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(p. 23) Counseling Students Living in Foster Care 

(p. 23) Counseling Students Living in Foster Care
(p. 23) Counseling Students Living in Foster Care

Emily S. Fisher

and Kelly S. Kennedy

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date: 23 July 2019


In the United States, approximately 400,000 youth are in foster care (U.S. Department of Health and Human Services [DHHS], 2014). This represents a significant decline over the last decade (DHHS, 2013b). Children of color, specifically Black/African American and Native American children, are overrepresented in the child welfare system, while Latino children are overrepresented in some states and underrepresented in others (McRoy, 2014). The majority of research on overrepresentation of children of color in the child welfare system has focused on Black/African American youth, with findings that indicate that overrepresentation is likely due to a complex interplay of risk factors that contribute to and stem from low socioeconomic status, such as “young maternal age, absent fathers, and poor child health” (Putnam-Hornstein, Needell, King, & Johnson-Motoyama, 2013, p. 42). As of 2012, 42% of youth in foster care were White, 26% were Black or African American, 21% were Hispanic, and 2% were American Indian or Alaskan Native (DHHS, 2013a).

Understanding the impact of being in foster care is complicated. A counselor working with these youth must consider both the series of events that led to placement in the system and the experiences a youth has during his or her time in this system (Zlotnick, Tam, & Soman, 2012). That is, youth enter the foster care system after some kind of significant negative life experience, such as abuse or neglect, and once in the system, many youth continue to have experiences that place them at greater risk for negative outcomes (Harden, 2004). What is clear, however, is that youth involved in the foster care system, “face multiple threats to their healthy development, including poor physical health, attachment disorders, compromised brain functioning, inadequate social skills, and mental health difficulties” resulting from risk factors and conditions such as maltreatment and poverty (Harden, 2004, p. 31).

One theme that emerges for students in foster care is the critical importance of social support. Although it is important for counselors to understand issues (p. 24) facing students in foster care and counseling approaches that may benefit these students, simply being present and consistent in the lives of students in foster care can provide some much-needed support and help students feel more open to seeking and accepting help.

Basic Considerations

The research on youth in foster care is fairly grim, with a host of well-documented negative outcomes extending into adulthood. There is no way to deny the multiple sources of risk for these young people, but as with any highly vulnerable group of children, there are those who demonstrate extraordinary resilience in the face of adversity. There is a small but growing body of literature on factors that promote resilience among foster youth, which provides hope for and insight into how counselors may be able to help foster youth build the internal capacity to overcome obstacles and reach their potential.

Development and Mental Health

Some youth enter the foster care system due to the inability of a parent to provide adequate care (e.g., parental incarceration, death, abandonment, substance abuse, or mental illness); most youth enter the foster care system after experiencing multiple forms of significant and substantiated maltreatment, including physical and emotional neglect and emotional, physical, and sexual abuse (Bruskas, 2008; Chipungu & Bent-Goodley, 2004; Harden, 2004; Oswald, Heil, & Goldbeck, 2010). Child maltreatment is associated with a host of negative outcomes, and research has found that up to 80% of children entering foster care have significant mental health problems (Kerker & Dore, 2006), up to 60% have health problems (Oswald et al., 2010), and up to 60% have developmental delays (Leslie et al., 2005). Youth in foster care experience both externalizing and internalizing disorders, with up to 40% to 50% of youth meeting diagnostic criteria for disruptive behavior disorders and 30% to 40% meeting criteria for mood disorders (Oswald et al., 2010). Foster youth also experience high rates of post-traumatic stress disorder (PTSD), with those who experienced sexual or physical abuse impacted the most (Oswald et al., 2010). Trauma and PTSD are associated with a host of other psychological sequelae such as depression, anxiety, and behavior disorders (Dorsey, Briggs, & Woods, 2011). Adolescents in foster care have high rates of alcohol and marijuana use (Thompson & Auslander, 2007), and research has found that up to 35% of adolescents in foster care have a substance use disorder (Vaughn, Ollie, McMillen, Scott, & Munson, 2007). Adolescents with PTSD or conduct disorder may be at greatest risk for substance abuse (Vaughn et al., 2007). Foster youth are at much greater risk for suicide than their peers, with 15% of adolescents in foster care reporting suicide attempts (Pilowsky & Wu, 2006).

