Care of the Foster Child: A Primer for the Pediatrician
Foster care was designed to provide temporary, nurturing environments to children while their caregivers (usually birth parents) receive services to help them facilitate eventual reunification. The number of children in foster care in the United States has been steadily increasing in the past 2 decades with more than 500,000 children in care on any given day [1,3]. However, according to the US Department of Health and Human Services, Adoption and Foster Care Analysis and Reporting System (AFCARS), there has been a gradual decline in numbers since fiscal year (FY) 2007. In AFCARS Report #17, an estimated 424,000 children were in foster care in the United States on September 30, 2009. Since 2007, the number of foster children exiting the system has been greater than those entering. Overall, the number of children in foster care has declined to its lowest level since 2002, and the number of adoptions has increased to its highest level [1,4]. The recent trend has been to (1) attempt to keep children with their birth families while providing family preservation services, (2) push for more timely reunification of families, and (3) commence concurrent planning early with the aim of expediting termination of parental rights and permanency preparation in cases where reunification is not possible [5,6]. Despite this progress, there still are a large number of children in foster care who require quality health care assessments, treatment, and close monitoring.
Training, Intervention, Education and Services (TIES) for Families is a University of California, Los Angeles (UCLA) program consisting of a multidisciplinary team of social workers, psychologists, psychiatrists, education and speech/language consultants, and a pediatrician who use a team approach to assist the integration of children within their new foster family, school, and community. The lead author has served as the pediatric consultant on this team since its inception in 1995. Families interested in becoming foster/adoptive parents are provided psychoeducation and other services before, during, and following a child’s placement into their home. This article was written by specialists on our team and provides primers for the primary care physician (PCP) focusing on the areas of health care, speech and language, education, mental health, and psychosocial functioning of the foster child.
Medical focus on the foster child
Environmental risk factors for the foster child
Children can be adversely affected by their environment while in utero. Maternal malnutrition and poor prenatal care (both often associated with poverty), substance abuse, intimate partner violence, and serious parental developmental disabilities and/or mental illness can all have a significant impact on the fetus, leading to an increased risk of morbidity (eg, low birth weight, preterm delivery) and mortality [2,7]. Children come to the attention of the child welfare system either shortly after birth because of prenatal substance exposure (PSE) or severe maternal developmental disability and/or mental illness, or they may present later because of abuse or neglect, often in association with these same factors [8].
The National Survey on Drug Use and Health estimates that more than 1 in 10 minors reside in homes with a substance-dependent or substance-abusing parent [9]. It is estimated that more than 400,000 infants are born in the United States each year prenatally exposed to alcohol or illicit substances [10]. Most maternal drug abuse can be categorized as polysubstance abuse. Drugs, alcohol, and tobacco use during pregnancy, especially in the first trimester, can have deleterious effects on the fetus. Research regarding the effects of drugs on the fetus is challenging because of difficulties in identifying users by self-reports; the combined effects of polysubstance use itself; unreliable estimations in the timing and dosage of drug and alcohol exposure; and variations in an individual’s metabolism of substances. The impact of other prenatal high-risk factors (eg, poor prenatal care, poor nutrition) as well as the influence of genetics and postnatal environmental factors also contribute to making it impossible to predict the outcome for any particular child.
The drug with the most deleterious effects on a fetus is alcohol. The most recent estimates of the prevalence of fetal alcohol syndrome (FAS) in the United States are 2 to 7 per 1000 live births [11]. Alcohol consumed in significant quantities during the first trimester can lead to FAS. FAS is the leading cause of preventable mental retardation in the Western hemisphere [12]. This diagnosis can be elusive at times. The characteristic facial features of small eyes measured from inner to outer canthus, smooth philtrum, and thin upper lip may not be apparent in infancy. Other findings include prenatal and postnatal growth retardation, central nervous system involvement, and prenatal alcohol exposure. The spectrum of disorders can be categorized using the fetal alcohol spectrum disorders classification system [13]. Use of this classification system has shown the prevalence of FAS in the foster care population to be 10 to 15 per 1000 [14]. Even though FAS is a permanent birth defect, establishing the diagnosis early in a foster child can assist in preparing caregivers in meeting the child’s needs, leading to more stability and fewer placements. A referral to a team with expertise in identification of FAS may be indicated when the diagnosis is entertained.
