October 2015, VOLUME136 /ISSUE 4

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care



    Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves.

    Foster Care in the United States

    The foster care system in the United States evolved over the last century as a means of providing care and protection to children and adolescents removed from their family of origin (predominantly for reasons of abuse and/or neglect and imminent safety concerns). The goal of the foster care system is to provide for the health, safety, and well-being of children and adolescents while fostering reunification or an alternative permanency arrangement (adoption, guardianship, placement with relatives, or independent living) when reunification is not possible. In this statement, the term “foster care” includes those living in court-ordered or formal kinship care (children living with extended family or kin), and the term “children” refers to children and adolescents from birth to 21 years of age. However, children remaining at home after a child protective services investigation experience many of the same childhood adversities as children in foster care and share many of the same health needs. Therefore, although the ensuing discussion and recommendations focus on children in foster care, they are relevant to all children who come into contact with the child welfare system.1,2 More complete information about health care for this population is available in the accompanying technical report.3

    In 2013, approximately 641 000 children ranging in age from 0 to 21 years spent some time in foster care, a number that has steadily declined from a peak of 814 586 in 2002.4 The majority of children entering foster care have lived in deprived and chaotic environments for a significant period of time until removal for imminent safety concerns secondary to maltreatment. More than 70% of children in foster care have a documented history of child abuse and/or neglect,5 and more than 80% have been exposed to significant levels of violence, including domestic violence.6 In addition, even before entering foster care, many children have experienced multiple caregivers, limiting their ability to form a stable attachment to a nurturing caregiver. Removal is emotionally traumatizing for almost all children,710 although for some, it is the first time they may feel safe. Understanding the effects of multiple adversities, trauma, and toxic stress on the health and development of children is fundamental to guiding their caregivers through the healing process.

    The Health Needs of Children and Adolescents in Foster Care

    The significant unmet health needs of children and adolescents in foster care are rooted in their complex trauma histories and compounded by their poor access to appropriate health care services.1,7,1015 Limited health care access and unmet health needs precede placement and often endure in foster care.2 Data from the last 30 years demonstrating the high prevalence of health problems have led the American Academy of Pediatrics (AAP) to classify children in foster care as a population of children with special health care needs. Health is defined broadly in this population and includes medical, mental health, developmental, educational, oral, and psychosocial well-being. Overall, 30% to 80% of children come into foster care with at least 1 medical problem,1,1618 and one-third have a chronic medical condition. It is common for such problems to have gone undiagnosed and untreated before these children enter foster care. Up to 80% of children and adolescents enter with a significant mental health need,1,7,8,10 and almost 40% have significant oral health issues.18 Approximately 60% of children younger than 5 years have developmental health issues, and more than 40% of school-aged children have educational difficulties.19 Children in foster care are more likely to change schools during the school year, be in special education, and have a history of grade retention.20 Adolescents in foster care have poor educational outcomes: high school dropout rates are nearly 3 times higher than those among other low-income children, and just over 50% graduate from high school, many with an equivalency diploma. Early data indicate that youth living in states where the age of emancipation is 21 years instead of 18 years have slightly higher educational achievement. Overall, 6% of foster care alumni have at least some college education, but only 1% to 2% graduate with a 4-year degree.20,21

    Essentially all children in foster care have psychosocial issues related to family dysfunction. Long-term outcomes of foster care have been inadequately studied, but national data suggest that young adults who were in foster care as adolescents experience high rates of mental health problems, unemployment, homelessness, low educational attainment, and posttraumatic stress disorder.2226 Although far less is known about the outcomes of younger children who left foster care before adolescence through reunification with parents, placement with relatives, or adoption, there is evidence that children in long-term stable foster/kinship care do better than those with unstable placements.27

    Early childhood trauma/toxic stress, especially if frequent or unremitting and not tempered by responsive, nurturing caregiving, adversely affects the neurobiology of the developing brain.28,29 Early childhood trauma has been correlated with poor emotional regulation, aggression, hyperactivity, impulsivity, attention and attachment problems, and the inability to associate thought and mood.8 Chaotic, unresponsive caregiving before foster care is associated with insecure attachment disorders that may present as indiscriminate friendliness, hypervigilance, or social withdrawal.