(p. 25) Raviv, Taussig, Culhane, and Garrido (2010) report that common events experienced by foster youth, such as physical and sexual abuse, school and caregiver transitions, and exposure to community violence, are cumulative in terms of their negative impact on their development and mental health. Thus, each additional type of negative life experience places foster youth at higher risk for significant mental health problems (Raviv et al., 2010).

Mental health services may be available to foster youth through child welfare systems, ranging from outpatient therapy to residential treatment to inpatient psychiatric care. At least half of youth in foster care receive mental health treatment (Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004), and because the likelihood of having received treatment increases with age, approximately three quarters of adolescents in foster care report having received outpatient therapy at some point in their lives (McMillen et al., 2004). Foster youth who have been sexually abused and those who have been physically abused who also exhibit significant behavior problems are the most likely to have received mental health services (Garland, Landsverk, Hough, & Ellis-MacLeod, 1996). Foster youth who experienced neglect or parental abandonment are less likely to receive services, despite the impact these events have on development (Garland et al., 1996). Research consistently finds that many foster youth who need mental health services do not get them (Petrenko, Culhane, Garrido, & Taussig, 2011; Shin, 2005). This may be particularly true for foster youth of color, with research finding that African American, Latino, and Asian foster youth receive fewer mental health services than their White peers, despite high levels of need (Dettlaff & Cardoso, 2010; dosReis, Zito, Safer, & Soeken, 2001; Kerker & Dore, 2006; Leslie et al., 2000, 2004; McMillen et al., 2004).

Attachment and Relationship Development

Secure attachment is the emotional bond between a child and a caregiver (Harden, 2004); the foundation of trust and the capacity to build relationships throughout life (Thompson & Auslander, 2007); and the way in which children come to see the world as reliable and understand that they are lovable (Gilligan, 2000b). Secure attachment allows children to seek comfort from caregivers and to feel safe exploring different environments (Gilligan, 2000b; Harden, 2004). Children in foster care who experience family instability and maltreatment are more likely to experience insecure or disorganized attachment (Harden, 2004). Along with the unstable, unreliable, and traumatic family experiences leading to placement in foster care, children in foster care may experience continued attachment disruption and trauma by being removed from their families, being maltreated in foster care, and being in multiple foster care placements (Bruskas, 2008; Kerker & Dore, 2006; Thompson & Auslander, 2007). These experiences can also impact foster youths’ peer relationship development, with research finding that childhood maltreatment is associated with fewer prosocial skills and more difficulties in peer (p. 26) relationships, and foster youth may experience further difficulties due to school transitions as they change placements (Price & Brew, 1998).

Contemporary perspectives offer a more fluid understanding of how early attachment impacts later development, recognizing that early attachment experiences are extremely important, but also that later experiences can shape developmental trajectories (Dore, 2014). This means that although children in foster care frequently have disrupted attachment with their parents, they can form healthy attachments with other people, such as peers, relatives, foster parents, mentors, or teachers (Gilligan, 2000b). These relationships may take on greater meaning for children in foster care (Gilligan, 2000b), and social support is frequently cited as an important factor to promote resilience, including educational attainment, for current and former foster youth (Collins, Paris, & Ward, 2008; Courtney & Dworsky, 2006; Day, Riebschleger, Dworsky, Damashek, & Fogarty, 2012). For example, research suggests that social support from classmates, such as being liked by classmates and not being teased by peers, has been found to predict engagement in fewer risk behaviors (Taussig, 2002). Further, Gilligan (2000b) explains that parental relationships remain salient for many children in foster care, and children benefit when these relationships with important others can be nurtured in a way that allows children to stay connected with their parents in some manner rather than forcing children to choose between caregivers.

School and Educational Attainment

Students in foster care often have poorer school outcomes and can struggle to meet the academic, social, emotional, and behavioral demands of school. They experience greater absenteeism (National Working Group on Foster Care and Education, 2014) and higher rates of grade retention (Burley & Halpern, 2001; Stone, 2007). Students in foster care experience greater school mobility due to entering foster care and changes in placements (Burley & Halpern, 2001; Stone, 2007); their school records may become lost, and school credits may not always transfer between schools (Bruskas, 2008). Older students are twice as likely to be suspended and three times as likely to be expelled from school (National Working Group on Foster Care and Education, 2014). All of these are risk factors for poor school functioning and dropping out (Stone, 2007; Trout, Hagaman, Casey, Reid, & Epstein, 2008). The National Working Group on Foster Care and Education (2014) reports that only 50% of foster youth complete high school by the age of 18.

