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Oral health may be causing behavioural or attachment issues in out of home care: check it regularly!

The topic of wellbeing in the caregiving space (kinship, permanent, foster or adoptive parenting) is important. Dr Stacy Blythe offers us advice, from research, that identifies how we might better impact attachment, minimise behavioural issues and improve outcomes when there has been prenatal exposure to harmful drugs or other impacts on executive functioning. Dr Stacy Blythe is well qualified to advise us as a parent of 8, with 4 biological and 4 non-biological children, and also a registered nurse, associate professor in the school of nursing and midwifery and deputy director of the translational research and social innovation group at Ingham Institute (health and wellbeing that make sense practically). 00:00 - Start 01:20 - Care for newborns falls short in out of home care 04:35 - Caregivers receive less prenatal or antenatal training or support 07:40 - Attachment might be compromised if we don't intentionally engage 11:31 - Methamphetamines like ICE may mean our children don't make eye contact 12:30 - Techniques that reward eye contact help 14:30 - Oral health care may compromise attachment too so we need to make it a priority 20:14 - Dentistry can be traumatic 23:41 - We don't know their biology, so check, check and check again 24:57 - Be sensitive and pre-emptive as they become teenagers searching for identity 25:50 - Executive function may be the cause of behavioural issues due to trauma history 29:37 - Communicate executive functioning deficits to others, like a new boss 32:18 - Resources and remember to look after yourself first  


This is Sonia Wagner, representing PCA Families in one of our recordings that capture lived experience and best practice research-based learning that assist kinship, permanent and adoptive parents/carers in supporting young people. PCA Families has a zero tolerance of child abuse. I would like to acknowledge the traditional custodians of the land on which we meet and pay respect to elders past and present and express our intention to move together to a place of justice and partnership.

Today we are discussing health and wellbeing in the caregiving space, whether kinship, permanent or adoptive parenting and caregiving with Dr Stacy Blythe.

Dr Stacy Blythe is a parent of 8, with 4 biological and 4 non-biological children, and also a registered nurse, associate professor in the school of nursing and midwifery and deputy director of the translational research and social innovation group at Ingham Institute, which is essentially an organisation focused on health and wellbeing practices that make sense practically, for South West Sydney, Australia and the world.

Dr Blythe’s research is focussed on children in out of home care and their families and she offers insight into infants who were prenatally exposed to harmful drugs. Dr Blythe has a developmental trauma postgraduate qualification and develops training for health care and social service providers.

01:20 We are delighted to have you here joining us. Welcome Dr Blythe. What else can you tell us about yourself?

Dr Blythe - Thankyou very much Im just glad to be here. That’s pretty much me.

01:22 You are amazingly talented at juggling a lot of different things. I wonder if you could share with us some of the research that you identified in how care is offered to newborns in out of home care and where that might fall short, relative to normal maternal health care offered to birth parents?  What should carergivers do about that? How can they help their child?

Thankyou very much. One of the things that I have learned through my own personal experience as a careprovider and my experience as a registered nurse is that the supports that we offer to kinship, foster and adoptive parents differs to those supports offered to biological families. One really good example of this is nurse home visiting.

In Australia we have this assumption of universality of our health care system, meaning that everyone gets equal support and those who require more support get more support. And this is true to an extent but only if you actually fit the mould.

So when I refer to families that are socially constructed, families that are foster or kinship or adoptive, they don’t get those same supports. In Australia we have nurse home visiting programs to work with women and infants and the whole family really, to help them in those early days after they have given birth. Usually referral happens during pregnancy or shortly after giving birth. For those families who have good support systems and who are knowledgeable and experienced, they may only have a handful of visits with the nurse. But for those families facing adversity, who have other issues that they might be dealing with such as domestic violence or homelessness or addiction issues or mental health issues, they may have increased visits where the nurse is working with the parents to help them parent well despite the adversity they may be experiencing.. The whole idea is to keep the baby front of mind so they can be a good parent in the middle of a bad situation. But because the referral pathways are usually during pregnancy or at birth, that automatically excludes foster, kinship and adoptive families. So one of the things I’m trying to do is change that so that we have pathways to offer the same support.