    Ideally, children receive a full mental health evaluation, including a trauma assessment, shortly after entering foster care.30 A mental health screening to assess for suicide risk and acute mental health needs is important at entry to care, but a full evaluation is probably best conducted after the child has had some time to adjust to his or her new living situation and visitation with family. Treatment, if indicated after evaluation, should incorporate appropriate therapy, including trauma-informed care, with appropriate education and support of the child’s caregivers and caseworker. Parent–child interaction therapy, child–parent psychotherapy, trauma-focused cognitive behavioral therapy, and the attachment, self-regulation, and competency model3033 are some recommended evidence-based trauma therapies that are unfortunately still not widely available. There is a shortage of mental health professionals with appropriate training in trauma-focused therapies, and funding is insufficient to ensure that all children who might benefit from these interventions can access them. Training in childhood trauma for caseworkers and foster parents has improved in recent years, but ongoing support for foster parents by well-educated professionals is of great importance.

    Pediatricians caring for children in foster care will often be asked to prescribe psychotropic medications for children with behavioral problems and/or they will encounter children on psychotropic medication. It can be challenging to discern the appropriateness of psychotropic medication for those children with multiple mental health diagnoses. The use of psychotropic medication to manage the behavioral and mental health problems of children in foster care has come under scrutiny in recent years, as data suggest that children in foster care are prescribed psychotropic medications at a rate 3 times that of other children enrolled in Medicaid and have higher rates of polypharmacy.34 Children in foster care are also likely to receive longer treatment regimens than children who are enrolled in Medicaid but not in foster care.35 Some children clearly benefit from psychotropic medications when appropriately prescribed, but concern exists that some children are not receiving appropriate mental health and trauma assessments before treatment and that medications are sometimes prescribed in lieu of evidence-based trauma care and other mental health interventions.34 Concern over these issues, coupled with the fact that the majority of psychotropic medication prescriptions for children constitutes off-label use, prompted a report in November 2011 by the US Government Accountability Office calling for increased oversight of these medications by states and subsequent federal legislation mandating greater oversight by states (Child and Family Services Improvement and Innovation Act of 2011 [Pub L No. 112-34]).36 In addition, there are concerns about the effects of psychotropic medications on the developing brain as well as the adverse effects (eg, obesity, hyperlipidemia) of some of these medications.

    It can be challenging for primary care providers to discern the suitability of prescribing psychotropic medications in a population with tremendous mental health needs. Optimal care for mental health concerns in a traumatized population includes a thorough mental health evaluation, including trauma assessment and assessment for comorbidities. Treatment should be diagnosis-specific and, ideally, evidence-based. Psychotropic medications, if indicated, should be initiated at low doses and titrated slowly, with close monitoring for efficacy and adverse effects. Polypharmacy should be avoided if possible. No patient should receive therapy with more than 1 psychotropic medication from any given class.37

    Foster parents remain the major therapeutic intervention of the foster care system. Stable placement with a warm, nurturing, empathic, attuned caregiver is ideal. Caregivers may have birth, adoptive, and foster children in their homes at any given time, which can create inherent conflict. Even in a stable home, entries and exits of other children can be traumatizing for the child in foster care. The foster/kinship home environment,38,39 stability in a placement, kinship placement,27 an empathic relationship among foster caregivers and birth parents,40 and consistent quality visitation41 have been shown to improve3840 (or are recommended by experts to improve40) child outcomes.

    Barriers to Receipt of Adequate Health Care in Foster Care

    Physician and nonphysician clinicians often face significant barriers in providing appropriate health care services to children in foster care. Health care for traumatized children is time-consuming and challenging. Care coordination is particularly difficult for children in foster care because of the transient nature of the population and the diffusion of authority among parents, child welfare professionals, and the courts.7,8,10 Receipt of health care is often fragmented and crisis-oriented rather than planned, preventive, and palliative. Evidence indicates that foster parents and caseworkers may not fully appreciate all of a child’s health conditions and lack the expertise to access and negotiate a complex health care system on behalf of children with significant needs.12 Pediatricians are, in general, equally unfamiliar with the structure, regulations, and intricacies of the child welfare system. Furthermore, in most communities, there are no structures or systems for coordinating care across disciplines.

