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Fostering Hope: A Pediatrician’s Role in Caring for Children in Foster Care
Hollie Edwards, MDPediatric Grand RoundsNovember 6, 2015
WHAT IS THE AVERAGE LENGTH OF STAY FOR A CHILD OR TEEN IN THE FOSTER CARE SYSTEM?
1 2 3 4
0% 0%0%0%
1. 5 years2. 3 years3. 1 year4. 6 months
A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR OFFICE THE DAY AFTER BEING PLACED WITH FOSTER PARENTS. YOU FIND OUT THAT
NEGLECT FROM THE BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION LED TO THE PLACEMENT. PATIENT APPEARS WELL ON
EXAM AND HAS NO KNOWN MEDICAL PROBLEMS. WHEN DO YOU NEED TO SEE HER BACK?
1 2 3 4
0% 0%0%0%
1. 1 year2. 6 months3. 2 months 4. 1 month
FOR A CHILD IN FOSTER CARE, WHO IS ABLE TO CONSENT FOR
MEDICAL PROCEDURES?
1 2 3 4 5 6
17% 17% 17%17%17%17%
1. Foster parents 2. Department of Social
Services (DSS)3. Birth parents4. 1 & 25. 2 & 36. All of the above
WHICH OF THE FOLLOWING SEQUELAE ARE TRUE CONCERNING
THE IMPACT OF TRAUMA ON A CHILD?
1 2 3 4 5 6
17% 17% 17%17%17%17%
1. Chronically elevated stress hormones
2. Development of permanent maladaptive behaviors
3. Altered development of prefrontal cortex and hippocampus
4. 1 & 25. 1 & 36. All of the above
DISCLOSURES
Neither myself nor Dr. Stephenson have any financial relationships to disclose.
OBJECTIVES
Gain overall knowledge about the process of the foster care system in America and the scope of the problem
Review existing recommendations related to the special healthcare needs of children in foster care
Become familiar with the sequelae of childhood trauma and adversity
Review frequently confused topics related to foster care and medicine
THE FOSTER CARE SYSTEM IN AMERICA
Temporary service Protection and shelter for children who
require out-of-home placement Opportunity for healing Ultimate goal- final placement in a stable,
safe, permanent, and secure living arrangement
SCOPE OF THE ISSUE
Each year, more than 3 million children are involved in investigations of abuse or neglect
Nearly 500,000 children are living in foster care on any given day
The federal government spends about $4.4 billion a year to maintain children in foster care
RACE STATISTICS
AGE STATISTICS
40% are teenagers 30% are under the age of 5 Median age entering system 6.7 years Median age currently in system 9.2 years
SOUTH CAROLINA DATA
COUNTY DATA
0-5yo 6-12yo 13-17yo 18+yo Total
Lexington 90 67 49 3 209
Richland 102 68 77 12 259
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation Removal and Placement Service Planning Permanency Planning
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation Removal and Placement Service Planning Permanency Planning
REASONS FOR REFERRALS
Child maltreatment accounts for 70% Child neglect Sexual abuse Emotional abuse Physical abuse
Disruptive behaviors Voluntary placements, <1%
BIRTH PARENTS
79% have significantly impaired parenting skills* 31% with serious mental health problems 25% with active alcohol abuse 37% with active substance abuse 12% with cognitive impairment
*National Survey of Child and Adolescent Well-being (wave 1)
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation Removal and Placement Service Planning Permanency Planning
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation
Removal and Placement Service Planning Permanency Planning
REMOVAL IS TRAUMATIC
Even if the children came from bad circumstances, removal from family is emotionally traumatizing. This is the only world they have ever known.