Students in foster care are significantly more likely to receive special education services (National Working Group on Foster Care and Education 2014; Stone, 2007), with as many as 44% of foster youth receiving special education services (Geenen & Powers, 2006). Research consistently reports that foster youth are often classified as emotionally disturbed (Stone, 2007), likely due, in part, to the impact that trauma has on foster youths’ ability to regulate emotions and to “focus, remember, learn, and engage in self-control” (Harden, 2004, p. 36). (p. 27) Research has also found that foster youth classified as emotionally disturbed are at much greater risk for school problems than foster youth in general and nonfoster youth classified as emotionally disturbed (Smucker, Kauffman, & Ball, 1996).

Although positive school climate has not been found to serve as a protective factor for students in foster care (O’Malley, Voight, Renshaw, & Eklund, 2014), school stability appears to be an important factor in promoting educational attainment. In a study of former foster youth attending a four-year university, researchers found that more than 80% had completed high school or some amount of college prior to leaving foster care, with just over half having attended only one high school and almost another quarter having attended only two high schools (Merdinger, Hines, Osterling, & Wyatt, 2005).

Foster Care Placement

There are three types of general placements in the foster system, with approximately half of youth placed in nonrelative family care, a quarter in kinship care, and 16% in group homes or residential institutions (Annie E. Casey Foundation, 2011). Although most states have laws that give preference to placing children in kinship care when possible, the number of children served in this manner decreases as children age, such that adolescents are more likely to be placed in group homes or residential facilities (Annie E. Casey Foundation, 2011). These nonkinship placements also typically serve children and adolescents who have more serious health or mental health needs (Harden, 2004). A subset of nonrelative family care is therapeutic or treatment foster care, which requires foster parents to have specialized training to better meet the needs of children who have more intense social, emotional, and behavioral issues and who often have been unsuccessful in other placements (Hussey & Guo, 2005; Thompson & Auslander, 2007).

Foster care placements range from supportive and nurturing to neglectful and abusive, and everything in between. Negative experiences while in foster care, most often taking the form of poor parenting practices, put children at further risk for negative outcomes, and research has found that placement instability, that is changing foster placements, increases childrens’ risk for negative outcomes (Harden, 2004). Although it can be difficult to tease apart the contribution that pre-foster and in-foster care experiences have on placement instability and children’s outcomes, it has been found that even when children entering foster care did not exhibit behavior problems, having an increased number of placements was predictive of having more internalizing and externalizing problems (Newton, Litrownik, & Landsverk, 2000; Rubin, O’Reilly, Luan, & Localio, 2007). In fact, each additional foster care placement predicts an increase in academic skill delays (Zima et al., 2000) and internalizing and externalizing disorders (Hussey & Guo, 2005). Foster youth in group homes, often placed there because of difficulty in other placements, are at the highest risk for behavior and achievement problems (Gramkowski et al., 2009).

(p. 28) Transition to Adulthood

The difficulties faced by youth in foster care continue as adolescents transition to adulthood and are no longer eligible for services, which is often referred to as aging out of the child welfare system. In fact, “the majority of youth who age out of foster care face enormous challenges” (Avery & Freundlich, 2009, p. 248), with research suggesting that these young adults are at even higher risk for emotional and behavioral disorders and substance abuse once they age out because they have access to fewer supports and resources than they did while in foster care (Pecora, White, Jackson, & Wiggins, 2009). Further, young adults leaving foster care are at increased risk for housing instability and homelessness (Dworsky, Napolitano, & Courtney, 2013), which in turn is associated with greater victimization, more emotional and behavioral problems, and more criminal involvement than those with more stable living situations (Fowler, Toro, & Miles, 2009). These young adults also have more health problems, leading to an inability to work and dependence on government financial support services (Zlotnick et al., 2012). These risks are even greater for young adults who experienced placement instability while in foster care, with a history of placement instability being associated with higher rates of teenage pregnancy and repeat pregnancy among young women who have aged out (Dworsky & Courtney, 2010), increases the likelihood of substance abuse (Stott, 2012), and higher rates of homelessness among young adults who have aged out of the system (Dworsky et al., 2013).