    Key challenges pediatricians may encounter while providing care for a child in foster care include:

    • Incomplete or unavailable health information, including: information about immunizations; newborn health screening results; medications; allergies; chronic illnesses; hospitalizations; surgeries; vision or hearing loss; family history; dental history; psychosocial history, including childhood trauma history; and developmental or educational problems. The child is frequently accompanied by individuals (caseworkers, transporters, and new foster parents) who have little to no knowledge of the child’s current medical or social situation.

    • Difficulty identifying who has the authority to consent for health care on behalf of the child.

    • Inadequate resources for evaluation and treatment. This limitation is a combination of workforce, systems, and funding issues. Medicaid (either fee-for-service or managed care) is the primary health care coverage for children in foster care but may impose limits on certain health services, especially subspecialty, dental, and mental health care.14,15,42,43

    Components of Key Health Care Services

    There is abundant literature documenting the health needs of children in foster care and a growing body of literature on effective mental health interventions. However, recommendations regarding care coordination, early and frequent pediatric visits, and mental health, dental, developmental, and educational assessments represent consensus among experts in the field rather than recommendations based on research evidence because these topics have not been studied. There is consensus among experts that health care coordination, more frequent health visits during transitions, and the receipt of health services in the context of a pediatric medical home are fundamental principles in caring for this population.

    Coordination of Care

    Although health care coordination is necessary for improving health outcomes for children in foster care, only a few states and localities have systems for communication among caregivers, child welfare professionals, and health and mental health experts. Federal legislation, the Fostering Connections to Success and Increasing Adoptions Act (Pub L No. 110-351 [2008]), requires that states, in consultation with pediatricians and other health experts, develop systems for health oversight and coordination for children in foster care. This act outlines the important pieces of coordinated care: periodic health assessments, shared health information, provision of care in the context of a medical home, and oversight of prescription medications (particularly psychotropic drugs). The Child and Family Services Improvement and Innovation Act (Pub L No. 112-34 [2011]) built on the well-being provisions of the Fostering Connections to Success and Increasing Adoptions Act to support children’s emotional and developmental health and to ensure the oversight of psychotropic medications.

    Information sharing is crucial to health care coordination. Several states have developed electronic data-sharing systems to improve communication among the child welfare and health care systems. Some states have adopted an abbreviated paper or computerized medical record, often referred to as a “health passport.” For the child in foster care, the health passport should include the child’s chronic health problems, allergies, medications, psychosocial and family histories, trauma history, and developmental and immunization information. Security can be built into such systems so that information is accessible depending on the professional’s role in the care of the child or adolescent. Electronic health records, regional health information systems, and immunization registries offer new tools for improving communication.

    Health Assessment at Entry Into Foster Care

    Assessing each child’s unique health needs at entry into foster care is critical, and pediatricians must be prepared to provide necessary care even when little or no specific information about the child’s health history is available at the time of the visit. Ideally, every child would continue to receive health care in his or her medical home of origin. When this option is not possible, establishing and maintaining continuous, comprehensive, and coordinated care in a new pediatric medical home should be one of the highest priorities for child welfare agencies and pediatricians.44 The child welfare professional is ultimately responsible for obtaining and making the child’s health information available, but pediatricians may be able to assist in obtaining some information from schools, previous health care providers, immunization registries, and regional health information organizations.

