Despite having resources available to provide for their healthcare needs, a vast number of children in foster care are not receiving adequate medical care.
Given that children in foster care are prone to physical, mental health, developmental, and psychosocial impairment, it is critical that pediatricians claim their role as advocate for this population, according to a new report from the American Academy of Pediatrics (AAP).
According to the updated position paper from the AAP on healthcare issues for children in foster care, 641,000 entered into foster care for some period of time in 2013—a figure that peaked at more than 814,000 children in 2002—and those children have a wide range of needs.
“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,” states lead author Moira A Szilagyi, MD, PhD, a professor of pediatrics at the University of California at Los Angeles. “More than 70% of children in foster care have a documented history of child abuse and/or neglect, and more than 80% have been exposed to significant levels of violence, including domestic violence. 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, although for some, it is the first time they may feel safe.”
Pediatricians are uniquely qualified in these situations to offer medical assessment and intervention for the child; mental and psychosocial counseling; education for caregivers; and to advocate for the best interests of the patient. The child in foster care will enter a pediatrician’s practice with a host of unmet healthcare needs precipitated in traumatic histories and inadequate access to care, Szilagyi says. The problem is so extensive that AAP has begun to classify children in foster care as a population with special healthcare needs, she adds.
“Overall, 30% to 80% of children come into foster care with at least 1 medical problem, 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,” she says. “Up to 80% of children and adolescents enter with a significant mental health need, and almost 40% have significant oral health issues. Approximately 60% of children aged younger than 5 years have developmental health issues, and more than 40% of school-aged children have educational difficulties.”
Szilagyi also pointed out in the study that foster children are 3 times more likely to drop out of high school compared to other low-income children, and slightly more than 50% graduate high school—most often with an equivalency diploma. Beyond schooling, Szilagyi says data suggests that children who were in foster care during their adolescence grow up to experience higher rates of mental health problems, homelessness, posttraumatic stress disorder, and low educational achievement.
Despite the clear need for intervention, however, data suggests that only a fraction of children in foster care are receiving the help they need before, during, and after entering the foster care system.
According to a 2013 report by the Council of Family and Child Caring Agencies and the New York State Health Foundation, children in foster care are receiving minimal care in many cases, and outcomes are generally unavailable for those that do receive care. National data on healthcare frequency in foster children is lacking, but the New York report provides a snapshot.
According to the New York report, a mere 15.7% of children had a preventive care visit with a physician in the 12 months prior to their entry into foster care. Statewide, the number rose to 31.9%. Once children were placed into foster care, the frequency of visits appeared to increase, but not by much. According to the report, preventive visits for children increased while in foster care in New York City from 15.7% to 25.2%, and from 31.9% to 36.5% across the entire state. After exiting foster care, however, the frequency of preventive visits dropped down further than before—to 11.9% in New York City and 25.4% statewide in the year after exit from foster care.
Where visits were higher were in emergency visits—42.8% of children in New York City and 40.4% statewide had at last 1 visit to an emergency department (ED) in the year before entering foster care. Those visits dropped by 38.8% and 30.9%, respectively in the year the children were in foster care, but dropped further in the year after exit from foster care, with 22.3% visiting EDs in New York City and 27.6% statewide.
For infants, the most common reason for an ED visit was childbirth, indicating a high number of deliveries occurred through the ED.
In terms of inpatient stays, a top reason children in foster care are admitted to hospitals is for treatment of mental health conditions. Attention Deficit Hyperactivity Disorder was the top diagnosis for children aged 1 to 5 years, followed by bipolar disorder. For children aged 6 years and older, bipolar and depressive disorders are top admitting diagnoses. Infants also were frequently admitted for respiratory problems, while toddlers and preschool-aged children were commonly hospitalized for injuries and asthma.
The most recent national data on healthcare compliance among children in foster care is from the 1990s, Szilagyi says, when the Government Accountability Office released a “scathing” report on the state of healthcare compliance in foster care.