The early extremely negative predictions as to the future for children with PSE have not been supported by research. At birth, children with PSE may be at risk for smaller head circumferences, lower birth weights, and may be small for gestational age [15,17]. During infancy they may have sleep difficulties as well as problems with state regulation (ie, inability to remain quiet, calm, and alert). Gross and fine motor delays as well as coordination difficulties noted early have been shown to improve with interventional services with potential resolution by 18 months of age [18]. Children with PSE may be at risk for difficulties in behavior, attention, language, and learning [19]. Although longitudinal studies examining long-term outcomes for children are ongoing, initial findings show that, early on, children who have been exposed to cocaine, methamphetamines, or opiates typically have an intelligence quotient (IQ) within the normal range [15,19,20]. Potential differences do exist, but have been found to be minimal. Even though studies show some relationship between PSE and outcomes, it does not mean that every child with PSE will be affected. Additional research is needed to evaluate the impact of environmental factors as well as services on outcome. The significance of postnatal environmental influences was noted in one study in which the IQ scores of children exposed to cocaine placed in more stimulating environments were found to be similar to scores of nonexposed children [20]. The importance of protective factors and early interventional services cannot be overemphasized. In summary, there is a range of outcomes for children with PSE. A host of factors, including genetics and postnatal environment, can influence these outcomes. It is prudent that the PCPs become familiar with the special needs of this vulnerable population and submit timely referrals for early assessment and interventional services to improve the foster child’s future.
Postplacement comprehensive medical care
Children placed in out-of-home care require a thorough medical assessment preceding or shortly following their first placement and any changes thereafter. The timing of this initial examination varies from state to state [21]. Many foster parents select their local community physicians for initial and ongoing health care [22]. The PCP plays a central role in caring for foster children and therefore it is imperative for them to be familiar with current guidelines for health care evaluation recommended by the Child Welfare League of America (CWLA) and American Academy of Pediatrics (AAP) [23,24] as well as those of their own state and locality. This examination is significant to ensure that (1) existing acute or chronic medical problems are identified and treated, (2) injuries and/or infections caused by physical or sexual abuse are documented and treated, (3) needed medications or medical equipment are supplied, and (4) referrals are made for urgent developmental or mental health issues.
The inability to interview birth parents, absence of records, and/or the lack of prior medical care can hinder the new PCP’s assessment. Foster children can present with growth indices concerning for short stature, failure to thrive, or even obesity [25]. Assessment of these disorders relies heavily on an accurate medical history for the child as well as a complete family history. Many children in foster care are inadequately immunized [2,26], with only two-thirds of them receiving necessary immunizations while in foster care [2,27]. Poor access to health records aggravates this problem. The use of a medical passport has proved helpful in maintaining an ongoing record of the foster child’s medical care [5,28]. Advocates may also use school immunization records as a source of information. If no records are located, many of these children may need to be reimmunized. Contacting the child’s caseworker to seek out additional records and information from the birth parents can be beneficial.
There is an increased incidence of acute and chronic health problems for foster children [25,29]. Commonly diagnosed conditions within the foster care population include respiratory (including asthma); ear, nose and throat (including otitis media); skin; and dental issues [21,30]. Many foster children have not received routine hearing and vision screens. Deficits in these areas can affect speech and language development as well as behavioral and school functioning. A referral for a hearing screen or evaluation is also recommended as soon as any speech, language, or hearing problem is suspected [31]. Studies have shown that unidentified vision impairments plague the foster care population at rates of more than 30% [30,32]. The adolescent population seems to be at risk for these common maladies as well as tuberculosis exposure, substance abuse, sexually transmitted infections, and pregnancy [32]. The PCP should be knowledgeable about and comfortable with the needs of adolescents, including issues surrounding confidentiality and consents. At times, referral to an adolescent medicine specialist may be appropriate.