Fostering Connections Act

Research on risk and resilience of foster youth is leading to ongoing policy changes aimed at providing greater protections and rights for these young people. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (P.L. 110-351; Fostering Connections Act) was enacted to promote greater well-being among foster youth, to promote greater stability for youth in home and school placements, and to provide funding for states to extend services for youth through 21 years of age if they are engaged in work or school-related activities (Leone & Weinberg, 2012; Schelbe, 2011; Stoltzfus, 2008). Provisions of the Fostering Connections Act related to school are aimed at increasing school stability by taking into account the educational appropriateness of the school when foster placements are made, such as considering the proximity of the new placement in relation to the child’s current school, and by providing funding for education-related transportation costs to reasonably allow the child to stay at his or her current school (Leone & Weinberg, 2012). The Foster Connections Act also requires that, if it is not in the child’s best interest to stay at the current school, the child must be immediately enrolled in the new school, and all of his or her educational records must be provided to the new school (Leone & Weinberg, 2012). Although the intentions and spirit of the Foster Connections (p. 29) Act are noble, it is difficult to measure if all states and counties have met its requirements and have been provided adequate funding to support them.

Counseling Approaches

When starting counseling with students in foster care, counselors may feel unprepared to address the intensive needs of this group. Instead of thinking of school-based counseling as a “fix,” with counselors somehow trying to undo the impact of students’ experiences, counselors can consider it as one additional area of support for students in foster care. With this mindset, they can approach counseling in a way that helps build students’ resourcefulness and coping strategies, providing building blocks to help students become better self-advocates and to be more open to accessing counseling and other support services throughout their lives. With some additional training, counselors may be able to help students in foster care address traumas that are impacting their healthy development and ability to access curriculum and social support at school. Further, counselors can help to coordinate school services with any outside mental health services students are receiving.

Empowerment and Self-Determination

Being placed in foster care impacts almost every aspect of students’ lives (Lawrence, Carlson, & Egeland, 2006). Students often have no control over the changes in family, school, community, and peer group, and they must endure great ambiguity once they are in a system with no clear outcomes or endpoints (Lawrence et al., 2006). A first step in helping students feel more empowered is to ensure that they understand why they are in foster care (Gilligan, 2000b). Counselors can use open-ended questions to find out what students know about the situations leading to foster care and make sure that students have accurate information appropriate to their developmental level. A next step in this process is to ensure that students understand their rights and whom they can talk to if they feel they are being treated poorly (Gilligan, 2000b). It might be necessary to provide students with guidance about how to communicate effectively if they believe their rights are being violated, such as using scripts or role plays. Another important step, especially for older students, is to engage students in discussions about planning for the future and the ways that students can impact their own outcomes (Gilligan, 2000b). Foster youth may need guidance and support to learn how to make decisions, especially difficult decisions that have long-reaching consequences (Quest, Fullerton, Geenen, Powers, & the Research Consortium to Increase the Success of Youth in Foster Care, 2012). These are critical skills for foster youth to have to help them be successful when they age out of the system (Geenen & Powers, 2007), and whenever possible, counselors can collaborate with and include students’ social (p. 30) workers in these discussions as a way to empower students to understand and communicate their experiences and desires.

Solution-Focused Brief Therapy

In promoting self-determination, it is helpful for counselors to view students in foster care as “resources in the process of seeking solutions in their lives” (Gilligan, 2000b, p. 119) and to recognize that self-efficacy, an important aspect of resilience, can be developed when students believe they can overcome obstacles and master situations (Drapeau, Saint-Jacques, Lépine, Bégin, & Bernard, 2007). Using a strength-based, problem-solving counseling approach, such as solution-focused brief therapy (SFBT), is ideal to help empower foster youth. A good deal of research supports the use of SFBT (Kim & Franklin, 2009), which has been applied to youth in foster care in individual and family therapy. For example, Koob and Love (2010) found that SFBT with foster youth and families increased placement stability; Cepukiene and Pakrosnis (2011) found that foster youth who participated in individual SFBT made significant behavioral improvements. Based on the research on SFBT, Pakrosnis and Cepukiene (2012) concluded that it “can be considered not only an effective but also an appropriate method for treating adolescents … and can be recommended as one of the first choices when working with adolescents from foster care” (p. 314). Chapter 2 of this volume provides more in-depth information about using SFBT, including examples of how to structure goal setting and the miracle question.

