Foster care support clinic helps kids envision better future

Abigail Esme Mills felt invisible.

When she formerly was in a group home, she passed out because she was in so much pain and had to be taken to an emergency room.

Her first request when she was adopted last year was for her parents, Darren and Jessica, to help her find someone to take her pains seriously. They brought her in to the Foster Care Support Clinic at MUSC Children's Hospital.

Jessica said they were impressed with the entire team, including adolescent pediatrician Elizabeth Wallis, who helped piece together a complicated medical history and give their daughter a diagnosis and treatment plan that allowed her to manage her pain for the first time in her life.

“She was the first person who listened to what we were saying,” Jessica said of Wallis. “She believed her and tried to figure out the situation. Overall, it’s a lot better than two years ago. Before it was, ‘Oh, you’re a foster care kid, and it’s all in your head.’”

Now Abigail is thriving at Wando High School, enjoying art again and considering a career as a veterinarian.

It’s stories like this that get the staff at the Foster Care Support Clinic pumped up. It’s part of why the clinic has experienced a fourfold increase in the number of cases handled monthly since 2013. It’s why, when families come through the door of the Foster Care Support Clinic, Tara Peevy, RN, and other team members shift into medical detective mode. They meticulously research their patients' health histories as if they were medical Sherlock Holmeses, giving the kids the chance to get what many have lacked – a comprehensive medical check-up.

Wallis, the clinic’s director, attributes the clinic’s success to the passion of the team and the overwhelming needs of the state’s foster care children. Wallis says about 500,000 children nationally spend time in foster care each year.

• The average age at placement is 9.1 years, but children from birth to age 5 are the fastest growing group to enter foster care.
• Children in foster care have higher rates of physical health problems than their peers.
• Up to 80 percent of children in foster care have one or more mental health problems.
• About 20,000 youth age out of the foster care system without being adopted each year, placing them at increased risk of poor educational outcomes, unemployment and homelessness.

When Wallis joined the clinic in 2013, it was handling about 30 patient visits a month. That number now is 140. The total number of patients has risen to 600 active patients from around 250 in 2013. The clinic's team has seen more than 1,000 foster care kids since the clinic started, Wallis says. One reason behind the success in the special model that the clinic uses. It is a partnership between the South Carolina Department of Social Services and MUSC Children’s Health, with the clinic serving as a medical home for children who have an open case with the Department of Social Services or who have been adopted.

Other team members include Tracy Halasz, a nurse practitioner; Karyn Kasian, a nurse coordinator; Machelle Green, a human services coordinator; and the most recent addition, Mollie Dadin, a licensed social worker who can provide much needed mental health services.

The team knows and educates others in the community about toxic stress, an area of specialty for Wallis. She always has been interested in the integration of primary care and mental health for vulnerable populations. The clinic is a dream come true for her.

“Unfortunately, the outcomes for youth in foster care are abysmal in terms of education, medical status, psychiatric health, rates of homelessness and PTSD,” she says, explaining that many youth experience post traumatic stress disorder because of the frequent and often prolonged adversity they experience. Research shows that abuse and neglect in childhood creates toxic stress that can disrupt brain architecture and other organ systems.

“The truth is that we don’t have a ton of data on what actually works. So this seemed for me the perfect marriage of what I was interested in clinically but also how to produce some high quality data about what we were doing and think creatively about how to look at outcomes in this population.”

Partnership for Change

It’s tempting when looking at the problems with the state’s foster care system to simply blame state agencies, but Wallis’ team knew from the beginning the only solution was to collaborate on creative solutions. They also were looking for ways to do research and provide community education on treatments for trauma that have been shown to work.

Research is showing just how much trauma impacts a child’s behavior, development, physical health, relationships and ability to be educated. Trauma can affect the immune system, the neuroendocrine stress response and brain development. The good news is that there are effective ways to intervene to help mitigate ill effects and give these kids a chance to thrive.

“We’re not doing the job of DSS or the jobs of private licensing agencies, but we really try to partner with them. We also partner with health professionals at MUSC and in the community, so we think about what do they need to do their job better to meet the needs of our kids who are really vulnerable.”

The clinic is an option for families who need a little bit more time and attention and want a better understanding of what a child has been through. Team members see a child for a first visit and then again in a month, which gives them time to gather medical data and figure out a treatment plan that fits the child’s needs.

“A lot of these kids have experienced a lot of trauma early on in their life, so sometimes even simple medical procedures can be traumatic. So we don’t update every kid’s vaccinations on the first visit if that’s something that’s going to be really scary for them. We may not be able to do a full physical exam on every kid at the first visit. It just depends on what is particularly scary to them.”

They follow the kids more closely than a typical primary care practice.

“I think the advantage of this model is that we are primary care doctors at heart. We are doing the type of care that we’re good at. People also think that being placed in foster care should fix the problems – that if a kid is being abused or neglected at home and you remove them from that environment, they’re going to get better. But the truth is that most kids will tell you the most traumatic thing that’s ever happened to them was being placed in foster care.”

That’s when the hard work of healing begins.

“Even though toxic stress and trauma is a huge part of what we see in pediatrics and really impacts kids and adults across their lifespan, it’s not something we get a lot of training on in pediatric training. We have educated ourselves so that we can provide that kind of specialized care.”

