Inside the program that helps kids in Philly’s foster system deal with trauma

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Studies estimate that up to 90% of children in foster care have experienced trauma, and up to 80% deal with significant mental health issues.

Those backgrounds, combined with the experience of being uprooted from their homes, can lead to significant struggles for both foster children and their families.

“Kids who are entering the foster care system are managing so many different transitions simultaneously,” said Liz Gravallese-Anderson, a psychologist with the Safe Place Treatment and Support Program at the Children’s Hospital of Philadelphia, which offers services for children who’ve experienced abuse and neglect.

First and foremost, Gravallese-Anderson says, is the transition to a new home, which comes with new rules, new routines and new relationships, both with their foster parents and, potentially, foster siblings. On top of that, many kids have to switch schools, leaving their old friends behind, and they may find themselves worrying about the biological family they left behind.

“I think just one of those experiences alone can cause somebody to feel a significantly increased sense of loneliness and isolation,” Gravallese-Anderson said. “And when a child is experiencing all of these things at once, it can feel really overwhelming.”

What struggling looks like

These struggles can manifest differently depending on the child’s disposition. Some internalize their feelings, leading to withdrawal, depression and anxiety. Often, they lead to new behaviors like sleep problems, nightmares, changes in appetite, separation anxiety or even flashbacks to traumatic events.

For children more prone to externalizing their feelings, they can lead to what Gravallese-Anderson calls “acting out behaviors” that tend more toward defiance.

“Kids may behave more aggressively or might even refuse to go to school,” she said. “They might attempt to elope. They might engage in behavior that we as adults might perceive as argumentative. This is how kids and how teenagers express their feelings when they don’t have the ability to put words to what they’re experiencing.”

Other symptoms are less obvious, but no less harmful — like difficulty forming healthy attachments, said Nancy Braveman, another psychologist at the Safe Place.

“So that might look like difficulty developing trust within relationships, either with peers or caregivers or other authority figures,” Braveman said. “Distrust, withdrawal, discomfort in social situations, lack of social skills.”

At the other end of the spectrum are children with indiscriminate boundaries, who are prone to approaching strangers for conversation or even hugs.

Another issue can be problems with focus and academic functioning, which are common symptoms of trauma that can be easily mistaken for ADHD.

And those aren’t the only symptoms of trauma that can be mistaken for something else.

“Like withdrawal, that can overlap and look like depression, or hypervigilance can look like anxiety,” said Kristine Fortin, a pediatrician at CHOP and the medical director for its Fostering Health Program. “So that is really why it’s important to have a trauma-trained provider that can help, because the treatment path is different.”

Seeking help: Trauma-focused cognitive behavioral therapy

So what does trauma-informed care for foster children look like?

One of the most effective tools in clinicians’ arsenal is trauma-focused cognitive behavioral therapy, or TF-CBT — a well-researched, evidence-based therapy for children and adolescents ages 3 to 18 who’ve dealt with traumatic experiences.

TF-CBT, which is a staple of the Safe Place’s treatment program, comprises a highly structured protocol that begins with what’s called the stabilization phase, in which children are taught coping skills to help them manage their trauma responses. These skills commonly include relaxation strategies, emotional expression techniques, and cognitive restructuring strategies, which involve becoming more aware of one’s own thoughts and replacing unhelpful or distorted thoughts with productive, accurate ones.

It also includes education for the child’s caregivers about trauma and traumatic stress, which — hopefully, Braveman said — helps to strengthen and improve their bond.

The goal is to help lay the groundwork for the next phase, in which children process their trauma.

“So we’re learning all these skills so that when we get to the direct work it can be done in a way that does not feel overwhelming and we can monitor and manage any associated distress the child may be feeling,” Braveman said. “So we don’t just jump into it from the beginning before we sort of build the capacity to do that and the trusting relationship.”

Next is the direct work phase, in which children, with the support of therapists and their caregivers, engage directly with their trauma. At the Safe Place, Braveman said, they typically rely on “trauma narratives,” or structured stories of past events that can help children make sense of fragmented and highly emotionally charged memories.

Finally, they move on to the third phase, in which they process those narratives, relying on the skills learned in the stabilization phase to deal with and make meaning out of them — as well as to dispel harmful and inaccurate beliefs.

A common one, Braveman said, is the belief that the abuse a child has experienced was their fault.

“If we can get to the point where some of those are revealed, then we can further explore those and harken back to the CBT skills we’ve learned earlier and support a child, and question, ‘Is that really true?’” Braveman said. “So we try to help them move along in that process and kind of expand their narrative. So maybe they will expand their story to say, ‘I used to think it was my fault. Now I know it wasn’t.’ ”

Accessing care — and the barriers foster families face

The first step to accessing care for most foster parents is contacting their child’s case manager, as well as their pediatrician, who can help connect them with programs like CHOP’s.

One of the biggest barriers they face to getting their child seen, Kristine Fortin said, is wait lists — which are common for anyone seeking mental health care, but can be especially detrimental to foster children in the throes of displacement.

“So even though all people experience wait lists, it can really have significant consequences for children in foster care,” Fortin said. “The delays could impact them in a really significant way. So when children are going through a transition, we would want to support them as soon as possible.”

Another issue is placement instability, in which children are shuffled from home to home, often interrupting therapy.

“And sometimes we have older youth who just don’t feel they want to engage in therapy right now,” Fortin said. “It’s really hard to start talking about your trauma narrative. So if you could, imagine you start with a therapist and then that gets interrupted and you start over. That’s a really challenging thing for a youth.”

So what would help?

“Having more providers, having fewer wait lists, and one thing that I think would be really helpful is having an easy transfer of care during times of crisis,” said Gravallese-Anderson. “When there aren’t enough resources to go around, having a child who is in acute crisis but not having an appropriate place to be able to direct the family can cause significant stress for the child who’s in crisis.”

In the meantime, Gravallese-Anderson said it’s important for foster parents to remember that the daily care and work they’re doing is helpful all on its own, even if it doesn’t always feel that way.

“I think it’s important to remember that these kids and teens may not be used to that amount of attention from adults who actually care, and that can be overwhelming,” she said. “They might try to reject some of that support and interest. And that reaction is not about the foster caregiver as a person — it’s really a reaction to what the children and teens are feeling and going through in that moment.

“And many times when these children have access to appropriate support and when the foster parents have access to support as well, those behaviors do decrease, and the relationship can feel more comfortable. So I would just encourage sticking with it and remembering that the reaction is not personal.”

Other resources for foster families

• The American Academy of Pediatrics’ resource guide “Safe and Sound: Helping Children Who Have Experienced Trauma and Adversity“: For more information on common symptoms of trauma in children and how to recognize it
• Sesame Street’s Foster Care Resources: For language to help explain foster care to younger children, as well as resource sheets for providers and caregivers
• Well Rooted: A Delaware County organization that provides mentorship for youth transitioning out of foster care, as well as support for both foster families welcoming a new child into their home, and biological families reuniting
• Fostering Hope: A nonprofit that provides clothing, dignity kits, phones and support to children, teens and families in the foster care system across the Philadelphia region
• Learn more about CHOP’s Fostering Health Program and Safe Place program or donate to Safe Place