Social Support

Research has found that foster youth have better psychological adjustment when they experience more positive social support (Legault, Anawati, & Flynn, 2006), but students in foster care often have multiple disruptions in their relationships that impact social support. In counseling, they may need targeted interventions to develop appropriate social and communication skills, with the overarching goal of increasing social support. One important source of social support comes from peers, as these relationships help meet students’ needs for acceptance and companionship and can serve as models for developing other relationships (Haskett, Nears, Ward, & McPherson, 2006; Price & Brew, 1998). In fact, Price and Brew (1998) posit that for foster students, “peer relationships are essential for the normal progression of development by providing [them] with a unique socialization context in which to learn and develop cognitive, social, and emotional competencies” (p. 201). Counselors can help students in foster care by assessing the quality of their social skills and peer relationships and providing interventions for areas of deficit. For example, students may need to learn how to enter a new group, how to stay engaged in social activities rather than withdrawing, and how to manage their anger and aggression in a prosocial manner (p. 31) (Price & Brew, 1998). Further, students in foster care benefit from engaging in recreational activities with peers, which serves multiple purposes, including helping them develop peer relationships and feeling a sense of purpose and mastery (Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Gilligan, 2000b). Counselors can help students develop skills to successfully navigate the social demands of these activities and skills for social problem solving and conflict resolution.

Relationships with foster families and families of origin are another source of social support. As Gilligan (2000a) states, “Children in [foster] care are not easily parted emotionally from their family of origin” (p. 43). In counseling, it is important to help students process their feelings about being removed from home and being placed in foster care separate from their feelings about their foster family. For example, Kerker and Dore (2006) report that younger foster students may blame themselves for family dysfunction and older foster students may project anger about their situations onto their foster families, both of which can disrupt bonding with foster families. Counselors can help students in foster care recognize that building relationships with their foster families does not make them disloyal to their families of origin. Counselors may want to emphasize that families of origin can care about their children even if they cannot care for them (Gilligan, 2000b). Research has found that adolescents, including those who have aged out of the system, report having ongoing contact with their biological families, especially their mothers and siblings, and this can serve as an important source of social support (Collins, Spencer, & Ward, 2010; Courtney & Dworsky, 2006). Counselors can work with older students in foster care to help them develop appropriate expectations about interactions with their families, set boundaries in a way that feels comfortable, and cope with changes that have occurred in the family since their removal (Collins et al., 2008).

Cognitive-Behavioral Therapy for Trauma

Cognitive-behavioral therapy (CBT) is widely recognized as an effective approach for addressing a range of psychological issues experienced by children and adolescents, such as depression, anxiety, anger, and PTSD, all of which can impact students in foster care. In recent years, CBT protocols have been developed specifically to address trauma and the associated trauma-related sequelae in children and adolescents (Dorsey et al., 2011), and CBT has been successfully adapted to be relevant and sensitive across cultures (Kar, 2011). In reviewing CBT for PTSD and related disorders, Dorsey and colleagues (2011) found that effective treatments generally include the following common elements: psychoeducation about trauma and its impact on children; affect regulation and relaxation training to help manage the psychological and physiological responses to trauma; gradual exposure and desensitization related to memories of the trauma or other triggering stimuli; and cognitive restructuring to provide more realistic and helpful ways to process the trauma. Research suggests that schools can be an ideal place to use (p. 32) CBT to address trauma because many barriers to treatment, such as attending counseling sessions, are reduced in the school setting (Rolfsnes & Idsoe, 2011; Wong et al., 2007). Two CBT-based interventions are reviewed here, trauma-focused CBT (TF-CBT) and Cognitive Behavioral Intervention for Trauma in Schools (CBITS), both of which have evidence of effectiveness and are appropriate to use with diverse student populations. A third intervention, Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS), which incorporates CBT and is appropriate for students in foster care who have experienced chronic trauma and life stress is reviewed in Chapter 2 of this volume. With some research and training, counselors can use these programs to help address the needs of students in foster care.

