Abstract
Greater numbers of infants and young children with increasingly complicated and serious physical, mental health, and developmental problems are being placed in foster care. All children in foster care need to receive initial health screenings and comprehensive assessments of their medical, mental, dental health, and developmental status. Results of these assessments must be included in the court-approved social services plan and should be linked to the provision of individualized comprehensive care that is continuous and part of a medical home. Pediatricians have an important role in all aspects of the foster care system.
BACKGROUND
The foster care system in America has evolved as a means of providing protection and shelter for children who require out-of-home placement.1 Although it is designed to be a temporary service with the goal of returning children home or arranging for suitable adoptive homes, children are often in foster care for several years. In recent years, child welfare agencies have been directing greater efforts toward supporting families in crisis to prevent foster care placements, whenever feasible, through preventive service programs and to reunify families as soon as possible when placements cannot be avoided. Increasingly, extended family members are being recruited and assisted in providing kinship care for children when their birth parents cannot care for them. However, during the past decade, the number of children in foster care has doubled despite landmark federal legislation designed to expedite permanency planning for children in state custody.2 Approximately 500 000 children are in foster care on any given day, an increase of 65% in the past 10 years.3,4 Between 1986 and 1991, the number of children younger than 5 years placed in foster care increased by 110% in large urban areas, with a larger proportion of infants than in previous years. Infants and young children are the fastest growing population in need of foster care. Most of these children are placed in foster care because of abuse or neglect occurring within the context of parental substance abuse, extreme poverty, mental illness, homelessness, or human immunodeficiency virus (HIV) infection.5 As a result, a disproportionate number of children placed in foster care come from the segment of the population with the fewest psychosocial and financial resources and from families that have few personal and extended family sources of support.6
Recent brain research has shown that infancy and early childhood are critical periods during which the foundations for trust, self-esteem, conscience, empathy, problem solving, focused learning, and impulse control are laid down.7–15 Because multiple factors (eg, an adverse prenatal environment, parental depression or stress, drug exposure, malnutrition, neglect, abuse, or physical or emotional trauma) can negatively impact a child’s subsequent development, it is essential that all children, but especially young children, are able to live in a nurturing, supportive, and stimulating environment.16
It is not surprising that children entering foster care are often in poor health. Compared with children from the same socioeconomic background, they have much higher rates of serious emotional and behavioral problems, chronic physical disabilities, birth defects, developmental delays, and poor school achievement.6,17–29 Moreover, the health care these children receive while in placement is often compromised by insufficient funding, poor planning, lack of access, prolonged waits for community-based medical and mental health services, and lack of coordination of services as well as poor communication among health and child welfare professionals.3,30–33
Despite the existence of recognized standards developed by the Child Welfare League of America (CWLA) in consultation with the American Academy of Pediatrics (AAP),34 many child welfare agencies lack specific policies for childrens’ physical and mental health services.35 Recently, the AAP District II Committee on Early Childhood, Adoption, and Dependent Care Task Force on Health Care for Children completed a comprehensive resource manual that outlines areas of health concerns and sets forth guidelines for evaluating foster children’s physical, developmental, mental health, and educational needs.36 Although a broad range of supportive and therapeutic services is needed, most children do not undergo a comprehensive developmental or psychological assessment at any time during their placement. State Medicaid systems, which provide funding for the health care of nearly all children in foster care, rarely cover all of the services these children require.36–38
It has been suggested that a variety of factors act as true barriers to care for these children. Information about health care services children have received and their health status before placement is often hard to obtain. In part, this is because children have had erratic contact with a number of health care providers before placement. In addition, social workers are not always able to review a child’s health history in detail with birth parents at the time of placement. Foster care parents often have been given limited training in health care issues or in accessing the health care system. Social workers often lack information about the type of health care services that children in foster care receive and are, therefore, unable to effectively oversee the amount or quality of care delivered.33 Increasingly complicated physical and mental health conditions in children in foster care make taking care of these children difficult, even for the committed physician.
A number of states are mandating that foster children shift from fee-for-service Medicaid to Medicaid managed care. Agencies must now consider arranging or purchasing comprehensive services within the 1996 managed health care model.39 Concerns exist about rationing of services, especially within the mental health area. General principles exist for developing and implementing a statewide health care system for children in foster care, irrespective of the model.40 When children are placed in foster homes outside the original jurisdiction or in another state, coordination of health care by the foster care agency becomes even more difficult.
