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
Supplemental Handouts for This Session
• Copy of PRIDE Connection Exercise on Loss
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-ofhome 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
The Child Health Program
• 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
Components of Health Care Services
• The American Academy of Pediatrics indicates there are
four primary components to health care services:
1.
2.
3.
4.
An initial health screening (pre-placement exam) within 24
hours of placement
A comprehensive medical and dental assessment (CHEC or
CME) within 30 days of placement
A developmental and mental health evaluation (part of CHEC)
Ongoing primary care and monitoring with the child’s Medical
Home
• Continuity of care for children in out-of-home placement
is paramount!
Initial Health Screening
• 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
Comprehensive Medical Exam
• 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
Developmental & Mental Health Evaluation
• 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)
Ongoing Primary Care and Monitoring with
Medical Home
• 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*.
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.
The Child Health Unit
Questions?
Activity – Guided Imagery
The Removal
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 selfesteem)
Pathway Through the Grieving Process
Loss
Health
This pathway illustrates
responses to grief, not
necessarily stages of grief.
Self-Esteem
Shock/Denial/Protest
Bargaining
Significant
Persons
These responses may not
occur in orderly
progression, as illustrated.
Anger
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Many people may go back
and forth from one
response to another …
Coping
Managing Loss
… or they may exhibit
several of these
responses at once.
Shock Denial and Protest
Loss
• We try to stop the loss from occurring or deny
Health
Self-Esteem
Significant
that
the loss has occurred.
Persons
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?
Loss
Health
• Flat
emotions, noSelf-Esteem
evidence of beingSignificant
upset
Persons
• Denial that theyShock/Denial/Protest
have been removed by
Bargaining
showing no reaction
to the separation
• Continually asking Anger
to go home
Acting Out
Depression
• (Outward
Refusal
to
eat,
sleeping
problems,
being
Anger)
(Inward Anger)
Understanding
susceptible to injuries
or developing
Coping
illnesses (real or imagined)
Managing Loss
What Behaviors Might Be Expected of Children
Experiencing Grief in Foster
Care & Adoption?
Loss
Health
Self-Esteem
Significant
• Denying
that there
is anything is wrong
in
Persons
Shock/Denial/Protest
their family
• Living in a fantasyBargaining
world that their parents
will show up any minute
to reclaim them
Anger
Acting Out to please and show compliant
Depression
• Eager
(Outward Anger)
(Inward Anger)
behaviors, pretending
that nothing really
Understanding
bad or scary has happened
Coping
Managing Loss
How to Handle Shock/Denial Responses
Loss
• Recognize that the absence
of outward
expression
of feelings
doesn’t mean thatSignificant
there is
Health
Self-Esteem
no feeling
Persons
Shock/Denial/Protest
• Provide information
to the child about the
situation in a reassuring
and age-appropriate or
Bargaining
developmentally-appropriate manner
• Ensure a comfortable Anger
and comforting
environment
Acting Out
Depression
Anger)
• (Outward
Reassure
the child that he or she is safe(Inward Anger)
Understanding
• Provide close supervision to prevent injuries and
Copingneeds are being met
to ensure child’s physical
Managing Loss
Bargaining
Loss
• Feeling that there must be some type of
Health
Self-Esteem
atonement
where they
may make a dealSignificant
and the
Persons
situation will go away.
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
Loss by Bargaining?