Trauma-Focused Cognitive-Behavioral Therapy

For students who have experienced significant trauma, either as a single event or as a series of events, TF-CBT can help them work through trauma and develop strategies to manage psychological and physiological responses (Mannarino, Cohen, & Deblinger, 2014; Weiner, Schneider, & Lyons, 2009). TF-CBT typically consists of 8 to 16 sessions and can be used with both children and adolescents (Mannarino et al., 2014). TF-CBT involves a significant parent component, and in the case of students in foster care, this purpose can be served by substituting a trusted caregiver, such as a foster parent, in place of a parent (Mannarino et al., 2014; Weiner et al., 2009). If it is not possible to engage a caregiver in the treatment, counselors can still use TF-CBT and provide periodic updates to caregivers via phone or email (Mannarino et al., 2014). There is strong evidence to support the use of TF-CBT with diverse students, including students in foster care, who have experienced different types of trauma (Cary & McMillen, 2012; Dorsey et al., 2014; Mannarino et al., 2014; Weiner et al., 2009). In reviewing the research, Mannarino and colleagues (2014) found that TF-CBT has shown efficacy for addressing trauma-related symptoms for students who have experienced sexual abuse, domestic violence, traumatic loss of a parent, and multiple traumas. For diverse youth in foster care, it was effective in reducing symptoms of traumatic stress and increasing youths’ strengths (Weiner et al., 2009). Further, there is a growing body of literature about implementation of TF-CBT in school settings (Fitzgerald & Cohen, 2012).

Mannarino and colleagues (2014), who have widely researched TF-CBT, provide a review of the process of treatment, which occurs primarily in parallel individual counseling sessions with the student and caregiver, with some conjoint sessions. The first phase, stabilization and skill building, helps students regulate emotions and behaviors. In this phase, psychoeducation is used to help students and caregivers understand the psychological and physiological responses to trauma, the efficacy of TF-CBT, and, for caregivers, how the trauma is related to students’ behavioral issues and how to manage these behaviors more effectively. Skills training, which provides students with foundational regulation and coping strategies, includes relaxation training, such as guided imagery, deep (p. 33) breathing, and progressive muscle relaxation; affective regulation, such as identifying and expressing feelings and developing a picture of a “safe place” to go to calm down if the feelings become too strong; and cognitive coping, which teaches students how thoughts, feelings, and behaviors are connected. These skills are practiced in session and at home as students gradually talk more about the trauma.

The second phase, trauma narrative and processing, helps students gain mastery over their trauma-related memories. In this phase, the student and the counselor collaborate to identify what specific trauma or traumas will be the focus of the narrative. Students can develop their trauma narrative in many different forms, such as writing a story or poetry, creating a book, drawing pictures, or using play materials. As students develop their narratives, the counselor encourages them to add more details, including their thoughts and feelings, to help the process of desensitization. As cognitive distortions or maladaptive thoughts arise, counselors can use cognitive processing techniques, such as Socratic questioning or reframing, to help students develop new ways to process the trauma. At this point in treatment, counselors help students put their trauma in context by focusing on what they have learned, how they have grown and gotten stronger, and how they would help others who have had similar experiences.

When students have completed their trauma narratives, they are ready to move into the final phase, consolidation and closure, which is typically done through conjoint sessions with caregivers. In this phase, students share their trauma narratives with their caregiver, which empowers students to face their trauma, process it in this new context, and build communication with the caregiver. During this phase, counselors can help students and caregivers plan for the future by engaging them in conversations about how they will manage future reminders of the trauma and practicing safety and assertiveness skills, as appropriate. Throughout the three phases, in vivo exposure techniques can be used to address specific and generalized fears.

There are some important considerations for counselors before they use TF-CBT with students in foster care. First, it is critical to ensure that there is some degree of placement stability so that treatment is not interrupted, which can be particularly damaging if it occurs during the second phase of treatment when desensitization is occurring as students create their narratives (Mannarino et al., 2014). Second, this is not an appropriate treatment to use if students are suicidal, and treatment should be suspended if students become suicidal (Mannarino et al., 2014). In this case, counselors should focus on emotional regulation and other coping skills rather than directly addressing the trauma. Third, TF-CBT should not be the first treatment for students with serious behavior problems or psychotic disorders; rather, these issues need to be addressed first with other evidence-based interventions before considering using TF-CBT to address trauma (Mannarino et al., 2014). Finally, counselors should be thoughtful about ensuring that students feel calm and safe and ready to return to class at the end of sessions (Mannarino et al., 2014).