Children in foster care are at high risk for human immunodeficiency virus (HIV). Estimates reveal that up to 78% of foster children could be at risk for HIV, with only 9% tested [26]. Routes of acquisition include perinatal transmission from HIV-positive mothers, infection via sexual abuse, and, as for adolescents, secondary to their own sexual activity and drug use. Perinatal HIV infection may remain asymptomatic for years or present with mild symptoms. Studies have noted some asymptomatic carriers presenting at or beyond 4 years of age [33,35] with 1 case report of an asymptomatic 13-year-old child with perinatal HIV acquisition [36]. It is recommended by the AAP that foster care agencies attempt to obtain information regarding maternal HIV status and for all foster children to undergo an HIV risk assessment [37]. If maternal status is unknown or the child is at high risk, then testing should be pursued. Early diagnosis, placement on antiviral regimens, and close follow-up can delay symptoms. In addition to HIV, these children are at risk for transmission of hepatitis B and C, which should also be investigated.
Most children in foster care are referred because of allegations of abuse or neglect. A meticulous physical examination during the initial assessment may reveal evidence of abuse and/or neglect that not only assists investigating agencies in substantiating allegations but also safeguards the new foster home placement from false accusations. Discovery and documentation of the presence or absence of injuries at every health care visit is imperative to ensure that foster children are safe and not subjected to additional abuse by foster parents, birth parents during visitations, or by siblings (birth or foster) [38,39]. A history of sexual and physical abuse, as well as other stressors such as witnessing intimate partner violence, places children and adolescents at risk for developing sexualized behaviors as well as an increased risk of victimization and/or perpetration of sexual acts on others, especially younger children [40,41]. Inappropriate sexual behaviors should be referred for mental health evaluation and services for the child and caregivers. For a review of normal versus abnormal childhood sexualized behaviors, please refer to Kellogg [42]. Children exposed to abusive and dysfunctional home environments may also have an increased risk for long-term medical and psychosocial issues in adulthood, as noted in the Adverse Childhood Experiences (ACE) study [43].
Enuresis and encopresis, both common problems in the foster care population [29,44,45], can lead to significant distress for both caregiver and child and disruptions in placement. Children struggle with anxiety, grief, distress, as well as shame, fear of being exposed, and issues of poor self-esteem that, if unresolved, may continue into adulthood. The magnitude of family distress can lead to a lack of empathy, harsh punishments, and can be a trigger for maltreatment, sometimes fatal [38,46,47]. The incidence of enuresis for children 5 years and older in out-of-home care can be as high as 17.9% [44]. Enuresis and encopresis lacking any organic cause have been associated with psychosocial stressors (ie, abuse and neglect) [44,48], developmental delays [47], and attention-deficit/hyperactivity disorder (ADHD) [49–52], findings frequently observed within the foster care population. For the PCP, urgent evaluation, treatment, and close follow-up of foster children with these issues are critical.
Early childhood experiences can profoundly affect the development of the brain during infancy and youth [53]. Delays in one domain (ie, language) can affect other domains (ie, cognitive and social) and areas of functioning (ie, education and mental health). In FY 2009, AFCARS estimated that more than 40% of children entering foster care in the United States were less than 5 years of age [1]. It is estimated that up to 60% of children in foster care have developmental delays [30,54]. Early assessment, identification, and interventional services can help those with delays. Screening for developmental delays is the responsibility of the PCP; however, PCPs are more likely to identify and refer issues related to physical health disorders versus developmental and mental health impairments [55]. Utilization of a validated screening instrument such as the Ages and Stages Questionnaire (0–5 years) can double the detection rate of developmental problems before school entry [56]. This questionnaire can easily be completed by caregivers before their appointment and can complement the physician’s office assessment and be factored in the decision of whether a more formal evaluation by a developmental specialist is necessary.
