Pediatric Annals

Ask the Experts 

Challenges to Care of Children and Youth in Foster Care

Marian F. Earls, MD, FAAP

Abstract

Q: The providers in our practice are often asked to provide exams for children who are in foster care. These kids seem to have a lot of needs. What do clinicians need to know about this population?

A: Nationally over 500,000 children are living in some form of foster care.1 These children experience discontinuity of home, school, health care, and relationships. They are likely to have problems with access to health care. They have an increased prevalence of acute and chronic health conditions, mental health issues, and sporadic care. Approximately 24,000 adolescents age out of foster care each year. They are at greatly increased risk for homelessness (85%), unemployment, illness, incarceration (at a rate triple that of the general population), welfare dependency, and sexual and physical victimization. Eighty percent will have mental health issues.2

Children in foster care cost Medicaid more than three times what non-disabled, Medicaid-eligible children cost due to their complex physical and behavioral health needs.3 Enhancing capacity of Medical Homes to serve this high-need population is the next step.

By definition, all children in foster care are considered CYSHCN (Children and Youth with Special Health Care Needs). In addition to the physical health needs that they are likely to have, many of these children have particular social-emotional challenges that include:

Foster parents themselves have social-emotional challenges. These can include:

Very often foster parents have not had specific training about the social-emotional needs of children in foster care and how to manage them.

The need for standards to ensure coordinated, comprehensive care for foster children, with active involvement of the Medical Home, is a national one. According to the American Academy of Pediatrics standards for the Medical Home and Foster Care,4 the Medical Home helps with obtaining and interpreting the child’s medical history, provides consistency in the child’s life, which may be unstable due to changing environments between homes, and makes recommendations to the child welfare agency and the court about medical (including developmental and behavioral) and safety issues.

In addition, fundamental principles summarized from the Healthy Foster Care America website,4 state that children and adolescents should have an enhanced health care schedule so the PCP can monitor for signs and symptoms of abuse or neglect as well as to monitor a child’s or youth’s adjustment to foster care and visitation. These office visits will also ensure a child or youth has all necessary referrals, medical equipment, and medications, as well as support and education for foster parents, birth parents and kin.

The enhanced health care schedule for children and youth in foster care reflects the principles of the chronic care model. Children and youth in foster care should be seen often upon entry to foster care. These visits occur over the first 2–3 months of care and include a health screening visit within 72 hours of placement; a comprehensive health admission visit within 30 days of placement; and a follow-up health visit within 60 to 90 days of placement. The initial visit is the health screening visit, which is brief and intended to assess for signs and symptoms of child abuse and neglect, for presence of acute and chronic illness, for signs of acute or severe mental health problems, and to ensure that a child or youth has all necessary medical equipment and medications at placement. In order to have time to collect and review pertinent health and school records, the comprehensive health admission visit in the Medical Home should occur at 30 days.

Within 30 days of placement, children and youth in foster care should have the following: a comprehensive mental health evaluation; a developmental health…

Q: The providers in our practice are often asked to provide exams for children who are in foster care. These kids seem to have a lot of needs. What do clinicians need to know about this population?

A: Nationally over 500,000 children are living in some form of foster care.1 These children experience discontinuity of home, school, health care, and relationships. They are likely to have problems with access to health care. They have an increased prevalence of acute and chronic health conditions, mental health issues, and sporadic care. Approximately 24,000 adolescents age out of foster care each year. They are at greatly increased risk for homelessness (85%), unemployment, illness, incarceration (at a rate triple that of the general population), welfare dependency, and sexual and physical victimization. Eighty percent will have mental health issues.2

Children in foster care cost Medicaid more than three times what non-disabled, Medicaid-eligible children cost due to their complex physical and behavioral health needs.3 Enhancing capacity of Medical Homes to serve this high-need population is the next step.

Foster Care and Special Health Care Needs

By definition, all children in foster care are considered CYSHCN (Children and Youth with Special Health Care Needs). In addition to the physical health needs that they are likely to have, many of these children have particular social-emotional challenges that include:

  • Removal from all that is familiar;
  • Self-blame about removal from birth parents;
  • Feeling unwanted;
  • Feeling helpless if multiple foster home changes;
  • Having mixed emotions about attaching to foster parents;
  • Feeling insecure about the future; and
  • Possible attachment disorder.4

Foster parents themselves have social-emotional challenges. These can include:

  • Limits to their emotional attachment to the child;
  • Mixed feelings towards the child’s birth parents;
  • Difficulty in letting the child return to birth parents;
  • Dealing with the complex needs of the child;
  • Knowing about and accessing resources for the child; and
  • Dealing with the child’s behavior and emotions, particularly if attachment disorder is present.4

Very often foster parents have not had specific training about the social-emotional needs of children in foster care and how to manage them.