If we think about families in this particular context and the children that are in this context, often they have a history of trauma, they may have a history of prenatal substance exposure, and they may have experienced abuse and neglect, and all of those things create an environment where those children have increased caregiving needs. So we are not equipping the carers early on to let them know that, so it’s a battle, raising that awareness and empowering carers and adoptive parents to the best carers they can be.

04:35 Often caregivers are very time poor too so going somewhere externally to get support can be challenging in itself. I assume the system is still based on going to the maternal health centre for support?

I did a study recently with carers, adoptive and kinship carers, across Australia, to look at who is accessing child and family health nursing services (different names in different States). What we found was that about a quarter of carers were taking their children to the maternal health centre and a very small percentage were getting visits from nurses in the home. So the majority of carers were getting nothing. That was really concerning.

Out of the sample, we had about 200 carers who participated in the online survey, between a quarter and a third had never had children of their own. So they hadn’t received prenatal or antenatal classes where you talk about how to feed a baby, bath a baby, settle a baby, they didn’t have that assistance from midwives or nurses after birth where they show them how to do those sort of things, they had never been educated on how to select formula or how to give a bottle. So the fact that we aren’t giving them this nursing support is a real issue. And when interviewing these carers, they talked about scenarios where a caseworker would turn up with a child and a tin of formula on a Friday evening, hand over the baby and said good luck.

Even for older more seasoned carers who have had children of their own and who chose to provide care to children in need at a later stage in life, they do have parenting experience, but the rules change and things change over time. The age difference in my children and foster children is 13 years. A lot of things changed during those 13 years: how we sleep the baby, how we interact with the baby, how their brains develop. You forget and things change. So there is a real need for this sort of service.

07:40 One of the things that you highlighted for me is the significant difference in children who have experienced methamphetamines vs opioids. Can you explain that for us?

One of my real keen interests in the out of home care system is children who have that history of prenatal substance exposure. There is a syndrome called neo-natal abstinence syndrome, which describes a constellation of symptoms that babies have after birth when they have been exposed to high levels of opioids during pregnancy (heroin, methodone, morphine). They experience withdrawal like an adult would when withdrawing from drugs like that. Those babies present quite irritably, they cry, they tremor, shake and often need hospitalisation and medication to help them through that phase. But what we are finding increasingly in the Australian context is that more babies are being born with methamphetamine addiction or ICE.  The way that particular drug works on the brain differs. Opioids interfere with our adrenaline and noradrenaline because that’s what happens when someone cuts us off in traffic or if we are really excited and our heart starts racing that is adrenaline. Because it interferes with adrenaline, they have a lot to do with regular body processes. The reason they become nauseous and experience vomiting is because of the alteration with noradrenaline to help them through that phase. Methamphetamine babies don’t experience that and they don’t experience the withdrawal symptoms. So these babies are very sleepy and sleep all of the time and are sluggish and progress very slowly. But for young babies they can appear like the perfect baby.

So one of the scenarios that we can see is that we might place that baby with a family that has other children, but because the baby is so quiet and placid, everything seems fine, but the danger with babies born with methamphetamine is that they self soothe and they don’t reach out and they don’t attach. They don’t actively seek out carers eye contact. If you are a busy carer or a busy adoptive parent you might take it for granted that this is the perfect baby, rather than going out of your way to stimulate the baby. Simple things like learning to pass a rattle from one hand to the other is really important to happen during the infant phase with the left and right sides of the brain talking to each other. So if we are not telling carers and engaging with carers and letting them know they need to actively stimulate the baby, we are setting up the baby for poor outcomes. That can devastate carers who find out later that some of the behavioural experiences they are experiencing is because they didn’t have that stimulation early on.

11:31 Babies who have been substance exposed whether opioids or methamphetamines or a cocktail of substances, don’t have the ability to engage with their primary caregiver like a “normal” baby would. When newborns are born they automatically look for human faces to connect. Babies from substance exposure don’t do that. They look away. So they don’t want to engage. So its so important we teach carers how to make eye contact with a baby that doesn’t want to look at them. We are human too. That’s also challenging for carers to fall in love with and attach to that baby where the baby is looking away all the time. It’s really It takes a lot of emotional intelligence.

12:30 Are there techniques that work?

I interviewed a carer recently who didn’t have children of her own but had been caring for 10 years. She realised after about 10 years that a theraplay therapist gave her ideas. She had a 6 month old baby that wasn’t giving her eye contact. The therapist said get one of those rubber bouncing ball and hold the baby on it and when the baby looks at her they bounce the baby on the ball. So every time I look at my primary caregiver I get a positive reinforcement where she smiles and I get a bounce on the ball. When we are born our brains are only 25% developed. So what happens in our environment dictates the way our brains become wired. If children aren’t having those positive experiences, their brains aren’t going to wire in a typical fashion.  That can make  it challenging as they get older more challenging.

14:30 Another area of health and how treatment falls short is in relation to oral health. Can you tell us a little more about how oral health of children in out of home care may be affected?

This is an issue that I have been working on for the past two years and it is surprising to me how little research and how few policies there are to guide caring for the oral health of children in out of home care. We recently conducted a peer review of literature to see what kind of research was out there on oral health care in out of home care and found very little

We found some things that reported they have bad oral health or that some things are so severe they need general anaesthetic and need attention in theatre because their teeth are so bade.

We did a small study and interviewed carers about their experiences and found a number of things occurred that compromised children’s oral health. In Australia, we generally have some sort of health assessment that occurs when a child is placed into care and some follow up more comprehensive assessment later. These are pretty consistent that we assess them and we see that they have oral health issues. But once they are in the system the problem is accessing services. The public health system has long waiting lists andaccessing private services often requires pre approval from the agency or government department.

The other thing we found is that if we are on a witing list to see a public health clinician, if the child moves, we often lose that appointment. If we go from one place to another, there is no clear handover. I also don’t know how many carers are going to open the child’s mouth and check their teeth when they get there.  There is an assumption that there are other things that are more important like attachment. But if we have children with poor teeth who are in pain or who can’t eat properly that is going to affect their behaviour and interfere with their ability to attach.

The other thing is that depending on the age of the child, we have no awareness of what oral health training they have received prior to coming into your care. There may be an assumption that an 8yo child knows to brush their teeth twice a day when in fact that wasn’t something they had done prior to coming into care.  There are so many different issues. We also don’t know when the children are having regular visits with their (birth) parents, we don’t know if they have the same oral health training and know not to put juice in their bottle for example. Know to follow up with healthy foods.

I had a personal experience of how often we gave fruit, as we should have been giving fruit two times a day not 7 or 8 times a day, as the acid on the teeth had a big impact.

There is emerging evidence of the correlation between poor oral health and prenatal substance exposure. It needs to be more explored but we need to be more understanding that there is a correlation of poor enamel on their teeth because of prenatal exposure.

Thinking about early childhood educators as well.  We also need to explore their training so that they can actively looking for and identify oral health.

That goes back to our carers and parents, if they aren’t actively looking for information about oral health, they can be missing information. For example we don’t put juice in the bottle and we don’t offer solids until they are 6 months old. Some of our practices before now have been different to that, so we need to stay up to date. Oral health isn’t just about brushing our teeth. Its about eating well and having having everythiung in moderation and having enough calcium in the diet. A lot of these children may have experienced nutritional deficits during pregnancy. After they are born they can still have those nutritional deficits and we need to look at that in their diet to make sure that they are getting what they need.

20:14 The other aspect to dentristy work is that there may be other trauma . Lying in a dentist chair when you have experienced abuse or even something as simple as flossing where you bring blood into the mouth. What have you discovered with trauma informed needs?

Like a lot of people thinking about going to the dentist makes me feel quite traumatised. I am not a big dentist fan. But you are exactly right though. For a lot of these children who have a history of trauma, one of the big things about trauma is giving up control. Children don’t have the control to get out and fight back quite often. That’s why trauma is so overwhelming. Sitting in a dentist chair where they can’t see and the dentist is making noises and maybe even causing pain, can be extremely triggering and overwhelming for them. There are a lot of things that we can do. We can slowly introduce them to the dentist. Today we are going in the chair up and down and play with the light. For one of my children we had a filling to complete and it took us two hours to get it done because she would get so scared, so there was a lot of talking and soothing. But often the dentists hasn’t been given any training and they ask the child to just sit still. We go to a general rather than paediatric dentist. There is still more to be done in being trauma aware and receiving training.

23:41 Are there any other areas which long term carers may need to be aware of as regards health matters for their children?

I think one of the things we really need to be aware of is we know so little about their history.Even though we have open adoption and we have some things on the file, we really don’t know the history. So we need to be really committed to regular health checks and that we don’t make assumptions that everything is ok. One of the things I have become aware of personally is that these children are really good at covering things up. They may not always tell you when they have an ache or pain or something isn’t quite right.  It so important to get their eyes or ears or teeth checked. I do a lot more checking with these children as it’s different when the biology comes from somebody else and we don’t know what they are predisposed to.

24:57 Attachment and belonging

One of the things too is that we talk so much about attachment and belonging. Where children live with a family that they are not born into, as they reach adolescence, all of those issues as a teenager are so much more complex. It’s not just coping with the family tree experience from kinder or primary school.  As teenagers things become exacerbated because its really that time of looking for their identity. We need to be really sensitive and pre-emptive during that time and have those conversations.

25:50 Executive Function

One of the things when I do training with carers is helping them to understand executive function. Executive function is higher order thinking that boils down to three things. Its attention span. It’s the ability to be flexible in situations and its short term working memory. 

Children who have a trauma history often have poor short term executive functioning. This often creates behavioural issues or what appears to be behavioural issues, but it’s really a neurological deficit. The great thing is that executive function can be trained. Its like a muscle. The more you practice it the more you can improve it but you have to be intentional and use that executive functioning.  In parenting these children we need to be creating situations where they can use their mental flexibility or their short term memory or their attention span.

27:26 The chance to have success with practicing those things. And it looks different across the trajectory. These children developmentally might be a different age to what they are chronologically. You might look like a 16yo but acts like a 4yo. A l ot of that goes back to their ability to use their executive function. A kindergartner might not be able to follow the rules because they can’t control their impulses. You may have a 16yo that wants to learn to drive but they don’t have the mental flexibility to adapt to a changing situation. The rule in my house has been you need to be able to navigate public transport on your own before you can go for your learners. Until you can develop that skill to navigate public transport, you cant navigate the care. Its my responsibility to say you have a deficit here and we are going to put these things in place to help you with that.

29:37 First Job

If they have a poor short-term working memory, unless they communicate that to their boss, they can be seen as lazy. An example might be a young apprentice on the job site whose boss says I want you to move those bricks and then put that stuff over there and then get me a coffee. With a short term working memory after he has completed the first task he may then be wandering around and the boss comes back and goes why didn’t you do what I asked you to do?

One of ours was working in a supermarket and as my husband walked away from dropping him off he noticed him on his phone. After work we bailed him up - what were you doing on your phone at work?. He explained he was writing notes on his phone to write a list of what to do so he didn’t forget the details of what to do. That’s a great strategy.

It’s a neurological deficit and creating those strategies is important. I have heard from carers saying the children are too dependent. But at the same time their mobile phones are their best friends.

One of my boys was consistently late coming home. He just loses track of time. He employed the strategy of setting a time reminder on his phone. He has never been late since. Giving them those strategies will make all the difference to them.

32:18 Any other tips or resources to discuss

There are some really good websites that I refer to.

The Australian Childhood Foundation have really wonderful training like their Certificate in Developmental Trauma which was phenomenal.

The Australian Research Alliance for Children and Youth. They advocate all across Australia for the education and wellbeing of children.

I would also like to emphasise that we need to look after our own health first. We need to model things well for the children and in moderation. I made the mistake of trying to be the perfect Mum and now I think did I try too hard as I watch my 29yo daughter struggle with trying to be the perfect Mum. I wonder is that my fault. Now I am no longer the perfect mum. But modelling health eating, exercise, mindfulness and deliberately going out of our way to build ourselves up. Our cup needs to be full if we are going to fill up the cup of the children that we love. It takes short periods of time on a regular basis.

We see that as spoiling ourselves but if we don’t do it our children aren’t going to grow up and do it. If you feel the need to make an excuse because you sat down for 10 minutes, don’t make the excuse.


To anyone making the time to listen to this recording, thankyou for giving up your valuable time for the benefit of the young people in your life.

Until next time have an amazing week.


Australian Childhood Foundation

ARACY – Australian Research Alliance for Children and Youth

Intervention Ideas for Children Impacted by Opioids (US Office of Special Education Programs)