    Medical Home

    Children entering foster care have often had limited access to preventive and other health services before placement or have sought care from multiple health resources and may continue to receive fragmented care because of transitions in foster care placements.45,46 Thus, enrollment in a medical home is imperative to ensure the receipt of high-quality, comprehensive, coordinated health care that is continuous over time, compassionate, culturally competent, family centered, and child focused.47 The medical home should provide uninterrupted care, regardless of the placement transitions a child may experience. Ideally, payment structures need to be aligned with the recommended health parameters for addressing the health needs and improving the health outcomes of this special needs population. The Patient Protection and Affordable Care Act (Pub L No. 111-148 [2010]) supports the expansion of the medical home model to meet the health needs of all patients, particularly those with complex health problems. Furthermore, given the similar health needs of all children who have been involved with the child welfare system, enrollment in a pediatric medical home should be prioritized by both the child welfare and health care systems.

    Guidelines for Health Care Services

    In 1988, the Child Welfare League of America, in consultation with the AAP, published guidelines for developing and organizing medical and mental health services for children in foster care. The Standards of Excellence for Health Care Services for Children in Out-of-Home Care were updated in 2007.48 The AAP published detailed practice parameters for primary health care, developmental and mental health assessments, child abuse and neglect screening, and health care management in 2005 in Fostering Health: Health Care for Children and Adolescents in Foster Care.13 This set of guidelines, developed by a panel of foster care health experts, is now available on the Healthy Foster Care America Web site,49 and pediatricians caring for children in foster care familiar with these guidelines can assist child welfare administrators, caseworkers, and foster parents in ensuring that children’s needs are met.

    The Role of the Pediatrician

    Screening, Assessment, and Enhanced Visitation Schedules

    Children entering foster care are ideally seen “early and often” to assess their health care needs, to document findings of child abuse or neglect, to support them and their families through the adjustment to foster care, and to ensure that all necessary referrals and services are in place. The AAP recommends an initial health screening within 72 hours of placement. However, younger or preverbal children, any child who is a suspected victim of abuse, or any child with a chronic medical or developmental condition should be seen within 24 hours. Ideally, children should have at least 3 health encounters over the first 3 months of foster care, as they adjust to their new circumstances. This schedule allows the pediatrician to monitor the child’s adjustment to placement, to identify emerging needs, and to support the caregiver in helping the child. In addition to the initial health screen, experts recommend a comprehensive evaluation of each child’s medical, dental, mental health, developmental, and educational needs within 30 days, resulting in a health plan that is shared with caregivers and child welfare professionals and integrated into the child’s permanency plan. Thereafter, children in foster care, as children with special health care needs, should be closely monitored.

    In a system abundant with transitions and psychosocial stressors, it is recommended that children in foster care be seen monthly during the first 6 months of life, every 3 months from 6 to 24 months of age, and then at a minimum of every 6 months to monitor their health, emotional well-being, development, psychosocial stressors, continued adjustment to their foster family, and visitation with birth parents or other relatives. There are some children in stable, long-term foster care placement who are faring well and may not need such close monitoring. However, the default should be close monitoring with exceptions made as indicated based on the needs of the individual child and family. Transitions in placement, changes in visitation, and separation of siblings represent events that indicate a need for even closer monitoring. Because of their more intensive health needs, children in foster care may also require longer appointments. It is important to assess the child’s overall health status, with a focus on developmental, educational, and emotional needs as well as the abilities of the child’s caregiving environment to meet those needs at each and every health visit. Continued communication with the child’s caseworker is essential to ensure implementation of the child’s health plan and its integration into the child welfare permanency plan.

    The Foster Care–Friendly Office

    A foster care–friendly office is a trauma-informed office.30 Pediatricians can welcome foster and kinship caregivers, caseworkers, and birth parents, when appropriate, to health visits and educate them about the effects of childhood trauma and adversity on a child’s emotional and developmental health. Focusing all caregivers on working together on behalf of the child is an important role for pediatricians. The medical home staff can provide information about managing health problems and emotional, behavioral, and developmental concerns; identify resources; and coordinate referrals. Pediatricians can be advocates for children in their care to ensure that each child’s health needs are met, screen for signs of abuse and neglect at every health encounter, remain alert to the quality of the caregiver–child relationship, and share any concerns with the child’s caseworker. Reframing child behavior issues in the context of childhood trauma and toxic stress and focusing on positive parenting principles and the child's strengths and talents can help to defuse caregiver distress and promote resilience. Recognizing and validating children’s complex and often conflicted feelings about the caregiving adults in their lives can be reassuring for them; almost all children in foster care love and worry about their birth parents, even if they feel safer in foster care, and they also love and care about their foster and kinship caregivers.