TYPES OF FOSTER CARE
Family foster care Kinship foster care Pre-adoptive foster
care Congregate care
SOUTH CAROLINA PLACEMENT
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation Removal and Placement
Service Planning Permanency Planning
THE FOSTER CARE PROCESS
Report and Referral After Hours Reporting:
(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake
Investigation Removal and Placement Service Planning
Permanency Planning
PERMANENCY PLANNING
Options for permanent placing Reunification Adoption Guardianship to relative Emancipation from foster care system
Mandated court reviews Guardian ad litem
FOSTER CARE TEAM
Department of Social Services (DSS) Caseworkers Foster parents Birth parents Guardian ad litem Pediatricians
PEDIATRICIANS ARE A CRITICAL PART OF THE FOSTER CARE TEAM…
OVERALL GOALS FOR PEDIATRICIANS
Be a medical home Help child welfare agencies, foster families,
and birth families minimize the trauma of placement separation
Improve the child’s health and development during the period of foster care
HIGH RISK POPULATION
In 1995, a Government Accounting Office Report stated that children in foster care are “sicker than homeless children and children living in the poorest section of inner cities.”
o 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.
BARRIERS TO GOOD HEALTH OUTCOMES
Lack of a medical home Lack of medical records Inadequate and delayed assessment of
needs upon entry into system Lack of follow-through in addressing
identified needs Lack of access to other health services Diffusion of authority and responsibility Health providers’ lack of knowledge about
child welfare and legal systems
NATIONAL INVOLVEMENT
AAP Council on Foster Care, Adoption, and Kinship Care
Healthy Foster Care America Child Welfare League of America (CWLA)
AAP RECOMMENDATIONS
Health screening within 72 hours of placement into foster care
A comprehensive evaluation within 30 days of placement
Follow-up health visit within 60 to 90 days of placement
Continuity of care Monthly for infants from birth to age 6 months Every 3 months for children age 6 to 24 months Twice a year for children and teens between 24
months and 21 years of age
INITIAL HEALTH SCREENING
Review the circumstances that led to placement
Monitor adjustment to foster care home
Inquire about the agency’s plans for permanency
INITIAL HEALTH SCREENING
Immunization status Review patient’s medical history Assess developmental or school progress Complete physical exam
Height, weight, head circumference All body surfaces should be unclothed Genital and anal examination
Laboratory tests when appropriate
GENERAL TIPS FOR HEALTH CARE PROFESSIONALS
Use respectful language Don’t label children or families Use the term “child in foster
care” instead of “foster child” After each visit, contact the DSS
caseworker Provide a copy of the health
summary to the caseworker and foster parent
COMPREHENSIVE EXAM
Physical health Oral health Relational health Developmental health (if under 6yo) Educational health (if over 5yo) Mental/behavioral health
PHYSICAL HEALTH
About 50% have chronic medical problems Asthma Iron deficiency anemia Obesity or FTT Enuresis and encopresis Visual and hearing loss Neurological disorders Genetic disorders Infection (STI, TB) Increased lead levels
ORAL HEALTH
Approximately 35% enter foster care with significant dental and oral health problems
Common problems: bottle tooth decay in
young children multiple dental caries in
older children AAP recommends that
every child and teen entering foster care have a dental evaluation within 30 days of placement
RELATIONAL HEALTH
Children and teens often enter foster care without a model for normal, healthy family relationships
They need to learn some of the basic principles of being a part of a healthy family
Overall, foster care is intended to allow children to develop a sense of belonging
DEVELOPMENTAL HEALTH
6x more likely to have developmental problems
60% of children <6yo enter foster care with developmental delay in at least one domain
Use validated developmental screen Referrals for PT, OT, ST May be a role for developmental pediatric
specialists
EDUCATIONAL HEALTH
Kindergarteners in foster care have half the vocabulary of their peers
Nearly half are involved in special education and of these children, half have significant behavioral problems that lead to high rates of school suspensions and missed educational opportunities
8% of young adults completed a bachelors degree compared to the general population of 24%
MENTAL/BEHAVIORAL HEALTH
30% of children in foster care vs. 4% of general population have emotional issues
5x more likely to have behavioral problems 16x more likely to carry a psychiatric
diagnosis 8x more likely to be on psychotropic
medications Consider referrals to mental health care
professionals with expertise in trauma, post-traumatic stress disorder, grief, and separation issues
