Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. e703-e709 (doi:10.1542/peds.2008-0360)
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ARTICLE

Medical and Mental Health of Children Entering the Utah Foster Care System

Julie S. Steele, MN, FNPa,b and Karen F. Buchi, MDa

a Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
b University of Utah College of Nursing, Salt Lake City, Utah


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
BACKGROUND. Investigators from several states have reported that children entering foster care are at risk for medical and mental health conditions. Additional information based on data from a larger statewide population of children in foster care would assist in the development of appropriate strategies of care for these children.

OBJECTIVES. The purpose of this work was to describe the prevalence of medical and mental health conditions, the number of referrals for specialty care, the use of medications and to compare the prevalence of these conditions across age groups of children entering foster care in Utah.

METHODS. We conducted an analysis of a statewide database containing abstracted medical and mental health information from the initial medical and mental health assessments of all children entering foster care between January 1, 2001, and December 16, 2004.

RESULTS. Of the 6177 children who entered foster care during the study period, 83% were white and 24% were Hispanic. One or more acute or chronic medical conditions were present in 54%, and 44% had ≥1 mental health condition. The most prevalent medical conditions in all of the children were overweight or obesity (35%), 30% had a referral for specialty care. The most prevalent mental health conditions were oppositional defiant disorder or conduct disorder (18%), reactive attachment and adjustment disorders (17%), and mood disorders (15%). The frequency of psychotropic medication use increased with age. Of the 2747 children of all ages with a diagnosed mental health condition, 35% were receiving psychotropic medications.

CONCLUSIONS. This study of a statewide cohort of children entering foster care supports and strengthens previous evidence that children in foster care are more likely to have more health care needs compared with the general pediatric population. Focused strategies are needed that address prevalent conditions, the need for continuity of care, ongoing mental health services, and medication management.

Key Words: foster care • child • mental health • medications

Abbreviations: MH—mental health • SAFE—State Automated Child Welfare Information System for Utah • ADD—attention-deficit disorder • ADHD—attention-deficit/hyperactivity disorder

More than half a million children are in foster care in the United States,1 an increase of 65% over the last 2 decades.2,3 It is the obligation of child welfare agencies to ensure that placements are safe and that the child's physical, emotional, and mental health (MH) needs are met.1,2 Yet, care for these children is often fragmented and complicated by preplacement circumstances that put these children at increased risk for medical, developmental, behavioral, and MH conditions. Most of these children are placed in foster care because of neglect, abuse, or behavioral issues occurring in home environments challenged by domestic violence, parental substance abuse, unstable living conditions, poverty, and/or mental illness. As a result, many of these children have previous unmet health needs that are complicated by the trauma that they have suffered. Once in foster care, these children often experience additional physical and emotional stress because of adjustment issues and lack of placement stability.1,4–7

Therefore, it is important to recognize that children in the foster care system have special health care needs unique to the circumstances that lead to their out-of-home placement. This requires a comprehensive approach and can make caring for these children more complicated, time consuming, and costly. Barriers to care are inherent in the system and may include frequent changes in placement, limited access to quality care, the inability of providers to access medical charts, poor continuity and coordination of care, and lack of accountability and funding for needed services. 4–6 To develop systems of care that can reduce these barriers, it is critical that child welfare agencies and policy makers have accurate information regarding the needs of these children at high risk at the time of entry into the foster care system.

Previous studies suggest that between 35% and 90% of children in foster care have medical, dental, behavioral, developmental, emotional, behavioral, and/or MH problems, numbers that are substantially higher than those of the general pediatric population.4–16 Many of these studies lack generalizability, however, because the data are limited by small sample sizes, are based on children from a single clinic, or are from urban locations with overrepresentation of minority groups.7–13 None of these reports are based on data from an entire statewide cohort.9–13

Data regarding the MH of children entering foster care are further limited by typically using only information available at the time of placement, reports from foster parents, or reports of the results of an MH screening tool rather than a comprehensive MH assessment.14–18 In addition, there are limited reports indicating how many children were on psychotropic drugs when they entered foster care, an important issue given both their increased use and the controversy surrounding potential overuse of these medications in children and adolescents.19–24 Additional information regarding medical and MH needs for this population based on data from a larger statewide population of children in the foster care system would assist in the development of appropriate strategies of care for these children.