Pediatricians can play a critically important role in helping child welfare agencies, foster families, and birth families minimize the trauma of placement separation and improve the child’s health and development during the period of foster care. Providing health care to these children requires considerably more time than it does for the average pediatric patient. Physicians must be prepared to provide necessary care even when little or no specific information about the child is available at the time of the visit. The pediatrician should attempt to identify physical, psychosocial, and developmental problems and assist social workers and foster parents in determining the types of additional evaluation, care, and community services the child requires.3,41
This statement provides specific suggestions for delivery of health services to young children in foster care. More detailed recommendations regarding developmental issues for young children in foster care have recently been published by the AAP.42
STANDARDS FOR HEALTH CARE SERVICES
In 1988, the CWLA, in consultation with the AAP, developed Standards for Health Care Services for Children in Out-of-Home Care.34 This document still serves as a comprehensive guideline for developing and organizing physical and mental health services for child welfare organizations. Child welfare agencies should be encouraged to adhere to these standards. Fostering Health: Health Care for Children in Foster Care, published in 2001 by District II of the AAP, details practice parameters for primary health care, developmental and mental health care, child abuse and neglect, and health care management.36 This manual is a useful reference for medical, developmental, and mental health practitioners as well as child welfare professionals. Pediatricians should become familiar with these standards and assist child welfare administrators, caseworkers, and foster parents in implementing them.
Because children in foster care have a high prevalence of chronic and complex illnesses, assessing each child’s unique needs is critical. Establishing continuity of care and ensuring a comprehensive and coordinated treatment approach by all professionals involved in their care should be one of the highest priorities for child welfare agencies. Diverse characteristics of child welfare agencies, wide geographic distribution of foster homes in some states, lack of comprehensive funding for children’s physical and mental health care services, and inadequate physician compensation for these services contribute to the difficulty of providing an organized approach to the care of these children. To avoid fragmentation of care, a variety of health care delivery models can be developed for this population, including: a) agency-based care, in which children are brought into the agency for health care; b) specialized foster care clinics, in which a medical home is established for the child; and c) community-based care, in which a practitioner provides health care through a private office, health maintenance organization, neighborhood health center, or general academic pediatric clinic. In all models, health care coordination remains the responsibility of the foster care agency.
Regardless of the model developed in a locale, it should adhere to certain principles. Whether services are delivered by a single team of professionals under one roof43 or as part of a planned program of care using many community resources,21 all professionals involved in the care of each child should communicate effectively with one another. Furthermore, compassionate assistance, education, and training for foster and birth parents should be included as an integral part of the overall program of services provided to children and their families during and after placement.
Pediatricians should be involved in the planning and development of systems of care for children in foster care. In addition to their role as primary health care providers, pediatricians may be contracted by child welfare agencies to serve as regional and statewide medical consultants and to develop and implement policies and programs that will improve the effectiveness and comprehensiveness of services for children in foster care.44 Pediatrician participation in the Committee on Early Childhood, Adoption, and Dependent Care of the local AAP chapter is also important.
THE COMPONENTS OF HEALTH CARE SERVICES
Health care services may be divided into 4 components: initial health screening, comprehensive medical and dental assessment, developmental and mental health evaluation, and ongoing primary care and monitoring of health status.
Initial Health Screening
Every child entering foster care should have a health screening evaluation before or shortly after placement. The purpose of this examination is to identify any immediate medical, urgent mental health, or dental needs the child may have and any additional health conditions of which the foster parents and caseworker should be aware. Careful measurement of height, weight, and head circumference may reveal growth delays or reflect poor nutritional or general health status. Because many children entering foster care have been victims of physical or sexual abuse, all body surfaces should be unclothed at some point during the physical examination, and any signs of recent or old trauma, bruises, scars, deformities, or limitations in the function of body parts or organ systems should be noted and documented photographically. If there is a history of physical abuse before placement or if signs of recent physical trauma are present, appropriate imaging studies to screen for recent or healing fractures should be considered. Genital and anal examination of both sexes should be conducted, and laboratory tests should be performed for HIV and other sexually transmitted diseases when indicated clinically or by history.45 Other infections and communicable diseases should be noted and treated promptly. The status of any known chronic illnesses should be determined to ensure that appropriate medications and treatments are available. The physician should discuss specific care instructions directly with the foster parents and caseworker and should not rely on an intermediary.
