Filling medical gaps in foster care

The pediatrician may be one of the only sources of advocacy, support, stability, and advice for the child in foster care. In that role, he or she must understand the needs and experiences of a foster child compared with other patients in the practice so that the unmet needs of this vulnerable population can be addressed.

Children in foster care are at increased risk for physical, mental, and developmental problems.¹ Children in foster care lack the orientation that most other children get early in life from their families who orient young children to expectations and requirements within their social unit through activities, rules, and discipline. Similarly, hospital systems institutionalize what can be expected and what constitutes appropriate employee behavior and work performance.

Children in foster care are often deprived of these basic orientations.² The pediatrician can help this vulnerable population by developing interdisciplinary collaboration and coordination skills as well as an understanding of the many health issues faced by foster children.

Challenges for the pediatrician

Caring for children who have suffered neglect, abuse, or trauma is challenging, time consuming, and difficult. Care coordination for this population is essential but difficult because of a number of factors. The population is often transient, and it is not always clear to the pediatrician with whom they need to coordinate care-parents, child welfare professionals, or the courts.³

Further, case workers and foster parents may not be aware of all the child’s health conditions and needs, and they may also lack the skills to access and negotiate the healthcare system for their child/client.³

Recommended: What is 'consent by proxy' for  medical care?

The foster care/child welfare system is a unique bureaucracy with structure, regulations, and systems with which the pediatrician, more than likely, is not familiar. The pediatrician also may be faced with a number of other challenges including:^3,4

• Incomplete health records documenting prior care, history, development, and current medical problems.

• Case workers/foster parents with poor knowledge of current medical and social issues.

• Identifying the appropriate person from whom to obtain consent for procedures and routine healthcare.

• Inability to refer for evaluation and treatment of needed services from subspecialist, dental, or mental health services.

A vulnerable population

More than a half million children are in foster care every day in the United States, and the foster care environment can sometimes lead to further instability and trauma in this already vulnerable population. Estimates of chronic health problems among foster children range from 30% to 80%. The American Academy of Pediatrics (AAP) designates foster children as having a special healthcare need because of the significant prevalence of health disparities. For example, it is estimated that between 35% and 50% of children in foster care have a special healthcare need compared with less than 20% in the general population.¹

NEXT: Mental health

Mental health

Nearly all children in foster care have some sort of family dysfunction.³ Significant numbers of foster children suffer from at least 1 mental health disorder, and nearly two-thirds continue to suffer some form of neglect. Depression, social problems, anxiety, and posttraumatic stress disorder are commonly experienced by patients in foster care.²

Additionally, in 1 study nearly half of children in foster care demonstrated observable, clinical signs of mental health problems. Unfortunately, large numbers of these patients did not receive mental health services.⁵

The pediatrician is often asked to prescribe psychotropic medications for behavior problems, and he or she will certainly have patients on these medications. One challenge for the pediatrician is knowing whether these medications are appropriate or not, with increasing concerns of polypharmacy. Compared with children enrolled in Medicaid, psychotropic medications are 3 times more likely to be prescribed to children in foster care.³ This is particularly concerning given the patients’ needing but not receiving mental health services.

Related: Trauma informed care for kids in foster care 

The most common drugs prescribed include antidepressants, attention-deficit/hyperactivity disorder drugs, and antipsychotic agents.⁶ Significant numbers of children are noted to start these medications before the age of 6 years, and there is not yet good data for long-term outcomes.⁷

When prescribing these medications, the pediatrician should keep the following general principles in mind:⁸

• Begin treatment with a single agent at the lowest starting dose.

• Increase dosing gradually with careful monitoring for adverse effects.

• Single-agent therapy is generally the goal when possible.

• The symptoms the pediatrician sees such as hyperactivity or inattention may be a result of trauma, neglect, abuse, anxiety, or depression rather than manifestations of an inattention hyperactivity disorder.

• Always consider referral for a mental health evaluation any child in foster care with symptoms.

