Foster Care : References and Resources

Greater numbers of young children with complicated, serious physical health, mental health, or developmental problems are entering foster care during the early years when brain growth is most active. Every effort should be made to make foster care a positive experience and a healing process for the child. Threats to a child's development from abuse and neglect should be understood by all participants in the child welfare system. Pediatricians have an important role in assessing the child's needs, providing comprehensive services, and advocating on the child's behalf. The developmental issues important for young children in foster care are reviewed, including: 1) the implications and consequences of abuse, neglect, and placement in foster care on early brain development; 2) the importance and challenges of establishing a child's attachment to caregivers; 3) the importance of considering a child's changing sense of time in all aspects of the foster care experience; and 4) the child's response to stress. Additional topics addressed relate to parental roles and kinship care, parent-child contact, permanency decision-making, and the components of comprehensive assessment and treatment of a child's development and mental health needs.

BACKGROUND: Children and youth in foster care (CYFC) are a population with special healthcare needs, and the American Academy of Pediatrics has healthcare standards to care for this population, but implementation challenges include identifying clinic patients in foster care (FC). Documentation of FC status in the Electronic Health Record (EHR) can support the identification of CYFC to tailor care delivery. Therefore, we aimed to improve the percentage of CYFC with problem list (PL) documentation of FC status from 20% to 60% within 12 months. METHODS: This study used a five-cycle plan-do-study-act quality improvement model in two co-located primary care teaching clinics. The primary outcome was the weekly percentage of patients with FC status on EHR PL. Ishikawa cause and effect analysis and resident survey identified barriers and informed interventions: education, patient list distribution, documentation training, email reminders, and clinic champion. We constructed statistical process control charts of the primary outcome to assess for improvement. RESULTS: Mean weekly percentage of patients with FC status on PL improved from 19.8% to 60.2%. The most extensive improvements occurred after designating a clinic champion and providing email reminders with enhanced patient lists. The sustainability of PL documentation (mean = 71.7%) was demonstrated 3-4 years after the completion of plan-do-study-act cycle interventions. CONCLUSIONS: Educating providers, collaborating with child welfare to provide patient lists to providers, standardizing documentation, and designating clinic champions are promising methods of improving EHR documentation of FC status. Identifying and documenting FC status are important initial steps to optimizing care for this vulnerable population in primary care.

OBJECTIVE: To compare the continuity of care experienced by children who are in foster care with that of children who are not in foster care and are covered under Medicaid managed care and Medicaid fee-for-service (FFS). METHODS: This retrospective cohort study used Medicaid claims/encounter data from Washington state. A total of 903 children who were in foster care and continuously enrolled in Medicaid for 24 months (1998-1999) were matched by age, gender, and rural/urban residence to 903 Medicaid managed care enrollees and 903 FFS beneficiaries who were not in foster care. Indices of the continuity of primary care experienced were calculated for each patient, and differences in continuity among the cohorts were assessed by running 3 multiple linear regression models for all possible pairings of cohorts, controlling for age, gender, rural/urban residence, and total number of primary care visits. RESULTS: Foster care status was associated with decreased continuity of care relative to nonfoster managed care status (beta = -0.12; 95% confidence interval [CI]: -0.15 to -0.09). Nonfoster FFS status was associated with lower continuity than managed care (beta = -0.09; 95% CI: -0.12 to -0.06) and slightly higher continuity than foster care status (beta = 0.03; 95% CI: 0.01-0.06). CONCLUSION: Although not dramatically different, continuity seems somewhat lacking for children in foster care. It is unclear to what degree the observed difference is confounded by the managed care/FFS distinction. As the enrollment of children in foster care into managed care plans has been controversial, efforts to promote the consistency of contact with providers while maintaining the flexibility afforded by FFS coverage seem warranted.

