Health Care Issues for Children and Adolescents in Foster Care and Kinship Care

Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in outof-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves. FOSTER CARE IN THE UNITED STATES The foster care system in the United States evolved over the last century as a means of providing care and protection to children and adolescents removed from their family of origin (predominantly for reasons of abuse and/or neglect and imminent safety concerns). The goal of the foster care system is to provide for the health, safety, and well-being of children and adolescents while fostering reunification or an alternative permanency arrangement (adoption, guardianship, placement with relatives, or independent living) when reunification is not possible. In this statement, the term “foster care” includes those living in court-ordered or formal kinship care (children living with extended family or kin), and the term “children” refers to children and adolescents from birth to 21 years of age. However, children remaining at home after a child protective services investigation experience many of the same childhood adversities as children in foster care and share many of the same health needs. Therefore, although the ensuing discussion and recommendations focus on children in foster care, they are relevant to all children who come into contact with the child welfare system.1,2 More complete information about health care for this population is available in the accompanying technical report.3 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. www.pediatrics.org/cgi/doi/10.1542/peds.2015-2655 DOI: 10.1542/peds.2015-2655 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics PEDIATRICS Volume 136, number 4, October 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 13, 2017 Downloaded from In 2013, approximately 641 000 children ranging in age from 0 to 21 years spent some time in foster care, a number that has steadily declined from a peak of 814 586 in 2002.4 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. More than 70% of children in foster care have a documented history of child abuse and/or neglect,5 and more than 80% have been exposed to significant levels of violence, including domestic violence.6 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,7–10 although for some, it is the first time they may feel safe. Understanding the effects of multiple adversities, trauma, and toxic stress on the health and development of children is fundamental to guiding their caregivers through the healing process. THE HEALTH NEEDS OF CHILDREN AND ADOLESCENTS IN FOSTER CARE The significant unmet health needs of children and adolescents in foster care are rooted in their complex trauma histories and compounded by their poor access to appropriate health care services.1,7,10–15 Limited health care access and unmet health needs precede placement and often endure in foster care.2 Data from the last 30 years demonstrating the high prevalence of health problems have led the American Academy of Pediatrics (AAP) to classify children in foster care as a population of children with special health care needs. Health is defined broadly in this population and includes medical, mental health, developmental, educational, oral, and psychosocial well-being. Overall, 30% to 80% of children come into foster care with at least 1 medical problem,1,16–18 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. Up to 80% of children and adolescents enter with a significant mental health need,1,7,8,10 and almost 40% have significant oral health issues.18 Approximately 60% of children younger than 5 years have developmental health issues, and more than 40% of school-aged children have educational difficulties.19 Children in foster care are more likely to change schools during the school year, be in special education, and have a history of grade retention.20 Adolescents in foster care have poor educational outcomes: high school dropout rates are nearly 3 times higher than those among other low-income children, and just over 50% graduate from high school, many with an equivalency diploma. Early data indicate that youth living in states where the age of emancipation is 21 years instead of 18 years have slightly higher educational achievement. Overall, 6% of foster care alumni have at least some college education, but only 1% to 2% graduate with a 4-year degree.20,21 Essentially all children in foster care have psychosocial issues related to family dysfunction. Long-term outcomes of foster care have been inadequately studied, but national data suggest that young adults who were in foster care as adolescents experience high rates of mental health problems, unemployment, homelessness, low educational attainment, and posttraumatic stress disorder.22–26 Although far less is known about the outcomes of younger children who left foster care before adolescence through reunification with parents, placement with relatives, or adoption, there is evidence that children in long-term stable foster/kinship care do better than those with unstable placements.27 Early childhood trauma/toxic stress, especially if frequent or unremitting and not tempered by responsive, nurturing caregiving, adversely affects the neurobiology of the developing brain.28,29 Early childhood trauma has been correlated with poor emotional regulation, aggression, hyperactivity, impulsivity, attention and attachment problems, and the inability to associate thought and mood.8 Chaotic, unresponsive caregiving before foster care is associated with insecure attachment disorders that may present as indiscriminate friendliness, hypervigilance, or social withdrawal. Ideally, children receive a full mental health evaluation, including a trauma assessment, shortly after entering foster care.30 A mental health screening to assess for suicide risk and acute mental health needs is important at entry to care, but a full evaluation is probably best conducted after the child has had some time to adjust to his or her new living situation and visitation with family. Treatment, if indicated after evaluation, should incorporate appropriate therapy, including trauma-informed care, with appropriate education and support of the child’s caregivers and caseworker. Parent–child interaction therapy, child–parent psychotherapy, traumafocused cognitive behavioral therapy, and the attachment, self-regulation, and competency model30–33 are some recommended evidence-based trauma therapies that are unfortunately still not widely available. There is a shortage of mental health professionals with appropriate training in traumafocused therapies, and funding is insufficient to ensure that all children who might benefit from these interventions can access them. Training in childhood trauma for caseworkers and foster parents has improved in recent years, but ongoing e1132 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 13, 2017 Downloaded from support for foster parents by welleducated professionals is of great importance. Pediatricians caring for children in foster care will often be asked to prescribe psychotropic medications for children with behavioral problems and/or they will encounter children on psychotropic medication. 