Educational challenges

Foster children sometimes move frequently, which can inhibit their educational achievement. Whether from frequently changing schools and the resultant challenges or having credits not transferred between school systems, there are many barriers to a productive education. In 1 study, only 50% of children graduated high school while another showed that 89% achieved a GED, but at a rate 6 times that of other children. Poor educational attainment can further these children’s vulnerability and impact their future educational attainment as well as adult quality of life.²

Physical health

Both missed and abnormal screenings are common among children in the foster care system. Whereas missed preventive visits often occur before entry into the foster care system, foster children often continue to fail to meet routine health maintenance benchmarks while in foster care. Examples of the chronic health conditions and failed screenings include:¹

• Failed vision screening.

• Failed hearing screening.

• Poor oral health with lack of dental screening and existing dental caries.

• Failure to obtain screening for anemia and lead exposure.

• Missing growth parameters such as growth failure, low height, and decreased head circumference.

• Both underweight and increasingly obese.

NEXT: Medical evaluation of a child on foster care

Medical evaluation of a child in foster care

The pediatrician often will need to assess a child’s healthcare needs with little or no available health history. Guidelines for the appropriate care of the foster child are available in the AAP document Fostering Health: Health Care for Children and Adolescents in Foster Care (available at bit.ly/AAP-fostering-health)⁹ and the Child Welfare League of America (CWLA) Standards of Excellence for Health Care Services for Children in Out-of-Home Care (bit.ly/CWLA-standards-excellence).nIn general, the foster child should have 3 visits over the first 3 months (Table^3,8). The pediatrician will need to support and educate the foster child, caregivers, and child welfare workers throughout the entire process as well as continue to monitor for any signs of abuse and neglect.

Within 30 days, the foster child should undergo a comprehensive assessment wherein the pediatrician is able to review all health records including developmental and mental health assessments. The pediatrician should assess how well the child is adapting to foster care and perform any appropriate screenings and developmental assessments. Approximately 60 to 90 days after placement, the child should be seen again to review health, mental health, and developmental issues as well as assess how well the child is adapting to his or her new environment.³

There are also several extra visits in addition to the general guidelines outlined in Bright Futures.¹⁰ Infants should be seen monthly between their regularly scheduled preventive visits for the first 6 months of life as well as have an additional visit at 21 months. From age 2 to 21 months, it is recommended that the foster child be seen every 6 months. The pediatrician is monitoring growth and development, assessing adjustment to placement, and monitoring any chronic medical problems as well as being alert for the development of any mental health issues.⁸

The pediatrician should consider a full mental health evaluation, but that may not be available in all communities. Instead, he or she could consider using an age-appropriate screening tool such as the Strengths and Difficulties Questionaire^11,12 or the Early Childhood Screening Assessment.¹³ The AAP has a mental health toolkit (bit.ly/AAP-mental-health-toolkit) that discusses many of the available tools. Another tool for the pediatrician is the list of evidence-based mental health services for children in foster care published by the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org/). 

Adolescents as a special population

Adolescents in foster care are at increased risk of poor educational outcomes with significantly higher dropout rates compared with other low-income and minority populations. Additionally, only 50% of foster children graduate from high school, and many of these are with an equivalency certificate.³

More: Refugee chuldren deserve compassionate care

Because of potential exposures to substance abuse, physical and sexual abuse, violence, and neglect, youth in foster care have a number of risk factors associated with sexually transmitted infections (STI). In fact, foster youth appear to be at increased risk of documented STIs (females, Trichomonas; males both gonorrhea and chlamydia) compared with children not in foster care.¹⁴

NEXT: Transitioning from foster care

Transitioning from foster care

In many transitions out of foster care, adolescents are essentially expected to become an adult overnight, often without the benefit of families or other social support networks to fall back on. This population is highly vulnerable and outcomes are poor with high rates of unemployment, homelessness, and lack of adequate healthcare.¹⁵

Many of these youth report being ill prepared for the transition, and significant numbers experience unwanted outcomes such as victimization, sexual assault, and problems with the law.

