Improving the Health and Well-Being of Children in Foster Care: The Pediatrician’s Role
Suzette Brown, MD, MPH
Attending, Pediatric Primary Care
Approximately 400,540 children and adolescents were in foster care in the United States at the end of 2011, with 24,962 residing in New York State. The majority of these children enter the child welfare system due to allegations of abuse or neglect that has often occurred in the context of parental substance abuse, parental mental illness, extreme poverty, homelessness, and domestic violence. Youth in foster care represent an extremely vulnerable population who experience rates of physical, developmental, and mental health problems that are significantly greater than that of the general population. Studies have demonstrated that up to 80% of children in foster care experience emotional and behavioral problems, and that the majority (87%-95%) of children entering non-relative foster care have at least one physical health condition. Developmental issues are also common among younger children less than 5 years of age in foster care, with estimated rates of developmental delay in these children ranging from 13 to 62%, compared with the prevalence of delay in the general pediatric population (4–10%). Yet despite their immense physical, mental health, and developmental needs, the care that these children receive is often fragmented, and many needs go unmet.
In 2001, the American Academy of Pediatrics published a manual entitled Fostering Health: Health Care for Children in Foster Care, which details the standards and practice parameters for providing primary health care, developmental and mental health care, and health care management for children in foster care. Health care services include: 1. an initial health screening upon entry into foster care; 2. a comprehensive medical and dental assessment within 30 days of a child’s placement; 3. a developmental and mental health evaluation; and 4. ongoing primary care and monitoring of children’s health status.
Initial Health Screening. The initial health screening should be conducted before or shortly after a child’s placement into foster care, and should focus on identifying immediate medical, mental health, or dental issues that require urgent attention. Because children entering foster care are often victims of abuse and/or neglect, careful assessment for signs of recent or old trauma, growth delays, infections (including sexually transmitted infections), and other functional limitations should be conducted. Appropriate imaging and laboratory testing should be performed where indicated based on physical examination findings and clinical and maltreatment histories, and treatment for communicable diseases and other infections should be promptly initiated. The status of any known chronic medical conditions and medications should be identified and discussed with the foster parent and caseworker.
Children in foster care should receive a comprehensive medical, dental, developmental and mental health assessment within one month of entering foster care. Detailed medical, social, and family histories should be obtained from the child’s foster parents, caseworkers, and prior medical providers, as well as from biological parents where possible, and the circumstances that led to the child’s placement should be ascertained. Immunization histories should be obtained from previous medical providers, immunization registries, and/or school records, and if incomplete, the child should be immunized according to standard guidelines. The child’s adjustment following placement into foster care, developmental progress, school performance, and the agency’s plan for permanency should be reviewed and discussed. The foster parent and caseworker should both be present for this visit, and a detailed care plan should be developed, shared and discussed.
Developmental and Mental Health Evaluation
Screening for emotional, behavioral, academic and developmental problems should be conducted at each health visit, using standardized screening tools or structured interviews with the foster parent and caseworker. Children with identified problems should be promptly evaluated and treated where indicated by mental health professionals, developmental/behavioral pediatric specialists, speech, occupational or physical therapists and by other community-based intervention programs where indicated. The results of these assessments should be incorporated into the child’s social services case plan to ensure that any needed services are delivered appropriately.
Ongoing Care/Monitoring of Health Status
All children in foster care should have a medical home, in which ongoing medical care and periodic reassessments of the child’s physical, developmental, and mental health status are conducted at regular intervals so that new issues or changes in their status are identified and appropriately addressed. The AAP recommends that at a minimum, periodic reassessments should occur monthly for children <6 months old, every 2 months for children ages 6 to 12 months, every 3 months for ages 1 to 2 years, and every 6 months for ages 2 years through adolescence. In addition, reassessment should be conducted if a change in foster placement occurs or if a child is reunified with their biological parent, due to the potential emotional impact of the change on the child and family.
Pediatricians must work to provide coordinated, comprehensive and continuous medical and mental health care for children in foster care, and effectively communicate with all professionals and caregivers involved in the care of the child to ensure that their complex needs are met, and that they experience optimal outcomes while in placement.