The foster care system in Utah provides a unique opportunity to examine data from every child who enters foster care. All of the children who enter foster care receive an initial health screening, including a comprehensive medical, dental, and MH evaluation within 30 days of out-of-home placement. The results of these evaluations are entered into a statewide confidential computerized information management system known as the State Automated Child Welfare Information System for Utah (SAFE). The Division of Child and Family Services uses the SAFE database for all aspects of care coordination. The objectives of this study were to (1) determine the overall and age-related prevalence of medical and MH problems, (2) determine the number of referrals for specialty care, (3) determine the use of prescription and nonprescription medications, and (4) compare the prevalence of these conditions across the age groups of children entering foster care.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Approval to conduct the study was obtained from the institutional review boards of the University of Utah and the Utah Department of Human Services. We reviewed the SAFE database to obtain information regarding the medical and MH information from the initial 5- and 30-day medical assessments and the 30-day MH assessment for all of the children and adolescents entering the foster care system from January 2001 to December 2004. Data included the reason for removal, medical and MH diagnoses, referrals, and medications that the child was receiving at time of entry or was prescribed at the 5- or 30-day visit. Because there is increasing concern about the increasing number of American children who are overweight, we examined the child's BMI to determine whether the child was either overweight or obese.25,26

All of the medical and dental assessments were conducted by local health care providers and dentists. The MH assessments were conducted by contracted local MH professionals. Screening for developmental issues was an inherent component of the medical and MH assessments, but a statewide, standardized developmental assessment tool was not in use at the time of the study. MH diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),27 diagnosis from the 30-day MH assessment. Medications were categorized as over-the-counter or prescription. Antidepressants, antipsychotic agents, mood stabilizers, stimulants, anxiolytic agents, and other sedative hypnotic agents were categorized as psychotropic medications.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Enrollment
Characteristics of the 6177 children in the sample are summarized in Table 1. There was an average of 2000 children in foster care in the state at any given time. Forty-two percent were from the Salt Lake Valley region, the only predominately urban region in the state. The majority of the cohort was composed of non-Hispanic white subjects (83%). The sample was equally distributed between male and female subjects, and 40% were <6 years of age. The reason for removal was available for 6108 children (99%). Neglect was the most common reason for removal of children ≤12 years of age, and delinquency was the most common reason for those >12 years old. Drugs or alcohol were contributing factors for 45% of the removals.


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  		TABLE 1 Demographics

 
Prevalence of Acute and Chronic Medical Conditions
Table 2 shows the frequency of medical conditions by age. More than half of the children had ≥1 acute or chronic medical condition, the majority of whom required a medical referral. The 6 most prevalent medical conditions are shown in Table 2. Overweight or obesity and dental problems were the most common. Height and weight measurements were available for 3221 (70%) of the 4598 children who were ≥3 years of age. Eighteen percent of these children had BMI values that were at >95th percentile for their age and gender (obese), and 17% were at >85th percentile (overweight). Less than 5% of the children <5 years of age had a diagnosis of failure to thrive or growth deficit reported on the initial health assessment. However, by analyzing height and weight data, 12% of children 12 months to 2 years of age and 10% of those 2 to 5 years of age were found to be at <3rd percentile for weight; 7% of the 2- to 5-year-olds were at <3rd percentile for height. Neurologic and genetic conditions, hearing deficit, communication disorders, and developmental delay were infrequent (<2%). One third of the children received a referral for follow-up care that included medical specialists or dental or vision services. Dental caries were the most common reason for referral for children who were ≥3 years of age.


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  		TABLE 2 Medical Conditions

 
Prevalence of MH Conditions
Table 3 shows the frequency of MH conditions by age. Forty-four percent of the entire cohort, including 68% of those >12 years of age had ≥1 MH condition, and 26% had ≥2. The 5 most prevalent conditions are listed in Table 3 by age. Frequency of MH conditions varied by age, and more than half of those with an MH condition had >1 condition. Reactive attachment and adjustment disorders were the most prevalent conditions in children who were ≤12 years of age. Oppositional defiant disorder and conduct disorder were the most prevalent in those >12 years of age. Anxiety and attention-deficit disorders were common comorbid conditions in those ≤12 years of age. Mood disorders were present in one third of those >12 years of age.