Comprehensive Health Assessment
Within 1 month of the child’s placement, a comprehensive health assessment should be performed by a pediatrician who is knowledgeable about, and interested in, the treatment of children in foster care and who can provide a medical home and arrange for the provision of regular, ongoing primary care services. Time permitting, it may be possible to do the screening and comprehensive assessments simultaneously. Child welfare agencies should make all pertinent past medical, social, and family information available to assist the physician performing the evaluation. The child’s caseworker and foster parents should be present for the initial visit. Whenever possible for this and subsequent visits, information should be obtained from the birth parents, and they should be kept informed about the health status of their child. When appropriate and as a part of the care plan of the child welfare agency, birth parents should be encouraged to be present at health care visits and to participate in health care decisions. The historical review should include the circumstances that led to placement, the child’s adjustment to separation from the birth family, adaptation to the foster home, developmental or school progress, and the agency’s plans for permanency (ie, most commonly, return to parent or relative, adoption, or independent living). The physical examination should focus on the presence of any acute or chronic medical problems that may require additional evaluation or referral. Screening tests should be performed according to the AAP Recommendations for Preventive Pediatric Health Care.46 Because many young children entering foster care come from settings in which substance abuse and sexual promiscuity are common, they should be considered to be at high risk for HIV infection, hepatitis, and other sexually transmitted infections. Laboratory tests for these conditions should be performed when appropriate.45,47–49
Children entering foster care are likely to be incompletely immunized,18 and determining the types and number of immunizations that a particular child has received in the past may be difficult. By communicating directly with previous medical providers or reviewing previous medical records (eg, from schools or immunization registries), it is often possible to reconstruct the child’s immunization history. For some children, despite a thorough effort, little or no immunization information will be available. These children should be considered susceptible and immunized according to AAP guidelines.50
Developmental and Mental Health Evaluation
At each health visit, the pediatrician should attempt to assess the child’s developmental, educational, and emotional status. These assessments may be based on structured interviews with the foster parents and caseworker, the results of standardized tests of development, or a review of the child’s school progress. All children with identified problems should be promptly evaluated and treated as clinically indicated. When available, local consultants and community-based intervention programs should be called on to assist in diagnosing and treating children with developmental and educational problems. Pediatricians may also assist social workers and foster parents by referring eligible children to various federal and state entitlement programs in their community (eg, Supplemental Nutrition Program for Women, Infants, and Children [WIC] and Head Start, Birth-to-Three,51 special education,52 early intervention,51,53 and Title V programs).
In some communities, child welfare agencies may be able to access or establish multidisciplinary teams to routinely evaluate children entering foster care. By their very nature, multidisciplinary teams provide a comprehensive and coordinated approach to assessment and are often an efficient and cost-effective means of accomplishing this task. Several successful community-based program models using this approach have been described.3,21,25,41,54
Regardless of how the comprehensive assessment is performed, the results and recommendations should be incorporated into the child’s court-approved social service case plan.55 To ensure that the multiple needs of children in foster care are addressed by those involved in the court process, 1 state judicial commission has developed an excellent guide for judges, advocates, and child welfare professionals to refer to, with a checklist of 10 basic questions that should be answered to ensure that standards of health care are met.55 The caseworker and pediatrician should then help the foster parents arrange for all of the services recommended for the child.
Providing Primary Care and Monitoring of Children’s Health Status While in Placement
Placement in foster care is a stressful experience for most children. Often, problems arise during the course of placement that were not apparent at the outset. For example, a child’s adjustment to separation from his or her family and adaptation to the foster home may be characterized by distinct behavioral changes over time.56 Similarly, significant emotional distress may occur after visits with birth family members or at times of transition, such as a change in placement or return to birth parents.57 Therefore, all children in foster care should have a medical home in which they receive ongoing primary care and periodic reassessments of their health, development, and emotional status to determine any changes in their status or the need for additional services and interventions. Ideally, at a minimum such reassessments should occur monthly for the first 6 months of age, every 2 months for ages 6 to 12 months, every 3 months for ages 1 to 2 years, every 6 months for ages 2 through adolescence, and at times of significant changes in placement (foster home transfers, approaching reunification). These periodicity recommendations, although not backed by evidence-based data, are considered by this committee to be the minimal number of preventive health care encounters required to closely monitor these children. Depending on the stability of the placement and changes in the child’s status, additional visits may be indicated. Any child prescribed psychotropic medication must be closely monitored by the prescribing physician for potential adverse effects. The social worker should maintain contact with the provider and receive periodic updates on the child’s progress. When changes in foster placement are planned or when decisions regarding permanency planning are anticipated, pediatricians can help child welfare professionals evaluate these decisions in light of the child’s age and developmental level. Pediatricians can also work with the child welfare agency and the court to determine what is truly in the child’s best interest.