    The medical home can create a foster care–friendly environment by obtaining a copy of signed consents from the foster care agency and maintaining them as a part of the child’s health record, having contact information for the child’s caseworker in the child’s chart, and sending a summary of the health visit that includes immunizations and other recommendations to the child’s caseworker after each health care encounter. Child welfare professionals can assist with determining who has the authority to consent for health care services on behalf of a child and familiarize pediatricians with specific consent guidelines, including those regarding the prescription of psychotropic medications, when applicable. Adolescents in foster care have the same rights to confidential services as other teenagers. Another way to create a foster care–friendly office is to familiarize staff with the effects of childhood trauma so that all staff members provide trauma-informed care and use trauma-informed language.


    Recommendations for Practice Readiness

    At the level of the individual pediatric practice, there are numerous opportunities to improve the quality of care that children in foster care receive. The AAP recommends that pediatricians:

    • Advocate for children and adolescents in foster care to receive health care in a medical home.

    • Become educated on the special health care needs of children and adolescents in foster care and assist other professionals in addressing these needs.

    • Become educated on the unique microculture of foster care, particularly the effects of previous trauma/toxic stress, especially abuse and neglect, and the effects of ongoing uncertainty, transitions, and losses on children, teenagers, and families.2830,50

    • Develop office systems for communicating with caseworkers, foster caregivers, and other professionals during or after each health encounter. Collaboration with the caseworker or the health care manager for the child is fundamental to ensuring that health needs are addressed.48,49,51

    • Become educated on state privacy, consent, and confidentiality laws affecting children and adolescents in foster care, including specific consent issues related to the administration of psychotropic medication.

    • Incorporate the results of a child’s comprehensive evaluation into a health care summary that is shared with the child welfare professional. Make a special effort to educate children and adolescents about their own health needs and care.

    Recommendations Regarding Health Information Gathering

    The child welfare caseworker is ultimately responsible for ensuring that the pediatrician has all needed health information. In reality, it is often difficult for the caseworker to obtain this information. Ideally, there is a health care manager who can contact schools, child care providers, former health care providers, health departments, immunization programs, or early intervention and/or Head Start programs to obtain and share health information on immunizations, newborn health screening results, hospitalizations, surgeries, allergies, chronic illnesses, medications, vision or hearing loss, family history, and developmental or educational evaluations when a child enters foster care.

    The rapid advances in the development of the personal health record portion of the electronic health record hold great possibilities for information sharing in the foster care population. In fact, the highly mobile foster care population should be prioritized for dissemination and implementation of the personal health record because it would greatly help improve care coordination for these children and adolescents. Pediatricians may also want to check immunization registries and regional health information organizations for information about individual children. An encounter that includes the birth parent(s) is an opportunity to obtain a more detailed health history. In addition, pediatricians can encourage foster care agencies to send the foster parent, or at least a knowledgeable case manager, to a youth’s appointment to facilitate the collection of health information.

    Recommendations for Clinical Care

    Child welfare caseworkers are also ultimately responsible for ensuring that children in foster care receive all appropriate and recommended health care. However, navigating the health care system is challenging and complex, and child welfare caseworkers lack the necessary expertise for this function. Pediatricians can assist child welfare administrators, caseworkers, and foster parents in accessing appropriate health services (in addition to the standard preventive services outlined in Bright Futures)52 for children in foster care by becoming familiar with the standards in Fostering Health: Health Care for Children and Adolescents in Foster Care, available on the Healthy Foster Care America Web site.13,49 Recommendations for clinical care and their justification are summarized in Tables 3–6 of the accompanying technical report3 and include:

    • All children and adolescents should have an initial health assessment (Table 3 in accompanying technical report3), ideally within 72 hours of placement; some children need to be seen within 24 hours, as noted previously.