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  		TABLE 3 MH Conditions

 
Use of Medications
The SAFE database listed any medication that the child was either on at time of assessment or prescribed during the initial assessment. More than half of the children were receiving medications (Table 4). One third were receiving ≥1 medication for medical conditions. Anti-infective agents were the most frequent. Of the total sample, 16% were receiving ≥1 psychotropic medication, and of these, almost half had ≥2 medications. Antidepressants were the most frequently reported, representing 67% of all of the psychotropic medication prescriptions. Six percent of the total cohort were receiving a stimulant medication, most of which were in children >5 years of age. Of the 2747 children with a diagnosed MH condition, 65% were not receiving a psychotropic medication at either their initial or 30-day evaluation. Psychotropic medication use increased with age along with the prevalence of MH conditions. Less than 1% of the children <6 years of age were receiving a psychotropic medication compared with 31% in children >12 years of age (P < .001).


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  		TABLE 4 Medication Use

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
In this comprehensive study of children entering foster care, we found that the majority had ≥1 acute or chronic medical condition. We also found that more than two thirds of children >12 years of age who entered foster care had ≥1 MH condition as defined by the DSM-IV, fewer than half of whom were being treated with a psychotropic medication. Because all of the children who enter foster care in Utah are mandated to have comprehensive medical and MH assessments and because the investigators had full access to the results of these assessments, our study adds to previous research conducted on smaller and less comprehensive samples of foster children.4–15

More than half of the children entering foster care in Utah had ≥1 acute or chronic medical condition, and close to one third of the children were referred for further specialty care, suggesting that the conditions were significant. The Utah cohort differed in demographic characteristics compared with cohorts from other studies, including a higher percentage of white children. In other studies evaluating smaller cohorts of children with different demographics and using different methodology and diagnostic criteria, the prevalence of diagnostic abnormalities varied.7,9,10,13 Common conditions reported in other studies included dental conditions; asthma; ear, nose, throat and skin conditions; short stature and growth failure; and communication disorders and developmental delay.4–7,9,10,16,28 Although we found that dental conditions were common (22%), rates of asthma (4%) were lower than expected when compared with other studies of children in foster care (15%),6,9,10 and when compared with the general pediatric population in the western mountain region (6%) and nationally (7%).29

Similar to national trends in the general pediatric population, we found that many children entering foster care were overweight or obese. Having an elevated BMI (>85%) was the most common condition reported. Thirty-five percent of children >3 years of age had a BMI at ≥85th percentile and 18% had a BMI at ≥95th percentile for their age and gender. Almost two thirds of the adolescent age group had elevated BMIs, a percentage that is higher than the reported rate of 15% to 20% in the general pediatric population.29–31 Earlier studies have shown a relatively high prevalence of growth deficits in children in foster care,8–10,13,16 but none have commented on the issue of obesity. The high prevalence of overweight among these children is a significant concern and has implications for their long-term health.

The prevalence of growth deficits was lower than expected. Of children <5 years of age, 7% and 10% had height and weight measurements at <3rd percentile, respectively. Other studies have reported prevalence rates of 9% for failure to thrive and 11% for short stature.13 Chernoff et al10 reported that 27.2% of foster children <2 years of age had height measurements at <5th percentile, and 15.4% were underweight. Reported prevalence of developmental delay was also less than expected in our study (<5% in all age groups). Leslie et al16 reported developmental delay in 16% of children in foster care, and Stock and Fisher28 reported deficits in >50%. We believe that these differences are most likely related to the fact that our sample included all of the children entering foster care from the entire state rather than those examined from a single clinic, which may have attracted a more selected high-risk sample, reported greater ethnic disparities, and used standardized assessment tools to screen for developmental delay.

We found that MH conditions were prevalent among children in foster care in Utah with behavioral and mood disorders the most common. A history of drug or alcohol use in the parent or child was present in one third of the total cohort and was common in older as well as in younger children. Delinquency was also common in older children, indicating that many of these children entered care because of confounding circumstances and behaviors.

Other studies that have used reports from the foster parent or a review of an MH screening tool have found an MH disorder in 40% to 60% of the children.10,15,16,19 Harman et al17 found that children in foster care were 3 to 10 times more likely to receive an MH diagnosis compared with children not in foster care who were receiving Medicaid. Compared with national prevalence data from the Centers for Disease Control and Prevention, the National Survey of Children's Health, and the National Mental Health Association,29,32,33 more Utah children in foster care have oppositional defiant disorder and conduct disorder (18% vs 10%) and mood disorders (15% vs 5%). Attention-deficit disorder/attention-deficit/hyperactivity disorder (ADD/ADHD) was similar, 10% in our sample compared with 8% in the general pediatric population.