o Largest unmet health need for children and teens in foster care
HOW PEDIATRICIANS CAN HELP FOSTER PARENTS
Explain health status Help access services Give advice on parenting Teach foster parents how
to cope with child’s history of trauma
HOW PEDIATRICIANS CAN HELP FOSTER PARENTS
Explain health status Help access services
Give advice on parenting
Teach foster parents how to cope with child’s history of trauma
STRESSORS
Change in visitation with parents Change in school or child care settings Separation from siblings Parents going to rehab or jail Court dates Another child entering/leaving the foster
home Being freed for adoption
HOW PEDIATRICIANS CAN HELP FOSTER PARENTS
Explain health status Help access services Give advice on parenting
Teach foster parents how to cope with child’s history of trauma
THE IMPACT OF CHILDHOOD TRAUMA
Trauma experiences such as maltreatment, violence exposure, poverty, and impaired caregiving lead to chronic elevations in stress hormones
As pediatricians, it is crucial to understand the impact of trauma on the developing brain and its translation into largely predictable emotions and behaviors
We must be able to reframe behaviors for foster parents in ways that might be helpful to them in parenting the child
PEDIATRICIANS ROLE IN CHILDHOOD TRAUMA: “TRAUMA INFORMED CARE”
Identify traumatized child
Educate families about toxic stress and the possible biological, behavioral, and social manifestations of early childhood trauma
Empower families to respond to child’s behavior in a manner that acknowledges past trauma, but promotes the learning of new, more adaptive reactions to stress
COMMON BEHAVIORS
Poor affect regulation Impulsive Hyperactive Limited attention span Inflexible Dissociation Poor self concept Act younger than they are Insecure attachment
Indiscriminately friendly Avoidant, ambivalent
Do not know difference between anger and sadness
REASONS FOR THESE COMMON BEHAVIORS
These children have developed different ways of perceiving and reacting to their world, ways that often prove maladaptive in a more normal environment
Altered neuroendocrine development
ADVICE FOR FOSTER PARENTS
Do not take these behaviors personally Help child understand your facial expression or tone Avoid yelling and aggression Come down to child’s eye level Validate their feelings Develop breathing techniques, relaxation skills, or
exercises that the child can do when getting upset Praise the child for expressing feelings or calming
down Be aware of your own emotional responses to child’s
behaviors With time, patience, and practice, the child’s brain
and body will learn more adaptive ways to respond to a new, safer environment
SPECIAL ISSUES
TRANSITIONING OUT OF FOSTER CARE AND IN TO ADULTHOOD
Importance of mentorship Major decisions Need copy of:
medical records including meds, immunizations, full history, birth, medical, and family history
emergency contact info legal form with POA health insurance card contact info for former doc, dentist, counselor birth certificate and SS card high school diploma or GED photo ID
MEDICAL CONSENT
Legal guardianship remains with birth parents unless freed for adoption
Whenever possible, the birth parents should make all important decisions and grant consent on behalf of their child
DSS also has the ability to consent for routine medical treatment
Foster parents do not have the authority to provide consent for medical procedures
When freed for adoption, birth parents no longer have any legal rights
CONFIDENTIALITY
Medical information may be shared with caseworkers and foster parents
Need to check with foster care agency before releasing information to birth parents
Once freed for adoption, may not share information with birth parents
Attorneys and court-appointed special advocates only have access to medical information through subpoena or written consent
ADVOCACY OPPORTUNITIES
Volunteering in agencies that serve children or teens in foster care
Becoming a mentor Teaching independent living skills Advocating for services and policies at the
federal and state level Starting a “backpack” program so that
children in foster care have items for school Donating to a fund that pays to enroll
children in foster care in extracurricular activities
CONCLUSIONS
The foster care system aims to uphold the health and well-being of children and teens in foster care, keep them safe, and promote stability
It is our job as pediatricians to provide high quality health services, health care coordination, and advocacy on their behalf
It is crucial to understand the impact of trauma on the developing brain and its translation into largely predictable emotions and behaviors
We must be able to reframe behaviors for foster parents in ways that might be helpful to them in parenting the child
WHAT IS THE AVERAGE LENGTH OF STAY FOR A CHILD OR TEEN IN THE FOSTER CARE SYSTEM?