The Role of PCPS

The need for standards to ensure coordinated, comprehensive care for foster children, with active involvement of the Medical Home, is a national one. According to the American Academy of Pediatrics standards for the Medical Home and Foster Care,4 the Medical Home helps with obtaining and interpreting the child’s medical history, provides consistency in the child’s life, which may be unstable due to changing environments between homes, and makes recommendations to the child welfare agency and the court about medical (including developmental and behavioral) and safety issues.

In addition, fundamental principles summarized from the Healthy Foster Care America website,4 state that children and adolescents should have an enhanced health care schedule so the PCP can monitor for signs and symptoms of abuse or neglect as well as to monitor a child’s or youth’s adjustment to foster care and visitation. These office visits will also ensure a child or youth has all necessary referrals, medical equipment, and medications, as well as support and education for foster parents, birth parents and kin.

The enhanced health care schedule for children and youth in foster care reflects the principles of the chronic care model. Children and youth in foster care should be seen often upon entry to foster care. These visits occur over the first 2–3 months of care and include a health screening visit within 72 hours of placement; a comprehensive health admission visit within 30 days of placement; and a follow-up health visit within 60 to 90 days of placement. The initial visit is the health screening visit, which is brief and intended to assess for signs and symptoms of child abuse and neglect, for presence of acute and chronic illness, for signs of acute or severe mental health problems, and to ensure that a child or youth has all necessary medical equipment and medications at placement. In order to have time to collect and review pertinent health and school records, the comprehensive health admission visit in the Medical Home should occur at 30 days.

Within 30 days of placement, children and youth in foster care should have the following: a comprehensive mental health evaluation; a developmental health evaluation if under age 6 years; an educational evaluation if over age 5 years; and a dental evaluation.

Because of patients’ status as CYSHCN, the follow-up visit schedule in the Medical Home should be at a greater frequency. This involves:

  • Monthly visits for infants from birth to age 6 months;
  • Every 3 months for children age 6 to 24 months; and
  • Twice a year for children and youth between 24 months and 21 years of age.

Working with Child Welfare Agencies

In an effective system, Medical Homes would have established a collaborative relationship with the Child Welfare Agency to include a standardized system for communication, scheduling and coordinating referrals. Through the initial visit process, the Medical Home can assist Child Welfare in information gathering at the time of removal. The Medical Home can identify and prioritize record needs and assist with ongoing information gathering (immunization records, medical records, early intervention records and school records). As noted above, the Medical Home provides the comprehensive medical assessment, including developmental and social emotional screening completed by both the birth parent(s) and the foster parent(s) (after placement time is adequate for screen completion). Optimally, this would be accomplished by 30 days after placement (may be somewhat longer due to time needed to gather records).

After the comprehensive visit, the Medical Home continues to provide ongoing preventive and follow-up care with the increased frequency noted above. In collaboration with the Child Welfare Agency, it is crucial to provide a “Medical Passport” to go with the child as the child transitions to another Medical Home or other foster setting, or if the child is returned to birth parents, or is adopted.

As with all youth with special health care needs, the Medical Home needs a process to assist with transition for adolescents into adult health care, and for educational/vocational needs. Challenges include complex coordination needs; confidentiality issues; transience of the population; and the need for a “trauma lens” in assessment and service delivery.

Each AAP Chapter has a foster-care champion, and can be helpful with systems building. To make contact with your chapter leadership or the Council on Foster Care, Adoption and Kinship Care go to aap.org and myAAP.5

References

  1. US Children’s Bureau, Administration for Children Youth and Families. Trends in foster care and adoption- FY 2000-FY 2005. Available at: archive.acf.hhs.gov/programs/cb/stats_research/. Accessed Aug. 20, 2013.
  2. Gardner D. Youth Aging Out of Foster Care: Identifying Strategies and Best Practices. Washington, DC: National Association of Counties, Research Division; February2008.
  3. Allen K. Medicaid Managed Care for Children. Center for Health Care Strategies. Available at: www.chcs.org/usr_doc/CW_MC_Brief.pdf. Accessed Aug. 20, 2013.
  4. American Academy of Pediatrics. Healthy Foster Care America. Available at: www.aap.org/fostercare. Accessed Aug. 20, 2013.
  5. American Academy of Pediatrics. My AAP. Available at: www.aap.org. Accessed Aug. 20, 2013.
Authors

Marian F. Earls, MD, FAAP, is Lead Pediatric Consultant, Community Care of North Carolina.

Address correspondence to: Marian F. Earls, MD, FAAP, Community Care of North Carolina, 2300 Rexwoods Drive, Suite 100, Raleigh, NC 27607; email: mearls@n3cn.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00904481-20130823-03

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