OBJECTIVE: This study aimed to characterize the rates and types of diagnosed mental health (MH) disorders among children and adolescents before and during foster care (FC) overall and by race and ethnicity. METHODS: We used population-based linked administrative data of medical assistance (public insurance) claims records and child protective services data from a cohort of early adolescents who entered FC at 10 to 14 years old. MH diagnoses were coded according to the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9 and ICD-10) and included adjustment disorders, disruptive disorders, attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, mood disorders, attachment disorders, autism, and other disorders. RESULTS: Before FC entry, 41% of children and adolescents had at least 1 MH diagnosis. Attention-deficit/hyperactivity disorder (25%), mood disorders (18%), and disruptive disorders (15%) were the most common pre-entry diagnoses. Among early adolescents entering FC with no previous diagnosis, 52% were later diagnosed with adjustment disorder (accounting for 73% of all youth with a new diagnosis during FC). White early adolescents had higher rates of diagnosed MH disorders before FC, whereas racial/ethnic minority early adolescents were more likely to receive a MH diagnosis during FC. Black early adolescents were more likely than White and Hispanic early adolescents to be diagnosed with disruptive disorders and less likely to be diagnosed with anxiety or adjustment disorders during FC. CONCLUSION: Results highlight the high rates of MH needs among early adolescents before entry into FC, whether detected before or during FC. Results also illustrate disparities in pre-entry MH care between racial/ethnic minority and White early adolescents, with minority youth less likely to be receiving services before entry.

• Summary: In 2001, federal research funding (#90-CO-0960) was awarded to conduct an in-depth study of one agency’s experience with domestic special needs adoption placements (US Department of Health and Human Services, 2001). This private Ohio agency has been involved in the placement of special needs children since the beginning of the US special needs adoption movement in 1976. A rigorous and comprehensive chart review was conducted profiling 362 consecutively referred special needs adoption cases from 1997 to 2005, providing one of the most accurate and in-depth profiles of both special needs adoption children and their biological mothers to date. • Findings: In summing the major child and biological mother risk factors reported in this study (i.e. child neglect + child physical abuse + child sexual abuse + child prenatal drug exposure + child positive toxicology screen at birth + maternal mental illness + maternal substance abuse + maternal homelessness + maternal history of domestic violence + parental incarceration + and death of a significant person), youth averaged 4.7 (SD = 1.61) cumulative risk factors, not including poverty, multiple placement disruptions, and other undocumented risk factors. • Applications: Accurate and comprehensive profiling of child and biological parent characteristics are required to inform the service needs of at-risk families, domestic special needs adopted children, and adoptive parents. Implications for adoptive parent recruitment, training, and support, as well child monitoring and treatment are discussed.

The child welfare system strives to provide children and adolescents in foster care with a safe, nurturing environment through kinship and nonkinship foster care placement with the goal of either reunification with birth parents or adoption. Pediatricians can support families who care for children and adolescents who are fostered and adopted while attending to children's medical needs and helping each child attain their developmental potential. Although this report primarily focuses on children in the US child welfare system, private and internationally adopted children often have similar needs.

This article reviews current research on emotional and behavioral disorders among children in foster care and summarizes findings regarding utilization of mental health services in this population. Barriers to needed care are explored, practice and policy implications of lack of care are discussed, and alternative, evidence-based treatment options for foster youth are examined and proposed.

Children in foster care have complexity around medical decision-making because of their unique custody status. When medical decision-making is necessary for a child in foster care, what perspectives are important? What if opinions are not aligned? Who makes the final decision for consent? This Ethics Rounds focuses on a young child in foster care who has had repeated ear infections. Foster caregivers and family of origin are not in agreement on the treatment plan. Two experts, a foster care pediatrician and a child welfare professional, comment on the important considerations for the case, including involvement of legal representation and best interest representation in medical decision-making as well as the variability in child welfare response by state.

Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. As such, they are designated as children with special health care needs. There are many barriers to providing high-quality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty. 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 in the context of a medical home, and health care coordination and advocacy on their behalf. This technical report supports the policy statement of the same title.

Designed for use by pediatric health care professionals, child welfare professionals, and all others working to improve outcomes for children and adolescents in foster care, this updated and expanded edition of Fostering Health serves as a comprehensive guide to health care for this population. Many children in foster care have complex physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. Fostering Health helps pediatric health care clinicians and other professionals understand the needs of these children and how to navigate the systems impacting their health. With contributions from leading experts in the field, topics included are health care practice, culture of child welfare, adolescents and specific populations, system and practice challenges and solutions, and policy and advocacy. In keeping with the latest science, this edition of Fostering Health incorporates the principles of trauma-informed relational health care into all aspects of caring for children involved with child welfare. Each chapter includes an equity lens, as well as review by people with lived experience in the foster care system—an important new addition to this long-standing, authoritative guide.