Mental health screening and referral for treatment when indicated is strongly recommended because of the prevalence of mental health issues in this population [24,25,29]. Information regarding this important area is covered later in this article.
In addition to the AAP preventative health care schedule, visits are recommended monthly up to 6 months of age, semiannually after 2 years of age, and into adolescence, as well as during periods of transitions [5,23,24].
As a final note, regarding confidentiality and consent issues surrounding foster children, the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted to protect health insurance, as well as to protect the privacy of patient health care data. In general, HIPAA regulations override state laws unless the state law is more stringent than HIPAA. For the PCP, questions as to who can provide medical consent for a foster care child, in which conditions, and to whom to release information may be confusing. HIPAA addresses issues regarding release of information of minors who are the suspected victims of child abuse and neglect [57]. All PCPs should be familiar with HIPAA regulations as well as their own state laws and the policies of their local agencies governing confidentiality. For a review, please refer to Refs. [24,57,58]. Most states prefer that birth parents retain medical consent [59]. However, in controversial situations, it is prudent for the PCP to clarify who holds the right for medical consent by consulting with legal counsel and the child’s caseworker.
Communication skills and the foster child
Developmental delays, including speech and language delays, are common among children who enter foster care. The rate of speech and/or language impairment in this population is 12.25% [60], twice the rate of speech-language impairments in the general pediatric population, which is 6.34% [61]. These numbers exclude children who present with a communication disorder secondary to primary developmental disabilities, such as mental retardation, autism, and sensory impairments, such as hearing loss. A review of the literature by CWLA in 2006 noted that the estimated prevalence of language delays amongst foster children is even higher; from 35% to 73% [62]. Despite the CWLA and AAP guidelines, 43.2% of children in foster care are not receiving developmental assessments at intake [22]. Given the high rate of communication disorders in children in foster care and the negative impact that these disorders have on their social and learning outcomes, PCPs need to be aware of how communication disorders are identified so that timely assessments and interventional services are provided.
Speech disorders
Speech disorders in a child include the areas of articulation (eg, speech sound substitution errors), fluency (eg, stuttering), and voice (eg, hypernasal voice). They may be developmental (eg, mental retardation) or acquired (eg, stroke) [63]. The prevalence of articulation delays in the general population is estimated to be 3.8% for children aged 6 years [63]. There are currently no prevalence estimates of articulation delays for foster children. Risk factors for articulation delays and disorders may include significantly less than normal intelligence, male gender, socioeconomic disadvantage, lower birth order/sibling status, delayed language development, delayed motor skills, poor auditory discrimination, hearing loss, and oral-facial structural anomalies [64]. We are most concerned about children who present with multiple speech sound errors and poor speech clarity. Children with poor articulation skills and intelligibility should be referred for speech, as well as language, testing to rule out receptive and expressive language delays, because poor speech intelligibility may mask delays in language development. Approximately 11% to 15% of children with articulation delays have a comorbid diagnosis of a language delay [63].
Language disorders
Language disorders are divided into receptive language disorders, expressive language disorders, and pragmatic language disorders. Difficulty understanding spoken language is a receptive language disorder. Difficulty using a spoken language system is an expressive language disorder. A pragmatic language disorder reflects difficulties coordinating verbal (eg, auditory comprehension and expressive skills) and nonverbal (eg, use of gestures, eye contact, facial expression) language skills for social interaction.