Wallis says that toxic stress over time changes brain chemistry and can cause architectural changes in the brain that may be permanent.

“So these kids are coming in with that, and they’re also coming in with grief and loss of separation from a parent – even if that parent was neglectful or abusive. They may have had substance exposure in utero, so they’ve been impacted early on, even before life started. And a lot of times they’ve just had a lot of hits really early in life. You’re supposed to know early in life that you have an adult caregiver who you feel safe and secure with, and not having that can be incredibly disruptive. There’s lots of early childhood research to tell us that.”

The issues are complex to solve. What the team offers is a stable place of support and continuity of care, something that’s usually been lacking. Wallis says they also are interested in disrupting the generational cycle of neglect and abuse.

“Sometimes these are kids who were neglected and then grow up to be adults who are neglectful. People don’t realize how disruptive it is for kids to have a treatment plan and a parent not to be able to follow through, not because they don’t love that kid in some way, but because of their own mental health or substance abuse, and that’s really difficult for kids.”

A Safe Haven

Wallis gives an example of a 10-year-old boy who has been in foster care for more than five years and had his parents terminate their rights. He watched as all of his younger siblings were adopted, and he got “bounced all around the state.” On top of all that, one of his biological parents died in an accident. Wallis’ team discovered the boy was in danger of losing a wonderful therapist he had been seeing. They strongly advocated that he be kept under her care despite where he ended up, and fortunately, a foster care family is working to make that happen. It gives her hope for his future.

“Sometimes it’s just hit, after hit, after hit. These kids do things that bother people and that is often what brings them to attention. Kids who are in the most need of love ask for it in the most unlovable ways. Many of these kids do things for love and attention because they’ve never learned how to get positive attention. And this kid really tries but just doesn’t have a lot of things in his corner. That kid needs lots and lots of help and support.”

When kids move from placements, they often lose their social support. They may have to switch schools, change their health care team and lose their therapist.

“One of our jobs in clinic is that we really try, especially for some of our higher needs kids, to think about how to maintain some of those connections and try not to disrupt those things every single time one of these kids moves.”

Wallis says the next step is to do more community outreach and establish resources for providers who are serving these kids. There are resources on the clinic’s website.

One thing the clinic team does, for example, is to go to group homes to do educational programs. It’s amazing what some of the families and kids don’t know. Peevy recalls teaching a group of teenage moms in a group home basic lullabies that they could use with their newborns. The young moms were fascinated to learn this would be a good bonding activity.  Some had never heard songs like “Twinkle, Twinkle, Little Star.”

“We think a lot about how we can help community providers who are seeing these kids already and don’t have the infrastructure or contract support that I have. A lot of what I can do, I can do because I have a nurse coordinator who can track things down and who can go to DSS,” she says.

“A lot of community pediatricians do this work, but without the support that I have. Our next steps in thinking about how we meet some of the need is seeing how we can empower some community pediatricians to get what they need to see these kids, especially the pediatricians in the more rural areas, because you can’t do this in ten minutes in a well visit.”

She’s excited that MUSC has many investigators across a wide range of disciplines studying the impacts of childhood trauma and toxic stress, and how that affects health across the lifespan.

“It impacts pretty much every area of medicine. It is not just behavioral health. It affects your heart disease risk, your stroke risk, and there are lots of things about toxic stress that we can’t fix. A lot of the social determinants of health it’s hard to think about how to fix on a systems level, but I think there’s a lot of opportunity to get patients and kids into good treatment and into thinking about resiliency and what it is that they need to be successful adults. That way we can break the cycle so that there’s not a third generation in foster care.”

Wallis, who did a pediatrics research fellowship training, says she’s not naive enough to believe they can solve the problems of poverty, mental health issues, abuse and neglect. She has no doubt they can improve the system of care, though.

“These kids use a lot of health care, a lot of mental health services and a lot of crisis services, and they don’t necessarily get the care that they need in between. A DSS worker who has a caseload of 60 kids cannot provide this one kid with the level of attention and care that they need. Our job is to say how can we help with the piece that we’re experts at, which is the medical and behavior health needs.”

It’s why Wallis and team members spend so much time with parents in the clinic. They are the heroes who will make this change happen. There is a need for more of these heroes, and it’s Wallis’ hope that the clinic might help convince more people to consider becoming foster care and adoptive parents.

“Kids with the right environment and the right support can do really well. The people who can put in the time and effort and not give up are the most important. They’re the ones who day in and day out are dealing with the behaviors and the most backlash from the kids because the kids know they will be there no matter what. So foster parents typically take the majority of the abuse,” Wallis says.

“And our team believes that the ones who are really willing to stick it out and to see the good in these kids, they’re really fun to work hard for.”

For more information on MUSC Children's Hospital's Foster Care Support Clinic or about becoming a foster care parent, call 843-876-7023.

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Editor's Note: This is the second in a three-part series about MUSC Health's Foster Care Support Clinic at the Children's Hospital.

Part 1 in the series: Foster care children get greatest gift of the season - a new home 

The story follows the heroic adoption journey of the Sismilich family and the impact they've had on two brothers who have joined their family. 

Part 3 in the series: Teen adoption becomes a work of art for family

This story describes the adoption of a teenage girl by parents who finally got her the treatment she needed for ongoing pain problems and love having her in their lives.