    • All children and adolescents should have a comprehensive evaluation of their medical, mental health, developmental, educational, and oral health status (Table 4 in accompanying technical report3) within 30 days of placement.

      • Ideally, all children should receive developmental, educational, and/or mental health evaluations, but priority should be given to children with needs identified through screening when resources are limited.51

      • The importance of good dental care should be communicated to foster parent(s) and older children and adolescents in foster care.

    • Child welfare professionals should incorporate the results and recommendations of comprehensive assessments into the child’s court-approved social service case plan (often called the permanency plan) to ensure that the multiple health needs of children and adolescents in foster care are addressed.

    • All children and adolescents should have a follow-up health assessment (Table 5 in the accompanying technical report3) within 60 to 90 days of placement.

    • Every health encounter, especially periodic preventive health visits, presents opportunities for pediatricians to screen for signs of abuse or neglect, including poor weight gain, lack of warmth between the child and foster parent, frequent missed or canceled appointments, and failure to comply with health recommendations.

      • Height and weight (and head circumference for children aged <3 years) should be measured and plotted on the growth curve, and BMI should be calculated beginning at age 2 years.

      • All body surfaces should be examined for burns, bruises, scars, deformities, and limitation of joint movement.

      • A genital and anal examination should be performed by the most experienced provider available (ideally an expert in child sexual abuse), especially for preverbal children.

        • Clinical judgment should be used regarding the timing of the examination. Ideally, it would be done at the initial visit but in cases in which the child is distressed and/or there is little concern regarding sexual abuse, the examination can be delayed until the comprehensive visit.

        • If concerned about sexual abuse, testing for HIV and other sexually transmitted infections should be performed.

        • Physical signs of abuse or neglect should be documented in writing and with photography of affected areas.

        • Any suspicion of abuse or neglect in a foster placement should be reported to child protective and foster care caseworkers.

    • Pediatricians have a role in educating foster caregivers, caseworkers, birth parents, and adoptive parents about a child’s health issues, the treatment plan, and the importance of providing predictable nurturance, normalizing activities, and the maintenance of similar routines and expectations across environments. Pediatricians also have a role in providing health information to judges, mental health professionals, child care providers, and early intervention specialists about the child’s health issues. Caseworkers, as the case managers, need to be informed about changes in the child’s health and are responsible for sharing information with the birth parent, child’s attorney, and the court.

    • Pediatricians should immunize children in foster care per AAP recommendations. Children and adolescents entering foster care are likely to be incompletely immunized, and determining the immunization status of a particular child may be challenging. Direct communication with previous physicians and review of school, child care, and immunization registry records increase the probability of accurately reconstructing the immunization history. Despite thorough effort, little or no immunization information will be available for some patients, who should then be considered susceptible and should be immunized according to AAP recommendations. Consent for immunization administration is usually covered in the general medical consent signed by the birth parent/guardian at the time of removal, and the child welfare agency should provide a copy of that consent to the medical home. In the absence of this signed consent, the pediatrician is advised to obtain permission for immunization administration through the child welfare agency administration according to its protocols. Foster parents do not have the right, under law, to refuse immunizations for children in foster care residing in their homes.

    • The pediatric medical home can schedule more frequent health visits for children and adolescents in foster care to monitor the child’s ongoing health needs and treatment, given the complexity of their health issues (see accompanying technical report3). For example, health visits around any change in caregiver (ie, discharge from foster care, change in foster care placement) are recommended to educate the new caregiver about the child’s health issues.

    Recommendations Regarding Health Care Coordination and Management

    Health care coordination and management are ultimately the responsibility of the foster care agency/caseworker but require health care expertise. The pediatrician may assist child welfare professionals with gathering and interpreting health information, communicating information around each health visit, making timely referrals and informing child welfare professionals about them, and monitoring the child’s health.