The Patient Protection and Affordable Care Act of 2010 addresses some of these young adult issues by making children aging out of foster care eligible for Medicaid until age 26 years.¹⁶ Other legislation allows for the use of federal funds to help provide housing for youth aging out of foster care.¹⁵

Recommendations for serving foster children

Because these children are victims of abuse, neglect, or trauma, they may not have appropriate advocates. The pediatrician can advocate not only individually but also for community development of services to better serve this vulnerable population.

To create a better medical home for the foster child, the pediatric practice should calibrate health needs, developmental and educational needs, dental health, anticipatory guidance, and office systems for the specific healthcare needs of children in foster care.^1,3,4,8,16 

Next: What does being in foster care mean for health?

Caring for foster children can be challenging, time consuming, and difficult, but it also can be tremendously rewarding. Doing so provides the pediatrician with the opportunity to advocate for their own patients as well as advocate on a local or state level to improve the overall care for this vulnerable population.

REFERENCES

1. Deutsch SA, Fortin K. Physical health problems and barriers to optimal health care among children in foster care. Curr Prob Pediatr Adolesc Health Care. 2015;45(10):286-291.

2. Bruskas D. Children in foster care: a vulnerable population at risk. J Child Adolesc Psychiatr Nurs. 2008;21(2):70-77.

3. Council on Foster Care, Adoption, and Kinship Care; Committee on Adolescence; Council on Early Childhood. Health care issues for children and adolescents in foster care and kinship care. Pediatrics. 2015;136(4):e1131-e1140.

4. Jee SH, Tonniges T, Szilagyi MA. Foster care issues in general pediatrics. Curr Opin Pediatr. 2008;20(6):724-728.

5. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry. 2004;43(8):960-970.

6. Zito JM, Safer DJ, Sai D, et al. Psychotropic medication patterns among youth in foster care. Pediatrics. 2008;121(1):e157-e163

7. dosReis S, Tai MH, Goffman D, Lynch SE, Reeves G, Shaw T. Age-related trends in psychotropic medication use among very young children in foster care. Psychiatr Serv. 2014;65(12):1452-1457.

8. Szilagyi M. The pediatric role in the care of children in foster and kinship care. Pediatr Rev. 2012;33(11):496-507; quiz 508.

9. Task Force on Health Care for Children in Foster Care. Fostering Health: Health Care for Children and Adolescents in Foster Care. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2005. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Fostering-Health.aspx. Accessed March 28, 2017.

10. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. Available at: https://brightfutures.aap.org/bright%20Futures%20Documents/BF3%20pocket%20guide_final.pdf. Accessed March 28, 2017.

11. Stone LL, Otten R, Engels RC, Vermulst AA, Janssens JM. Psychometric properties of the parent and teacher versions of the Strengths and Difficulties Questionnaire for 4- to 12-year-olds: a review. Clin Child Fam Psychol Rev. 2010;13(3):254-274.

12. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry. 2000;177(6):534-539.

13. Gleason MM, Zeanah CH, Dickstein S. Recognizing young children in need of mental health assessment: development and preliminary validity of the early childhood screening assessment. Infant Ment Health J. 2010;31(3):335-357.

14. Ahrens KR, Richardson LP, Courtney ME, McCarty C, Simoni J, Katon W. Laboratory-diagnosed sexually transmitted infections in former foster youth compared with peers. Pediatrics. 2010;126(1):e97-e103.

15. Reilly T. Transition from care: status and outcomes of youth who age out of foster care. Child Welfare. 2003;82(6):727-746.

16. Council on Foster Care, Adoption, and Kinship Care; Committee on Early Childhood. Health care of youth aging out of foster care. Pediatrics. 2012;130(6):1170-1173.

Dr Bass is chief medical information officer and associate professor of medicine and of pediatrics, Louisiana State University Health Sciences Center–Shreveport. The author has 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.