1 2 3 4
0% 0%0%0%
1. 5 years2. 3 years3. 1 year4. 6 months
A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR OFFICE THE DAY AFTER BEING PLACED WITH FOSTER PARENTS. YOU FIND OUT THAT
NEGLECT FROM THE BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION LED TO THE PLACEMENT. PATIENT APPEARS WELL ON
EXAM AND HAS NO KNOWN MEDICAL PROBLEMS. WHEN DO YOU NEED TO SEE HER BACK?
1 2 3 4
0% 0%0%0%
1. 1 year2. 6 months3. 2 months 4. 1 month
FOR A CHILD IN FOSTER CARE, WHO IS ABLE TO CONSENT FOR
MEDICAL PROCEDURES?
1 2 3 4 5 6
17% 17% 17%17%17%17%
1. Foster parents 2. Department of Social
Services (DSS)3. Birth parents4. 1 & 25. 2 & 36. All of the above
WHICH OF THE FOLLOWING SEQUELAE ARE TRUE CONCERNING
THE IMPACT OF TRAUMA ON A CHILD?
1 2 3 4 5 6
17% 17% 17%17%17%17%
1. Chronically elevated stress hormones
2. Development of permanent maladaptive behaviors
3. Altered development of prefrontal cortex and hippocampus
4. 1 & 25. 1 & 36. All of the above
REFERENCES Ahrens, KR. et al. Youth in foster care with adult mentors during adolescence have improved
adult outcomes. Pediatrics 2008; 121 (2): e246-e252.
“Foster Care.” American Academy of Pediatrics. Web. <www.aap.org/fostercare>.
“Smart Spending.” Casey Family Programs. Web. <http://www.casey.org/smarter-spending/>.
Committee on early childhood, adoption, and dependent care. Health care of young children in foster care. Pediatrics 2002; 109 (3): 536-540.
Greiner, MV. et al. Foster caregivers’ perspectives on the medical challenges of children placed in their care: Implications for pediatricians caring for children in foster care. Clinical Pediatrics 2015. epub ahead of print.
American Academy of Pediatrics District II New York State Task Force on Health Care for Children in Foster Care. Fostering Health: Health care for children and adolescents in foster care. Elk Grove Village, IL: American Academy of Pediatrics; 2005.
Szilagyi, M. The pediatrician and the child in foster care. Pediatrics in Review 1998; 19 (2): 39-50.
Jee, SH. et al. Foster care issues in general pediatrics. Current Opinion in Pediatrics 2008; 20 (6): 724-728.
Bruskas, D. Children in foster care: a vulnerable population at risk. Journal of Child and Adolescent Psychiatric Nursing 2008; 21 (2): 70-77.
Task Force on Health Care for Children in Foster Care. Fostering health: Health care for children and adolescents in foster care, 2nd addition. New York: American Academy of Pediatrics, 2005. Print.
Leslie, LK. Et al. Comprehensive Assessments for children entering foster care: A national perspective. Pediatrics 2003; 112 (1): 134-142.
Halfon, N. et al. Health status of children in foster care. The experience of the Center for the Vulnerable Child. Arch Pediatr Adolesc Med. 1995; 149 (4): 386-392.
Chernoff, R. et al. Assessing the health status of children entering the foster care system. Pediatrics. 1994; 93 (4): 594-601.
American Academy of Pediatrics and Dave Thomas Foundation for Adoption. Helping Foster and Adoptive families cope with trauma: A guide for pediatricians. Elk Grove Village, IL: American Academy of Pediatrics; 2013.
Schor, E. The foster care system and health status of foster children. Pediatrics 1982; 69 (5): 521-528.
QUESTIONS??
(THIS EXCLUDES DR STALLWORTH)