One third of those with MH diagnoses were receiving ≥1 psychotropic medication. Psychotropic medication use increased with age, along with the prevalence of MH conditions. Green et al20 reported that 23% of children in foster care in Florida were using psychotropic medications, and Zima et al19 found that the level of psychotropic medication use in 6- to 12-year-old children in foster care was ~3 times that reported among a sample in the general pediatric population, and the use of a stimulants was twice as high. Stimulant use among children in foster care was higher than in the general pediatric population. A previous study of Utah children reported that 3% of 6- to 12-year-olds and 4% of 13- to 18-year-olds were taking stimulant medications.31 In contrast, we found that, for children in foster care, the numbers were 11% and 8%, respectively. Even so, the number of children receiving stimulants at the time of entry was lower than the prevalence of ADD/ADHD diagnoses.

There are limitations to our study. The information in the SAFE database was not independently verified and was limited to the information that providers documented on the Division of Child and Family Services health visit report forms. As with any large database, there may have been incomplete data or input errors. Multiple providers performed the physical and MH assessments and may have differed in their diagnostic approach. In addition, it is not known whether the child entered foster care with a previous diagnosis or whether the diagnosis identified in SAFE was new. A child could have had a chronic condition, such as asthma, that was not identified at the time of the assessment because of a lack of available information and medical history. Information regarding prescription medication was limited. We could not link psychotropic medication with diagnosis nor could we determine whether the medication represented a new or pre-existing prescription.

The low prevalence of documented developmental delay in the SAFE database is concerning and should be interpreted cautiously. This finding is in contrast to other published reports that consistently demonstrated high rates of developmental delay in children with a history of abuse and neglect and indicates the need for early intervention services.4–7,16,28 The results of our study were likely impacted by the lack of a standardized developmental screening tool. It is also possible that those performing the assessments were hesitant to label a child with a developmental delay so soon after removal from the home.

In light of these limitations, our data may underestimate the number of children with physical, developmental, and MH conditions entering foster care. More research is needed to identify the prevalence of developmental delay using a standardized assessment tool. Ongoing research is also needed to evaluate changes in physical and MH conditions and medication use patterns over time.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
We believe that the results from this study, involving a large number of foster children, have several important implications. First, the data support and strengthen previous evidence that children in foster care are more likely to have many health care needs compared with the general pediatric population. This information reinforces the need for timely comprehensive medical, dental, and MH evaluations at the time of entry into care as recommended by the Child Welfare League of America and the American Academy of Pediatrics.1,34–38 Second, information from a large statewide database was useful in identifying several major health issues, including obesity and MH conditions, that have long-term implications for care. Third, focused strategies are needed that address prevalent health issues in the context of a medical home that can provide continuity of care over time. As circumstances change, services need to include periodic reassessment of needs, access to ongoing MH services, and medication management. Finally, results of this study emphasize the need to educate agency policy makers and legislators about the needs of children in the foster care system to ensure access to ongoing comprehensive services within a system that can coordinate and monitor care.39–41 State protective service agencies have legal and ethical obligations to safeguard the health of these children at high risk.42 Pediatric providers can play an important role by becoming aware of the complex needs of these children, initiating referrals, and advocating for services and funding.


   ACKNOWLEDGMENTS
 
We thank Paul C. Young, MD, and Carrie Byington, MD, for critical review of the article. We also acknowledge the assistance of Navina Forsythe, MS, MPA (Utah Division of Child and Family Services), and Chris Chytraus, RN, BSN, CPM (Utah Department of Health), for assistance with the SAFE database.


   FOOTNOTES
 
Accepted Apr 22, 2008.

Address correspondence to Julie S. Steele, MN, FNP, University of Utah School of Medicine, Department of Pediatrics, 50 N Medical Dr, Salt Lake City, UT 84132. E-mail: julie.steele{at}hsc.utah.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Previous studies indicate that children in foster care are at increased risk for medical and MH problems compared with the general pediatric population. Data from a statewide cohort are lacking.

 

What This Study Adds

To our knowledge, this is the first study to report findings from a large statewide cohort of children in foster care. Information from this study strengthens previous research and may assist in the development of focused strategies to address prevalent health issues.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




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