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.34 Children in foster care are also likely to receive longer treatment regimens than children who are enrolled in Medicaid but not in foster care.35 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.34 Concern over these issues, coupled with the fact that the majority of psychotropic medication prescriptions for children constitutes off-label use, prompted a report in November 2011 by the US Government Accountability Office calling for increased oversight of these medications by states and subsequent federal legislation mandating greater oversight by states (Child and Family Services Improvement and Innovation Act of 2011 [Pub L No. 112-34]).36 In addition, there are concerns about the effects of psychotropic medications on the developing brain as well as the adverse effects (eg, obesity, hyperlipidemia) of some of these medications. It can be challenging for primary care providers to discern the suitability of prescribing psychotropic medications in a population with tremendous mental health needs. Optimal care for mental health concerns in a traumatized population includes a thorough mental health evaluation, including trauma assessment and assessment for comorbidities. Treatment should be diagnosisspecific and, ideally, evidence-based. Psychotropic medications, if indicated, should be initiated at low doses and titrated slowly, with close monitoring for efficacy and adverse effects. Polypharmacy should be avoided if possible. No patient should receive therapy with more than 1 psychotropic medication from any given class.37 Foster parents remain the major therapeutic intervention of the foster care system. Stable placement with a warm, nurturing, empathic, attuned caregiver is ideal. Caregivers may have birth, adoptive, and foster children in their homes at any given time, which can create inherent conflict. Even in a stable home, entries and exits of other children can be traumatizing for the child in foster care. The foster/kinship home environment,38,39 stability in a placement, kinship placement,27 an empathic relationship among foster caregivers and birth parents,40 and consistent quality visitation41 have been shown to improve38–40 (or are recommended by experts to improve40) child outcomes. BARRIERS TO RECEIPT OF ADEQUATE HEALTH CARE IN FOSTER CARE Physician and nonphysician clinicians often face significant barriers in providing appropriate health care services to children in foster care. Health care for traumatized children is time-consuming and challenging. Care coordination is particularly difficult for children in foster care because of the transient nature of the population and the diffusion of authority among parents, child welfare professionals, and the courts.7,8,10 Receipt of health care is often fragmented and crisis-oriented rather than planned, preventive, and palliative. Evidence indicates that foster parents and caseworkers may not fully appreciate all of a child’s health conditions and lack the expertise to access and negotiate a complex health care system on behalf of children with significant needs.12 Pediatricians are, in general, equally unfamiliar with the structure, regulations, and intricacies of the child welfare system. Furthermore, in most communities, there are no structures or systems for coordinating care across disciplines. Key challenges pediatricians may encounter while providing care for a child in foster care include: • Incomplete or unavailable health information, including: information about immunizations; newborn health screening results; medications; allergies; chronic illnesses; hospitalizations; surgeries; vision or hearing loss; family history; dental history; psychosocial history, including childhood trauma history; and developmental or educational problems. The child is frequently accompanied by individuals (caseworkers, transporters, and new foster parents) who have little to no knowledge of the child’s current medical or social situation. • Difficulty identifying who has the authority to consent for health care on behalf of the child. • Inadequate resources for evaluation and treatment. This limitation is a combination of workforce, systems, and funding issues. Medicaid (either fee-for-service or managed care) is the primary health care coverage for children in foster care but may impose limits on certain health services, especially subspecialty, dental, and mental health care.14,15,42,43 PEDIATRICS Volume 136, number 4, October 2015 e1133 by guest on September 13, 2017 Downloaded from COMPONENTS OF KEY HEALTH CARE SERVICES There is abundant literature documenting the health needs of children in foster care and a growing body of literature on effective mental health interventions. However, recommendations regarding care coordination, early and frequent pediatric visits, and mental health, dental, developmental, and educational assessments represent consensus among experts in the field rather than recommendations based on research evidence because these topics have not been studied. There is consensus among experts that health care coordination, more frequent health visits during transitions, and the receipt of health services in the context of a pediatric medical home are fundamental principles in caring for this population. Coordination of Care Although health care coordination is necessary for improving health outcomes for children in foster care, only a few states and localities have systems for communication among caregivers, child welfare professionals, and health and mental health experts. Federal legislation, the Fostering Connections to Success and Increasing Adoptions Act (Pub L No. 110-351 [2008]), requires that states, in consultation with pediatricians and other health experts, develop systems for health oversight and coordination for children in foster care. This act outlines the important pieces of coordinated care: periodic health assessments, shared health information, provision of care in the context of a medical home, and oversight of prescription medications (particularly psychotropic drugs). The Child and Family Services Improvement and Innovation Act (Pub L No. 112-34 [2011]) built on the well-being provisions of the Fostering Connections to Success and Increasing Adoptions Act to support children’s emotional and developmental health and to ensure the oversight of psychotropic medications. Information sharing is crucial to health care coordination. Several states have developed electronic data-sharing systems to improve communication among the child welfare and health care systems. Some states have adopted an abbreviated paper or computerized medical record, often referred to as a “health passport.” For the child in foster care, the health passport should include the child’s chronic health problems, allergies, medications, psychosocial and family histories, trauma history, and developmental and immunization information. Security can be built into such systems so that information is accessible depending on the professional’s role in the care of the child or adolescent. Electronic health records, regional health information systems, and immunization registries offer new tools for improving communication. Health Assessment at Entry Into Foster Care Assessing each child’s unique health needs at entry into foster care is critical, and pediatricians must be prepared to provide necessary care even when little or no specific information about the child’s health history is available at the time of the visit. Ideally, every child would continue to receive health care in his or her medical home of origin. When this option is not possible, establishing and maintaining continuous, comprehensive, and coordinated care in a new pediatric medical home should be one of the highest priorities for child welfare agencies and pediatricians.44 The child welfare professional is ultimately responsible for obtaining and making the child’s health information available, but pediatricians may be able to assist in obtaining some information from schools, previous health care providers, immunization registries, and regional health information organizations.