Making Sense of Alphabet Soup

Trauma & attachment

What do common mental health diagnoses mean, and how can you address them?

By Emily Jo Wharry

Opening the medical history file of a child in foster care can be a sobering confirmation of the disproportionate health burdens carried by those in the foster care system. Due to their increased exposure to trauma, neglect or maltreatment, youth in foster care are at a much higher risk of experiencing mental health disorders. According to 2010 research in the Journal of Pediatric Psychology, 32% to 44% of foster youth have a diagnosis, with many simultaneously experiencing comorbidity, or the presence of two or more diagnoses.

As a parent, how can you begin to untangle the mental health disorders experienced by a child in foster care?

The first barrier to overcome is the shame and stigma that surrounds mental health, said Dr. Richard J. Delaney, an internationally recognized trainer of foster, kinship and adoptive parents. Oftentimes, parents consider mental health concerns to be less critical than other health issues — but by not being open to talking about mental health with their children, they run the risk of missing key conversations that can lead to a diagnosis or treatment. 

It’s common for youth in foster care to have multiple mental health disorders that have been diagnosed over time, Delaney said. Rather than trying to understand each individual diagnosis — which may feel overwhelming — it may help to learn about groupings of certain diagnoses, which often co-occur.

Delaney and James M. Kagan, MD, who co-authored the book “A 3-D View of Foster, Kinship, and Adopted Children,” recently developed a mental health screening tool designed to provide a list of possible diagnoses that a foster or adoptive child may experience based on a questionnaire regarding visible symptoms. Below is a breakdown of some of the most common diagnoses and their symptoms.

Trauma and Stressor-Related Diagnoses

Three of the most common mental health diagnoses present in youth in foster care stem from witnessing or experiencing trauma firsthand. 

“Relational trauma is not like a car accident or a fire, but it means abuse, neglect, exposure to domestic violence, sexual exploitation,” Delaney said. “It’s often chronic, serious and accumulates.”

Post-traumatic stress disorder (PTSD) is the most recognizable in this category: After a traumatic event, a child may experience flashbacks or nightmares, or cope with their lost sense of security by reverting to baby-like behaviors, being hypervigilant to danger or mentally “zoning out.”

A child’s early traumatic experiences of neglect can also shape how they relate to and interact with others. If they didn’t have ample early opportunities to form healthy bonds with caregivers and were deprived of care, they may develop reactive attachment disorder (RAD). Symptoms of RAD center around withdrawal, a reluctance to seek out comfort from anyone and a limited expression of emotions.

RAD’s “twin,” Delaney explains, is disinhibited social engagement disorder (DSED). Rather than becoming emotionally withdrawn as a result of childhood neglect, youth with DSED have neither hesitation nor fear when it comes to approaching adults, or even strangers. They may talk to unfamiliar people or seek intimate physical comfort, such as hugging or cuddling, without checking for permission from their caregiver.

Restlessness and Opposition-Related Diagnoses

Although the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), published by the American Psychiatric Association in 2013, groups attention-deficit/hyperactivity disorder (ADHD) with neurological diagnoses such as autism spectrum disorder (ASD), Delaney said it’s not uncommon to see a younger foster child with ADHD age into a diagnosis of oppositional defiant disorder (ODD).

ADHD, caused by a dopamine deficiency that hinders one’s ability to perform the executive functions that control behavior, is characterized by impulsivity, time mismanagement, forgetfulness or hyperactive behavior, as though the child is driven by a motor. Youth who were raised with punitive or abusive parenting styles may shift from restlessness with ADHD to resentfulness with ODD, becoming argumentative or irritable toward others — a coping strategy for children who feel that because they fail at good behavior, they may as well succeed at bad behavior.

Conduct disorder (CD) is a more severe expression of aggression and societal norm-breaking — what Delaney describes as a concerning tipping point. Bullying, damaging property, robbing, coercing or running away are a handful of CD symptoms.

The following three diagnoses are common in foster youth, but fall outside the above groupings.

Depression

A foster child experiencing depression may exhibit both physical and emotional symptoms: deep sadness, irritability, fatigue, insomnia or little appetite or motivation, difficulty concentrating or crying, according to Kagan. At its worst, children may possess suicidal thoughts. Depression is oftentimes hereditary.

Food Maintenance Syndrome

Youth with Food Maintenance Syndrome have a dysfunctional relationship with food, oftentimes hiding, hoarding or excessively eating it. According to Delaney, foster parents observe that their child won’t seem to know when they’re full, or have a “starvation mentality,” worried about when their next meal will come.

Generalized Anxiety Disorder

If a foster child has Generalized Anxiety Disorder (GAD), they often worry excessively about seemingly everyday situations, to the point where their worry interferes with their ability to upkeep a healthy and happy lifestyle. In an attempt to cope with feelings of uncertainty and fear around the possibility of unexpected life changes — which a foster youth likely experienced when moved to a new home — those with anxiety may become overly attached to people or objects or exert rigid, controlling behavior.

As a parent, how can you help?

Recognizing common symptoms and self-educating about the root causes of these diagnoses — oftentimes, traumatic events that occurred outside of a child’s control — can help parents console a child who feels broken, damaged, guilty or helpless, Delaney said. Also, it’s important to remember that alongside childhood trauma, many youth in care have had prenatal substance exposure, head injuries, shaken baby syndrome or other early childhood events that can compound to produce chronic biological, psychological and psychiatric issues.

If a parent feels overwhelmed by multiple diagnoses, they can turn to a therapist for guidance on which mental health issues are most prominent, in remission or provisional. A good therapist for youth will be trauma-informed and work closely with a foster parent, biological parent and any other relevant adults in a child’s life to assess the child’s history, seeking multiple sources of information to better pinpoint the most accurate diagnoses. (Caseworkers can recommend therapists they know with reputations of expertise in trauma.) Delaney warns foster parents to avoid “taxicab therapy,” or a hands-off approach to engaging with the child’s therapist.

Lastly, a foster parent may wonder, “If my foster child is safe now, and we’re feeding them and loving them, why do problems and symptoms not go away or reduce?” To this, Delaney reminds parents that serious trauma can affect the structures and chemistry of the brain. In other words, “The brain keeps the score.” A child’s trauma will make them more reactive to subtle stimuli or triggers that adults may not even pick up on.

Parents seeking resources that intersect mental health and child welfare can visit the California Evidence-Based Clearinghouse for Child Welfare (cebc4cw.org). For more information on Delaney and Kagan’s foster youth mental health screening tool, email [email protected]

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