(p. 34) Cognitive Behavioral Intervention for Trauma in School

CBITS is a group counseling intervention for students in 4th through 12th grade who have symptoms of PTSD, anxiety, and depression related to exposure to violence and other trauma (Jaycox, Kataoka, Stein, Langley, & Wong, 2012; Stein et al., 2003). It was originally developed for schools serving primarily low-socioeconomic-status, urban, middle school students (Stein et al., 2003), but it has been expanded for use with older teens. Research has shown a significant decrease in self-reported PTSD and depression symptoms and parent-reported psychosocial dysfunction for students receiving the CBITS intervention (Stein et al., 2003). Research has also found that CBITS may have a small but positive impact on academic achievement (Kataoka et al., 2011). Because CBITS was originally developed for recent immigrant students, counselors are encouraged to incorporate student examples and adapt activities to make it meaningful for students whenever possible. For example, when cultural adaptations were made to the program to be relevant for rural American Indian students, such as modifying case examples, adding native linguistic concepts, and embedding allegories in the lessons, similar results were found for decreased symptoms of PTSD and depression (Morsette et al., 2009). Although the program contains a parent component, this is not a requirement, and students can benefit without parent participation (Jaycox et al., 2012), which makes this program a good fit for students in foster care.

The full CBITS program includes 10 group counseling sessions, 1 to 3 individual counseling sessions, 2 to 4 parent education sessions, and 1 teacher education session (Jaycox et al., 2012). The 10 group sessions are conducted using a combination of psychoeducation, examples and games, worksheets, and homework, and students are encouraged to apply what they are learning to their individual situations and problems (Stein et al., 2003). Jaycox and colleagues (2012) outline the content of the program, which includes

  • psychoeducation for students, parents, and teachers about common reactions to trauma and stress to help everyone understand the connection between past traumatic experiences and current symptoms and behaviors;

  • relaxation training for students and parents through guided imagery, progressive muscle relaxation, and breathing;

  • helping students understand how thoughts, feelings, and behaviors interact;

  • teaching students how to challenge dysfunctional thoughts;

  • teaching students how to use a feeling thermometer to monitor their emotional responses and progress;

  • working with students individually and in groups to recognize triggers and avoidance behaviors related to the trauma;

  • creating a fear hierarchy and making a plan to systematically approach fears; (p. 35)

  • using talking, writing, and drawing to gradually expose students to their traumatic memories and help them process the memories using the new skills they are learning; and

  • improving students’ social problem–solving skills by teaching them new ways to cope with problems occurring in their lives.

Beyond the Counseling Office: Transition Planning

The transition from adolescence to adulthood often looks very different for youth in foster care. For many youth not in foster care, the transition to adult independence happens gradually, often with ongoing financial and emotional support from their families as they pursue higher education or seek employment. In contrast, many foster youth age out of the foster care system, usually at age 18 years, which forces them to “attain independence prior to achieving stability in housing, education, and employment” (Collins, 2014, p. 468). One requirement of the Fostering Connections Act is that caseworkers help youth in foster care develop a personalized transition plan 90 days prior to aging out of the foster care system (Collins, 2014), but this three month plan is clearly insufficient because foster youth who age out of care are highly vulnerable for a host of negative outcomes as described earlier in this chapter. Developing effective transition plans is well within the scope of practice for some counselors working in schools, and as is done with students receiving special education services, it is suggested that transition planning be initiated early for all foster youth, long before they age out of the system (Daining & DePanfilis, 2007).

