantasy world that their parents will show up any minute to reclaim them
• Eager to please and show compliant behaviors, pretending that nothing really bad or scary has happened
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
How to Handle Shock/Denial Responses
• Recognize that the absence of outward expression of feelings doesn’t mean that there is no feeling
• Provide information to the child about the situation in a reassuring and age-appropriate or developmentally-appropriate manner
• Ensure a comfortable and comforting environment
• Reassure the child that he or she is safe• Provide close supervision to prevent injuries and
to ensure child’s physical needs are being met
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Bargaining
• Feeling that there must be some type of atonement where they may make a deal and the situation will go away.
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
What Behaviors Might Be Expected of Children Responding to Grief by Bargaining?
• Child may have conversations with self• Use of inappropriate behaviors as a way of
getting “kicked out” or sent to where the child wants to be
• May try to be “perfect” as way of making the situation “perfect”
• May have feelings of guilt and self blame
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
How to Handle Bargaining Responses
• Provide opportunities to talk and express feelings
• Give permission to express sad, guilty, angry and blaming feelings
• Help them understand returning home depends primarily on family’s behavior, not theirs
• Provide consistent and supportive reminders that they are safe
• Give factual and nonjudgmental information about what happened and the reason for it
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Anger
• Shows itself in two different ways:
Acting Out - “Outward Anger”
Depression - “Inward Anger”
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Acting Out
• Expressing angry, hostile behaviors• Realization that the loss has occurred and it
cannot be undone• Children may find it easier to express these
feelings toward resource families rather than toward their birth families
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
How to Handle Acting Out Responses
• Give permission to feel angry, while giving them ways to express this in a healthy and non harmful manner
• Give them daily, consistent and structured support in managing their angry feelings
• Connect them to counseling or therapy• Teach good behavior management strategies • Openly support child’s relationship with birth
families and siblings
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Depression
• Can be less visible to resource families, teachers and social workers
• Equally important to manage these feelings
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
How to Identify Depression Responses• May have excessive fear• Lack of interest or ability to engage in the normally expected
activities• Clingy behaviors• Lack of feelings in response to happy or sad experiences• Anxious behaviors• Withdrawn from peers or adults• Suicidal gestures or ideation• Substance abuse and sexual promiscuity• Poor school performance• Poor hygiene and physical appearance
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
How to Handle Depression Responses• Reassurance that the child is valuable, important and lovable• Permission for the child to feel sad and reassurance that over
time things will feel better• Time to be left alone without expectations of joining the family
life• Encouragement for even small accomplishments • Close structured supervision• Comfort, reassurance of safety and sense of hopefulness• Availability and nurturing child without pushing child to talk• Opportunity for the child to cling, while providing reassurance
for independent actions• Collaboration with mental health professionals• Collaboration with substance abuse professionals
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Understanding
• Children are beginning to let go of their powerful feelings of grief and begin to understand in a more realistic way what has happened to them and why it happened
• They begin to express why they felt ashamed, guilty, mad, sad or glad
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
Coping• This is moving beyond understanding, allowing more
energy to accomplish the tasks of life and providing a sense of hope for the future
• May begin to demonstrate new behaviors and feel a sense of having changed or grown
Loss
Health Self-Esteem SignificantPersons
Shock/Denial/Protest
Bargaining
Anger
Acting Out Depression(Outward Anger) (Inward Anger)
Understanding
Coping
Managing Loss
What is a Loss Manager
• When one is successful in completing the pathway through the grieving process, they are able to offer their awareness and skills to help others grieve
• Children need Loss Managers to help them on the pathway through the grieving process
Factors that Influence How Loss is Experienced
• Nature of the Loss• Age at the time of the Loss• Degree of Attachment• Ability to Understand Why• Amount of Emotional Strength• Cultural Influences• Circumstances Causing the Loss• Number of Previous Separations and Losses• Help given Prior to, During, and After the Loss
Why is it important for resource families to understand their own experiences with loss?
