Foster Care

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As I think back over the years I have been practicing, one encounter comes to mind that has had the most impact on my development as a psychiatrist.

Soon after I finished my residency at a large, urban hospital that served the poor and uninsured in Dallas, I found myself entering the world of private practice with patients who had insurance, jobs, homes, food, and transportation. I also started working part time at a psychiatric hospital in a nearby rural town. A psychologist I befriended at the hospital joined my practice and soon asked me to become a consulting psychiatrist at the foster care agency where he worked. I had no experience with foster children, but I thought I needed to take on whatever jobs I could find while I was building my practice. It was a relatively new foster care agency, so I only saw up to 8 teenagers a month.

One of the case workers from the agency brought the children to my office every month either for a medication follow-up or an initial evaluation. The agency was well-run and took care of these children in a most respectful and kind manner. As a result, the number of youngsters in the agency grew rapidly. They could no longer be brought to my office every month in the agency van, so I drove about 20 miles to see them at the agency’s center. It was hard hearing their stories of abuse, neglect, and difficult times at such a young age. I tried connecting with these young, neglected, and unloved children-but many of them were closed off to any human connection out of fear of rejection or being moved again and ripped away from their caring foster parents. Many were angry, defiant, oppositional, and I had to build some sort of trusting relationship if I wanted them to be compliant with the medication I was recommending.

One day I decided to gather up a bunch of cool, flashy pharmaceutical pens that had been left at my office that week. More pens than we needed . . . ones you couldn’t just buy at a store. These pens had different colored lights, bright colors, liquids in them, lights to read by, etc. I brought them with me and as I finished with each encounter, I invited the child or teen to pick the pen he or she wanted. Soon the kids were requesting to be the first in line to see me so they got first pick of the pens. They looked forward to their visits and couldn’t wait to see what kind of pens I had brought to their visit.

One of those children was an 11-year-old boy who had been terribly hurt by family members and was unable to trust anyone in authority. He was so sad and depressed; no sparkle in his eyes. He wouldn’t talk, or look at me, and was quite reluctant to even take one of the pens. He did want to feel better though, and I promised him I could help him. He started on an antidepressant and within weeks was smiling, laughing, and enjoying life again. I saw him every month for the next 3 years, and he manipulated the case workers so he could be seen first nearly every time to get the best pen. He would show his latest pen off to the other kids waiting for their appointment.

Unexpectedly, the boy was moved to a new foster home where his older brother lived. I didn’t even know where he was staying. I felt bad not getting a chance to say goodbye to him.

It wasn’t long after this encounter that the pens stopped coming to the office so I had no more fancy pens to bring to the children. By then I was visiting the agency twice a month and seeing 24 children.

Two years passed. And then one day the same young boy’s name was once again on my schedule. No one told me he was back at the foster care agency and that he was scheduled to see me.

When he came into the office, I hardly recognized him; he was wearing braces, growing facial hair, and had developed into a young man. He gave me a hug and sat down in his chair. When I asked what brought him in to see me, he said, “I don’t need any medication, Dr. Kelt. I just told my case worker I was depressed so I could come see you. I missed our talks and I missed my pens.”

I laughed and realized he still knew how to manipulate his way to get what he wanted and had to break the news that I no longer had any pens to offer. He grinned and said that was okay. Then he reached down under his chair and pulled out a shoebox and placed it on my desk. He asked me to open the box, and when I did I saw every pen that he had been given over the 3 years I had seen him. There must have been over 40 “one of a kind” pens in that shoebox. He looked up at me, got a little teary-eyed, and said he took them everywhere he went over the 2 years he was gone. He had changed foster homes multiple times but never gave up those pens. He told me that no matter where he was, he always felt connected when he had his pens.

I had no idea how important those objects were to him, or how important his relationship with me was to him until that moment. When you have been neglected, made to feel so unimportant, passed around from place to place as though your life doesn’t matter, any genuine caring attention you can give that young person means the world.

The boy stayed at the agency until it was time for him to graduate, and he left with his box of pens.

I continue to work at the foster care agency, and it has now been 28 years. I drive there 3 times a month and bring a third-year medical student with me as part of her psychiatry rotation. I have no more pens, but sharing this experience with my medical student is the most effective way I can teach young physicians the importance of finding a way to connect with their patients.

Disclosures:

Dr. Kelt is Assistant Clinical Professor at Texas A&M Health Science Center, and Psychiatry Clerkship Director at the Dallas Campus of Baylor University Medical Center. He also has a private practice in Dallas, TX.