TRANSFER OF MEDICAL INFORMATION
Up to one quarter of children placed in foster care experience 3 or more changes in foster homes. Furthermore, up to 35% of children reenter the foster care system after being returned to their families. Placement changes are usually accompanied by changes in physicians.58 As a result, available health information about these children is often incomplete and spread across many different sites. To enhance continuity of care, several states have developed an abbreviated health record often called a medical passport.44 A medical passport held by the foster parent has the potential to play a valuable role in the overall health care of children in foster care for some time to come. This form is retained by the child’s custodian and is designed to facilitate the transfer of essential information among physical and mental health professionals. It provides a brief listing of the child’s medical problems, allergies, chronic medications, and immunization data as well as basic social service and family history. Foster parents are instructed to keep this document for the child and bring it to all health visits. As the child’s condition changes, health care providers should update the information on the form. If the child changes foster homes or returns to his or her birth family, the medical passport should also be transferred to the child’s new caregiver. Computerized health information systems are also being developed in several states to make specific health information about children in foster care more readily accessible to practitioners and child welfare agencies. Computerized medical records for these children should be accorded the same confidentiality as written records.
THE IMPACT OF FOSTER CARE PLACEMENT ON CHILDREN
Society has always been reluctant to involuntarily remove children from their parents. Certainly, even brief separation from parental care is an unfortunate and usually traumatic event for children.41,59,60 Despite legal mandates to expeditiously formulate a permanency plan, many children may remain in foster care interminably while the child welfare and legal systems deliberate their fate. However, concerns about time should be balanced against other evidence that suggests that foster care placement may be a positive and therapeutic intervention for some children.61 The importance of a competent, caring, nurturing foster parent in supporting and advocating for a child’s health and well being cannot be stressed enough. Significant improvements in a child’s health status20 and development, intelligence, school attendance, and academic achievement have been noted consequent to foster care placement.42 Thus, for children who have suffered severe neglect and abuse or whose families cannot adequately care for them, placement in foster care can be an important opportunity to receive intervention and rehabilitation and should not be considered only as an option of last resort.
RECOMMENDATIONS
Pediatricians should participate in the care of children in foster care as primary care physicians and as consultants to child welfare agencies. Child welfare agencies, general pediatricians, and pediatric subspecialists should work together to implement standards for health care of children in foster care developed by District II of the AAP.36
All children entering foster care should have an initial physical examination before or soon after placement. This examination should focus on identifying acute and chronic conditions requiring expedient treatment.
All children in foster care should receive comprehensive physical and mental health and developmental evaluations within 1 month of placement.
Individual court-approved social service case plans should include the results of physical and mental health and developmental assessments and incorporate the recommendations of health professionals.
Pediatricians and child welfare agencies should work together to ensure that children in foster care receive the full range of preventive and therapeutic services needed and participate in all federal and state entitlement programs for which they are eligible.
Although in placement, the child in foster care requires physical, developmental, and mental health status monitoring more frequently than children living in stable homes with competent parents.
Child welfare agencies and health care providers should develop and implement systems to ensure the efficient transfer of physical and mental health information among professionals who treat children in foster care.
Committee on Early Childhood, Adoption, and Dependent Care, 2001–2002
Peter A. Gorski, MD, MPA, Chairperson
Deborah Ann Borchers, MD
Danette Glassy, MD
Pamela High, MD
Chet D. Johnson, MD
Susan E. Levitzky, MD
S. Donald Palmer, MD
Judith Romano, MD
Moira Szilagyi, MD, PhD
Liaisons
Claire Lerner, LCSW
Zero to Three
Pat Spahr
National Association for the Education of Young Children
Phyllis Stubbs-Wynn, MD, MPH
Maternal and Child Health Bureau
Ada White, LCSW, ACSW
Child Welfare League of America, Inc
Consultant
Neal Kaufman, MD, MPH
Staff
Eileen Casey, MS
Footnotes
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
REFERENCES
- Copyright © 2002 by the American Academy of Pediatrics
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