Infant Mental Health for the Pediatric Nurse Practitioner

Infants in Out-of-Home Placement (Foster Care)
Infants who are removed from their families due to child abuse and/or neglect and placed in foster care are at high risk for emotional and behavioral issues. Once placed into foster care, infants tend to stay longer, may change placement more frequently, exhibit behavioral problems, developmental delay, and physical health problems. Violent and abusive home situations and inconsistent, neglectful, or harsh adult caregivers cause high levels of stress and changes in the infant’s brain.

Infants may respond to this increased stress with feeding issues, sleep issues, strong and/or prolonged startle reflex, irritability, self-comforting deficits, and fearfulness. The move from birth home to foster home can elicit feelings of loss and grief even when leaving an abusive situation. Infants who have been abused/neglected may exhibit fearful reactions to even gentle touch, to exhibit fearful interaction with men (if male was abuser), have nightmares, or have insatiable hunger (in situations of history of neglect and undernutrition). Some estimates suggest that up to 60% of young children in foster care have developmental delay. 

Very often infants are placed in foster care, with very limited birth, developmental, family, medical, and health history. The PNP needs to work diligently to obtain medical records. In addition, information should be solicited from foster parents, birth parents, child welfare worker, law guardian, previous primary care clinician, child care providers, newborn screening laboratories, and immunization registries. The PNP should also make time to clearly explain results to child welfare worker and foster parent. Foster parents are often undervalued by the community and need to receive reinforcement for their critical role in keeping infants safe. The PNP should determine if a referral to early intervention is indicated. The PNP is in a critical position to coordinate the care and advocate for the infant in foster care, but this will likely require a great deal of effort.

Mental Health Assessment should include: medical conditions and recommendations for referrals, additional evaluations, and tests, developmental assessment, mental health assessment (reason for referral, family relational history, infant’s social relatedness, relationships with other children, infant’s contact with biological family, assessment of the infant’s behavioral organization, assessment of infant’s response to stress, quality of play, assessment of infant’s strengths, assessment for signs and symptoms of maltreatment, assessment for risks of placement disruption, and diagnostic and clinical formulation) (Silver & Dicker, 2007). This mental health assessment should be performed within 30 days of the child's admission to out-of-home care. Who exactly performs the assessment may be determined by provider availability as well as state child welfare policy. Assessment conditions need to take account of the infant’s developmental level, use an interdisciplinary approach, and provide an emotionally safe environment for the infant with the presence of a known caregiver (Silver & Dicker, 2007).  

Reflection:  How does my office specially identify children in foster homes? What kind of additional supports do I provide for the child and family?

References and Resources:

The Mental Health Needs of Children in Foster Care:

A Call to Action of Behalf of Maltreated Infants and Toddlers:

Bernard, K. & Dozier, M. (2011). This is my baby: Foster parents' feelings of commitment and displays of delight. Infant Mental Health Journal, 32, 251-262.

Kools, S. & Kennedy, C. (2003). Foster child health and development: Implications for primary care. Pediatric Nursing, Jan-Feb.

Leslie, L., Gordon, J. & Lambros, K. (2005). Addressing the developmental and mental health needs of young children in foster care. Journal of Developmental and Behavioral Pediatrics, 26:  140-151.

Osofsky, J. & Lieberman, A. (2011). A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children. American Psychologist, 66: 120-128. 

Silver, J. & Dicker, S. (2007). Mental health assessment of infants in foster care. Child Welfare, 86, 35-55.

The use of documentation prompts as an intervention strategy for primary care providers managing children in out-of-home placement: