Elizabeth M Wallis, MD, MSHP

Approximately 500,000 children spend time in foster care annually, and the majority of children in foster care have complicated and unmet health care needs.

 Many primary care providers (PCPs) have little training in caring for this vulnerable population; may not be familiar with their specific healthcare needs; and may not recognize symptoms of traumatic stress.

	Up to 80% of children entering foster care have 1 or more chronic medical conditions, 80% have behavioral health problems, and 60% have developmental delays.

 Systemic challenges exist, including a fragmented healthcare system; pressure for foster placement stability within the child protective services system; insufficient education and oversight of foster parents; and poor access to qualified mental health professionals.

	All these issues further impact the health of this vulnerable population and can be difficult for PCPs to navigate.

	Childhood exposure to trauma is a public health crisis, and repeated exposure increases the risk of long-term adverse health effects. A growing litany of evidence repeatedly demonstrates the long-term morbidity and mortality associated with traumatic stress, including increased rates of heart disease, obesity, chronic lung disease, alcoholism, disorders of the immune system, depression, suicide, and multiple cancers, to name a few.

 explored the health of youth who spend time in foster care and found these children had significantly more physical and mental health problems as compared with children not in foster care.

	Despite these outcomes, PCPs receive very little education in screening, recognition of symptoms, and understanding effective treatments for trauma. In fact, when we asked our colleagues informally what came to mind when we mentioned childhood trauma, the majority referenced a physical injury, car accident, or emergency department evaluation. Instead, PCPs must consider child maltreatment as a form of trauma and understand that there are multiple typologies of child abuse, including neglect-the most common reason for foster care placement. Furthermore, children in foster care often view being placed in foster care and moving from home to home as more traumatic than the abuse or neglect that resulted in the placement.

	Trauma experiences cannot be separated in evaluating a child in foster care, and these experiences impact development, medical disease, psychiatric illness, and social functioning. Most PCPs have experience in managing common behavioral problems in children that can be aptly applied to children in foster care. Children in foster care often have sleep difficulties, inattention and impulsivity, aggression, food hoarding, and toileting issues. For children in foster care, PCPs must view these concerns through a trauma-informed lens and assess the impact that trauma may have on the child’s presenting problem.

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	For example, a child in foster care who is hiding linens after wetting the bed might be doing so because he was beaten after nighttime accidents in his previous home. The management strategy the family employs is the same as for a child not in foster care: not to punish, but to use positive rewards for progress, and have a nonpunitive plan when there are accidents. In understanding the impact of trauma, PCPs can remind foster parents that the trauma may impact the length of time the behavior persists or affect the intensity of the child’s response.

	Another example pertains to the child who hoards food in foster care. Caregivers and PCPs need to remember that the child might be hoarding food because of previous food insecurity. Although a foster parent may encourage the child to remember there is sufficient food available, the deeply held fear of insufficient food will not disappear overnight, and neither will the behavior.

	Trauma symptoms are diverse and often are confused with other behavioral health disorders, such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, depression/anxiety, complex grief, and bipolar disorder. Inadequate attention to trauma results in poor behavioral outcomes, misdiagnosis, and inappropriate psychiatric medication prescribing. Many children in foster care are on multiple psychotropic medications, often for diagnoses for which they aren’t indicated, and at rates that far exceed Medicaid controls.

	Common symptoms of trauma vary by age but broadly include symptoms related to hyperarousal or misperceiving danger; difficulty with core functions of sleep, appetite, and toileting; distrust or inappropriate friendliness; and intrusive thoughts, nightmares, and flashbacks. Understanding these symptoms can help providers to tease out comorbid conditions and limit inappropriate prescribing.

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	It is also imperative for PCPs to realize that therapy is the cornerstone of trauma treatment, at times with medications to manage comorbid conditions. Effective, empirically supported trauma treatments exist, including 

Trauma-Focused Cognitive-Behavioral Therapy

. It is important to have a basic understanding of these treatments and knowledge of local availability so that children can be referred to an appropriate treatment modality. Secondly, children in foster care can display trauma symptoms but often have other comorbid psychiatric and medical conditions. It is equally important to recognize and manage these comorbid conditions with the help of specialty providers as needed.

	Understanding the health needs of children in foster care, referral to evidence-based therapy, and managing any comorbid health conditions are keys to improving the health of children in foster care. Often PCPs are these children’s first access to healthcare, so a standard framework for evaluating children in foster care can help ensure that their health needs are met. As strong advocates for vulnerable children, PCPs have the opportunity to effect significant impact on these children and their long-term outcomes.

	1. Council on Foster Care, Adoption, and Kinship Care; Committee on Adolescence; and Council on Early Childhood. Health care issues for Children and adolescents in foster care and kinship care. 

	2. Committee on Early Childhood, Adoption, and Dependent Care; American Academy of Pediatrics. Health care of young children in foster care. 

	3. Forkey H, Szilagyi M. Foster care and healing from complex childhood trauma. 

	4. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. 

	5. Turney K, Wildeman C. Mental and physical health of children in foster care. 

	6. Rubin DM, Feudtner C, Localio R, Mandell DS. State variation in psychotropic medication use by foster care children with autism spectrum disorder. 

	7. Dosreis S, Yoon Y, Rubin DM, Riddle MA, Noll E, Rothbard A. Antipsychotic treatment among youth in foster care. 

	Ms Halasz is a pediatric nurse practitioner in the Foster Care Support Clinic, Medical University of South Carolina (MUSC), Charleston. Dr. Wallis is assistant professor of Pediatrics, Medical University of South Carolina, and director, MUSC Foster Care Support Clinic, Charleston. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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Approximately 500,000 children spend time in foster care annually, and the majority of children in foster care have complicated and unmet healthcare needs.

Elizabeth M Wallis, MD, MSHP

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Trauma-informed care helps children in foster care