At the time of the report, the number of children in foster care more than doubled over the previous 5 years but was still half of what it is today. The review at the time found that, despite resources being made available to provide healthcare services for children in foster care, roughly 12% of young children in foster care received no routine health care; 34% were not immunized; at least 32% had unmet healthcare needs; and an estimated 78% were at risk for human immunodeficiency virus but only 9% had been screened for infection. Another 62% of children in foster care were estimated to be at risk for health problems related to prenatal drug use, the report states.
Pediatricians play a big role in providing caregivers—who come to foster care with a wide range of experiences and skills—with education and support to connect them with the services they need and to emphasize the importance or regular, timely healthcare intervention.
To address these healthcare needs, and the special circumstances involving children in foster care, AAP’s updated statement places greater emphasis on early childhood trauma and its impacts on all aspects of health, including physical and mental wellness, developmental health, and how trauma becomes predictive of poor outcomes, Szilagyi says.
If caught early while the brain is still malleable, pediatricians, through good care and good experiences, can help shift the trajectory for these children in a better direction, Szilagyi says.
“The pediatrician has both a responsibility and an opportunity to really improve outcomes for these children. It really does require some work across systems to implement everything and it requires a lot of time they might not be reimbursed for,” Szilagyi says. “However I think it’s just a really big opportunity to make a big difference in a child’s life. I really view foster care as an opportunity for healing. It’s an opportunity to make sure all their needs are assessed and they have all the services they need.”
Even in cases when children don’t require medical or psychological support upon entry to foster care, things can change quickly, Szilagyi says. Birth parents may be struggling to comply with visitation and mental health care, and noncompliance during the foster care period may negatively impact the child.
“It’s really incumbent on pediatricians to reassess them periodically,” Szilagyi says. “It’s a great thing about having a periodicity schedule in pediatrics. There is an argument for seeing these kids more frequently because they have a lot of stresses and things that can go wrong in their lives.”
By staying attuned to the needs of the children in foster care, as well as their caregivers, pediatricians can provide valuable support at the personal and population level.
Ideally, the AAP guidance recommends that all children receive a full mental health evaluation, including a trauma assessment, shortly after entering foster care. Assessing for suicide risk and acute mental health needs is a priority, but the full evaluation is probably best conducted after the child has had some time to adjust to their new living situation, Szilagyi says. Social workers and foster caregivers may not have adequate experience in caring for a child’s mental health needs, and the pediatrician can offer support and guidance. In instances where psychotropic medications are needed or have already been prescribed to a child, pediatricians must weigh the benefits of the regimen.
“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,” according to the AAP statement. “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. …In addition, there are concerns about the effects of psychotropic medications on the developing brain as well as the adverse effects of some of these medications.”
When the use of psychotropic medications is warranted, they should be initiated at low doses and titrated slowly, with close monitoring, and no patient should receive more than one psychotropic medication from any given class, Szilagyi says.
In physical assessments, pediatricians should assess upon entry to foster care any evidence of abuse or developmental delay. Follow-up assessments should be performed within 60 to 90 days after placement and include screenings for abuse, poor weight gain, compliance with healthcare recommendations, and bonding between children and their foster caregivers.
In terms of frequency, it is recommended that children in foster care be seen monthly within the first 6 months of life, every 3 months from 6 months to 24 months of age, and then every 6 months thereafter to monitor the wide range of physical and emotional stressors the children can face within the foster care system.
Pediatricians should allow additional time for assessing children in foster care due to the complex nature of their situations, and also develop an office system for communicating with caseworkers and foster caregivers following each encounter.
Even with the best efforts, however, many barriers exist to providing adequate healthcare to children in foster care, Szilagyi says. Care coordination is particularly difficult given the transient nature and diffuse authority of the foster care system. Pediatricians may also be faced with incomplete medical records, inadequate resources, and difficulty in identifying an authority to consent to health care services for the child.
“See them early, see them often, and continue to see them to monitor their progress and be an advocate when needed,” Szilagyi says. “We’re often the first real child professional that families encounter so we really have an amazing opportunity to either prevent adversity or ameliorate the impact of adversary. Sometimes that just starts with recognizing that bad things have happened and for both children and parents it can begin the healing.”