• If you are overwhelmed with your own losses, it will be difficult to help children manage their losses
• Thinking about how we have been helped to grieve may help us help others with their grieving
• Cultural influences and “rules” about grieving may lead us to expect others to grieve in the same way we grieve
• Seeing how we have been able to manage losses in our past may give us confidence in helping someone else
• Children experiencing losses may “trigger” sad memories and feelings related to losses in our own past
Losses Specific to Adopted Children
• Finality of the separation from their birth family• Loss of their foster family• Loss of friends, neighbors, teachers, coaches
and others they knew • Loss of the hope that they might return to their
birth family
Grieving is an Ongoing Process!
• Children may proceed through the grieving process and come to an understanding of their loss and develop healthy ways to cope
• During adolescence or adulthood, they may need to grieve the loss again, this time, with greater cognitive and emotional capabilities
Using a Loss History Chart
• PRIDEBook Page 137 shows a template for a Loss History Chart
• Helpful tool to help foster/adoptive parents understand losses a child has experienced
• You will complete your own Loss History Charts as “homework”
Loss History Chart• Overview of child’s history• Information to help understand how well they have grieved old
losses• Information on what early developmental stages may have been
affected by the losses• Information to prepare us for what we might expect the child to
experience with current losses• Information about past behaviors that may help with handling
current behaviors and predict future behaviors• Better understanding of emotional age and problems with
attachment• Assess if past losses may have prevented child from achieving
expected physical, intellectual, social, emotional and moral development
• Assists us in planning for the child
The Importance of Teamwork
• Resource families need to work with other members of the professional team to help children manage their losses
• Managing loss is an ongoing process as the feelings of old losses are triggered by life experiences
CLOSURE
• Review Key Points, PRIDEBook Pages 141-147• Review You Need to Know!, PRIDEBook Pages 148-151• Read A Birth Parent’s Perspective, PRIDEBook p. 152• Complete the PRIDE Connection exercise on
PRIDEBook Pages 153-154 (copy in packet)• Read Making A Difference!, PRIDEBook Page 155-156
• Session 5: Strengthening Family Relationships
Group Exercise: “Nathan”
• Remember Nathan from the “Making a Difference” video
• PRIDEBook Page 122 contains a vignette that provides more detail about Nathan
• Consider the losses Nathan has experienced, how the team can help him, and what supports he may need
Group Exercise: “Nathan”
• What losses has Nathan had to grieve? Of these losses, which will he need to continue to grieve and why?– His mother (killed in a random shooting)– His father (alcoholism led to placement)– Extended family– School (quit school to care for his father)– Childhood (had to care for his father)– Self-esteem
Group Exercise: “Nathan”
• How might the team help Nathan now with his past and present losses?– Give him time to grieve and heal– Nurturing, structure and consistency at home– Gentle encouragement– Acknowledgement of successes and efforts– Help him to understand the nature of
alcoholism and its impact on the family– Refer him to counseling
Group Exercise: “Nathan”
• What supports may Nathan continue to need in the future?– Continued contact with the resource family– Counseling for Nathan to deal with
separation, his father to continue his sobriety, and for the family to help them heal
– Guidance for Nathan when he graduates high school (college, training, life skills)
Activity
• Picture a loved one in your mind• Think about how important this person is to you
and how they impact your life• Write down this person’s name on a piece of
paper and concentrate on how important they are to you
• Fold the paper in half and set it in front of you, keeping your eyes closed and focusing on this person
• Now … Open your eyes
What Kevin’s Loss History Teaches Us
• Being a Loss Manager for Kevin will be a challenging job
• Seeing how Kevin’s behaviors changed over time and after many losses may help us predict future behaviors (running away, continued inappropriate behavior)
• May help Kevin’s foster family not to take his reactions personally
• Can help the foster family set realistic expectations for Kevin