    Recommendations for Advocacy at a System Level

    Pediatricians can play an important role in advocating for policies that would improve the delivery of effective and integrated health services within their communities and states for children in foster care. Policy makers may need education about the amount and quality of health services that children in foster care require and about the structure of the systems that will promote coordination of care across disciplines. Pediatricians choosing to do this work must understand regional and state laws and guidelines regarding health information, confidentiality, and consent for children in foster care. The AAP Division of State Government Affairs (available at stgov{at} can be contacted for more information on related state laws. The following list contains some policy goals for discussion with policy makers:

    1. Pediatricians and mental health professionals should be included in interdisciplinary team meetings with state and local child welfare in developing the health care coordination and oversight plans mandated by federal law and in promoting the connection of children in foster care to pediatric medical homes.

    2. State and local child welfare systems should ideally appoint a medical director, preferably a pediatrician, responsible for the oversight and coordination of health care systems for children in foster care.

    3. Pediatricians can advocate for enhanced education about childhood trauma, its impact on child development and behavior, and appropriate treatment, including evidence-based parenting education for foster parents and other caregivers, caseworkers and all professionals involved with children in foster care.

    4. Pediatricians can advocate for realigning financial resources with evidence-based and promising treatments and interventions.

    5. Pediatricians can help ensure that children who are moved by the state into a foster care program are tracked and immediately enrolled in and covered by Medicaid until age 21 years by using the Chafee option. Since 2014, youth aging out of foster care have the option to elect Medicaid coverage under the Patient Protection and Affordable Care Act until 26 years of age.53

    6. Dedicated planning and oversight can be implemented when managed care organizations contract for care delivery for children with special health care needs (including children with complex and/or rare diseases, children with behavioral/mental health conditions, and children in foster care).53


    Moira A. Szilagyi, MD, PhD


    David S. Rosen, MD, MPH* – Committee on Adolescence

    David Rubin, MD, MSCE – PolicyLab at The Children's Hospital of Philadelphia

    Sarah Zlotnik, MSW, MSPH – PolicyLab at The Children's Hospital of Philadelphia


    Moira Szilagyi, MD, PhD, Chairperson

    David Harmon, MD

    Paula Jaudes, MD

    V. Faye Jones, MD, PhD, MSPH

    Paul Lee, MD

    Lisa Nalven, MD, MA

    Lisa Prock, MD, MPH

    Linda Sagor, MD, MPH

    Elaine Schulte, MD, MPH

    Sarah Springer, MD

    Thomas Tonniges, MD


    George Fouras, MD – American Academy of Child and Adolescent Psychiatry

    Jeremy Harvey – Foster Care Alumni of America

    Melissa Hill, MD – AAP Section on Medical Students, Residents and Fellowship Trainees


    Paula K. Braverman, MD, Chairperson

    William P. Adelman, MD

    Elizabeth M. Alderman, MD, FSAHM

    Cora C. Breuner, MD, MPH

    David A. Levine, MD

    Arik V. Marcell, MD, MPH

    Rebecca O’Brien, MD


    Margo Lane, MD, FRCPC – Canadian Pediatric Society

    Julie Strickland, MD – Department of Obstetrics & Gynecology

    Benjamin Shain, MD, PhD – American Academy of Child and Adolescent Psychiatry


    Dina Lieser, MD, FAAP, Chairperson

    Beth DelConte, MD, FAAP

    Elaine Donoghue, MD, FAAP

    Marian Earls, MD, FAAP

    Danette Glassy, MD, FAAP

    Terri McFadden, MD, FAAP

    Alan Mendelsohn, MD, FAAP

    Seth Scholer, MD, FAAP

    Jennifer Takagishi, MD, FAAP

    Douglas Vanderbilt, MD, FAAP

    Patricia Gail Williams, MD, FAAP


    Abbey Alkon, RN, PNP, PhD, MPH – National Association of Pediatric Nurse Practitioners

    Lauren Gray, MA – National Association for the Education of Young Children

    Barbara U. Hamilton, MA – Maternal and Child Health Bureau

    Claire Lerner, LCSW – Zero to Three


    Mary Crane, PhD, LSW

    Karen Smith

    Charlotte Zia, MPH, CHES



    • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.