Integrating the research on transition planning in special education with the research on transition planning in foster care, a clearer picture emerges about what best practices might look like for all students in foster care. At a very basic level, transition planning works most effectively when interagency collaboration is highly valued and families are actively involved (Geenen & Powers, 2007; Morningstar, Kleinhammer-Tramill, & Lattin, 1999). The student should always be at the center of any transition planning meeting (Kohler & Field, 2003), and there is no limit to who else can be included, such as school personnel, caseworkers, foster parents, and other interested and invested adults, which could possibly include biological parents or relatives as appropriate. Self-determination is often cited as a critical component of students’ transition to more independent living; if all meetings and discussions are focused in a way that promotes students’ self-determination, students will feel more empowered to identify and communicate their goals and dreams; advocate for themselves; actively participate in creating and evaluating the steps through which they will reach their goals; and feel more comfortable asking for help when they need it (Kohler & Field, 2003; Morningstar et al., 1999; Mueller, Bassett, & Brewer, 2012). It is important to note that the skills for self-determination can be taught to students, perhaps through counseling, as (p. 36) described earlier in this chapter. Research has also found several specific practices that lead to better outcomes for students in special education, which seem highly applicable for students in foster care regardless of their educational status, including participation in employment preparation programs, paid and unpaid work experience during high school, and training in social skills and daily living skills (Landmark, Ju, & Zhang, 2010).

In considering the specific needs of students in foster care, a major component of transition planning must include identifying specific supportive individuals and developing social support networks that will help youth prior to and after they age out of foster care (Collins, 2014; Merdinger et al., 2005; Pecora, 2012). This ongoing relationship with caring and supportive adults is consistently cited in the literature as one of the best predictors of a successful transition into adulthood for foster youth (Geenen & Powers, 2007; Pecora, 2012). Many adults could serve in this role, such as mentors, counselors, caseworkers, foster parents, or biological family members. Given that many youth transitioning out of foster care reconnect with parents and other family members, sometimes even living with them as young adults (Collins, 2014; Collins et al., 2010), part of the transition plan may need to include family counseling to help students develop more functional relationships with family members. Educational attainment and postsecondary education are two other key areas to consider in transition planning with students in foster care. This might include identifying needs and resources to support high school graduation, as this increases the likelihood of postsecondary education and employment (Pecora, 2012). Similarly, students in foster care need concrete advisement and guidance about college, financial aid, and college preparation classes (Merdinger et al., 2005).

Related to transition planning, programs that teach independent living skills are commonly available for youth in foster care, although there is little standardization across organizations and states (Collins, 2014; H.R. Rep. No. HEHS-00-13, 1999). These programs often include services to assist youth in completing high school, finding employment, and learning independent living skills such as money management, hygiene, and nutrition (H.R. Rep. No. HEHS-00-13, 1999). Although research suggests that these programs can be beneficial, they have not been found to “alter the course of the transition trajectory in a positive direction that impacts outcomes at a substantial level” (Collins, 2014, p. 473) for foster youth. One finding that stands out related to these programs is that foster youth who participated in independent living programs were more likely to stay in contact with former caseworkers and counselors, increasing social support networks for these young adults (Lemon, Hines, & Merdinger, 2005). These ongoing, stable relationships with adults can help former foster youth better navigate the transition to adulthood and learn strategies to meet the demands of independent living (Collins, 2014), highlighting once again how critical social support is for ongoing success.

Although effective transition plans cannot address all of the ongoing challenges of young adults with this level of heightened vulnerability, they can help ease the transition to adulthood. Similarly, school-based counseling services are not likely (p. 37) to be the only supports that youth in foster care need or are provided with, but they represent an important resource in the lives of these youth.


Casey Family Programs

Casey Family Programs is a foundation that aims to improve the lives of children and adolescents in the foster care system. The website includes unique resources such as current research, case studies, data overviews, and policy and practice toolkits.

Cognitive Behavioral Intervention for Trauma in Schools

This website provides information about the CBITS program and online and in-person trainings.

Foster Care to Success

Foster Care to Success is a website aimed at students in foster care who want to attend college. This website provides college funds, scholarships, mentorship programs, and a comprehensive knowledge center with valuable resources for students and for professionals involved in helping students transition out of high school.

National Resource Center for Permanency and Family Connections

The National Resource Center for Permanency and Family Connections is a comprehensive website that provides foster youth, foster parents, and social service–based professionals with various types of resources. Online toolkits are available for training on working with youth, foster siblings, guardianship, family engagement, and placement stability. Handbooks and podcasts are also available that provide valuable insight on the intricacies of foster parents, foster youth, emancipation, and legislation.

Trauma- Focused Cognitive-Behavioral Therapy

This website provides information, resources, and printable handouts and worksheets related to TF-CBT.