Healthmay have conversations
Self-Esteem
• Child
with self Significant
Persons
• Use of inappropriate
behaviors as a way of
Shock/Denial/Protest
getting “kicked out” or
sent to where the child
Bargaining
wants to be
Anger
• May try to be “perfect” as way of making the
Acting Out
Depression
situation
“perfect”
(Outward Anger)
(Inward Anger)
• May have feelings Understanding
of guilt and self blame
Coping
Managing Loss
How to Handle Bargaining Responses
• Provide opportunities Loss
to talk and express
feelings
Health
Self-Esteem
Significant
Persons
• Give permission Shock/Denial/Protest
to express sad, guilty, angry
and blaming feelings
Bargaining
• Help them understand returning home depends
Anger
primarily on family’s behavior,
not theirs
• Provide
Acting Out consistent and supportive reminders
Depression
(Outward
Anger) are safe
(Inward Anger)
that they
Understanding
• Give factual and nonjudgmental information
about what happenedCoping
and the reason for it
Managing Loss
Anger
Loss
• Shows itself in two different ways:
Health
Self-Esteem
Significant
Persons
Shock/Denial/Protest
Acting Out - “Outward
Anger”
Bargaining
Depression - “InwardAnger
Anger”
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
Acting Out
Loss
• Expressing angry, hostile behaviors
Health
Significant
• Realization
that the Self-Esteem
loss has occurred and
it
Persons
Shock/Denial/Protest
cannot be undone
Bargainingto express these
• Children may find it easier
feelings toward resource
families rather than
Anger
toward their birth families
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
How to Handle Acting Out Responses
Loss
• Give permission to feel angry, while giving them
Healthto express this
Self-Esteem
Significant
ways
in a healthy and non
Persons
harmful manner Shock/Denial/Protest
• Give them daily, consistent
Bargaining and structured
support in managing their angry feelings
Anger
• Connect them to counseling or therapy
Acting Out
Depression
• (Outward
Teach
good behavior management strategies
Anger)
(Inward Anger)
Understanding
• Openly support child’s relationship with birth
families and siblings Coping
Managing Loss
Depression
Loss
• Can be less visible to resource families,
Health
Significant
teachers
and socialSelf-Esteem
workers
Persons
• Equally importantShock/Denial/Protest
to manage these feelings
Bargaining
Anger
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
How to Identify Depression Responses
• May have excessive fear Loss
• Lack of interest or ability to engage in the normally expected
Health
Self-Esteem
Significant
activities
Persons
• Clingy behaviors
Shock/Denial/Protest
• Lack of feelings in response to happy or sad experiences
Bargaining
• Anxious behaviors
• Withdrawn from peers or adults
Anger
• Suicidal gestures or ideation
• Substance
Acting Out abuse and sexual promiscuity
Depression
• (Outward
Poor school
performance
Anger)
(Inward Anger)
Understanding
• Poor hygiene and physical
appearance
Coping
Managing Loss
How to Handle Depression Responses
Loss
• Reassurance that the child is
valuable, important and lovable
• Permission for the child to feel sad and reassurance that over
Health
Significant
time
things will feel betterSelf-Esteem
Persons
• Time to be left alone without
expectations
of
joining
the family
Shock/Denial/Protest
life
• Encouragement for even small
accomplishments
Bargaining
• Close structured supervision
Angerand sense of hopefulness
• Comfort, reassurance of safety
• Availability
and nurturing child without pushing child
to talk
Acting Out
Depression
• (Outward
Opportunity
Anger) for the child to cling, while providing reassurance
(Inward Anger)
for independent actions Understanding
• Collaboration with mental health professionals
Coping
• Collaboration with substance
abuse professionals
Managing Loss
Understanding
Loss
• Children are beginning to let go of their powerful
Health
feelings
of grief andSelf-Esteem
begin to understandSignificant
in a
Persons
more realistic way
what has happened to them
Shock/Denial/Protest
and why it happenedBargaining
• They begin to express why they felt ashamed,
Anger
guilty, mad, sad or glad
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
Coping
Loss
• This is moving beyond understanding,
allowing more
energy to accomplish the tasks of life and providing a
Healthof hope for the future
Self-Esteem
Significant
sense
Persons
• May begin to demonstrate
new behaviors and feel a
Shock/Denial/Protest
sense of having changed or grown
Bargaining
Anger
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
What is a Loss Manager
Loss
• When one is successful in completing the
Health
Significant
pathway
through theSelf-Esteem
grieving process, they
are
Persons
able to offer theirShock/Denial/Protest
awareness and skills to help
others grieve
Bargaining
• Children need Loss Managers to help them on
Anger
the pathway through the grieving process
Acting Out
Depression
(Outward Anger)
(Inward Anger)
Understanding
Coping
Managing Loss
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