Screening for language delays
The rate of language-only impairments (specific language impairment) in the foster care population is reportedly a little more than 15% [65], whereas specific language impairment in the general pediatric population is 7.40% [66]. Studies have documented that both parents and medical professionals often rely on expressive language delays to identify language impairments. Concerns for delay typically arise if there are no verbalizations by age 1 years, or if speech or language is different from that of other children the same age [67]. Cohen and colleagues [68] studied unsuspected language impairment in children from psychiatric outpatient populations and found that, of 288 children referred solely for a psychiatric disorder, 99 (34.4%) had a language impairment that was not identified until a routine systematic assessment had been completed. Although this study did not directly address children in foster care, it is relevant to this population because a significant number of children entering foster care have emotional and behavioral health problems, with estimates ranging from 35% to 50% [22]. Therefore, when screening the foster child for possible language disorders, it is important to remember that (1) a high percentage of children with mental health disorders also have language disorders, (2) mixed receptive-expressive language and receptive-language–only delays are more common than expressive-language–only delays, and (3) their language impairments are often missed because they are more difficult to discern by adults or are overshadowed by more salient externalizing behavior problems (such as symptoms of delinquency and aggression) [68].
Although children continue to develop their vocabulary skills and more complex sentence forms in the school years, most children have acquired the basic forms and functions of language by 5 or 6 years of age, an accomplishment that has led some researchers to believe that language development is essentially complete by school entry [64,69].
Inconsistent language stimulation and exposure
Children in foster care may be at risk for inconsistent language stimulation and may be exposed to multiple languages, both of which may affect normal language acquisition and/or development. Children who enter foster care tend to come from minority groups and impoverished backgrounds [70]. They have been separated from their families and are frequently placed with caregivers of different cultural backgrounds. The language used in their foster home might be different from that of their biologic home. Given the changes and stresses of removal, separation, new rules, and possibly a new language, it is common for the foster child to present with developmental regression [71]. Therefore, when screening for language delays in young children who have been newly placed in foster care, the screening guidelines mentioned earlier apply. A wait-and-see approach should only be taken if the child is not talking and does not show any other problems in the areas of auditory comprehension, social interaction, behavior, attention, or development. Such a child needs to be rescreened and referred for a comprehensive evaluation of speech and language if delays persist.
For bilingual language exposure, children who are exposed to multiple languages are not normally delayed in their acquisition of language. When a child is in an environment in which more than 1 language is used, the child is expected to develop multiple linguistic systems and become proficient in the language, or languages, that they use most. Children who are exposed to 2 languages at the same time before the age of 3 years are expected to acquire both languages at the same rate [72]. There are some variations to consider: language structure variations are normal (ie, the child transfers the language structure of one language for use in another language) and vocabulary is counted as if it were 1 language (ie, a Spanish-English 2-year-old speaker is expected to have a total of 50 English and Spanish words). For the child who was speaking 1 language and then introduced to a second language later in life, the first language is expected to develop dominance and reach language milestones per age expectation. Ideally, the use of the child’s first language is maintained and reinforced while the second language is being introduced and developed. If the first language is not reinforced, there could be a loss of language that can be detrimental and frustrating for a child [73]. The child who exhibits delays in the acquisition of the dominant language or both languages likely has a language delay. It is recommended that this child be referred for a speech-language evaluation, and helped to develop a firm language base in the dominant language before a second language is introduced [72].
Abuse and neglect
The most common reason for a child’s placement in foster care is neglect (44%), followed by abuse (13%) [70,71]. Culp and colleagues [74] studied the effects of different forms of maltreatment on speech and language development and found that child neglect was the form of maltreatment most detrimental to the development of both receptive and expressive language skills. Their findings showed that neglected children were delayed by 6 to 9 months and abused children were delayed by 0 to 2 months compared with normative expectations. The linguistic skills of children who had experienced both abuse and neglect were at a level between the abused group and the neglected group on measures of language ability.
The consensus amongst researchers is that there is an association between neglect and language delays that may be attributed to a general lack of stimulation within the child’s environment. It is believed that abused children show comparatively minimal language delays because language development is particularly vulnerable to disruption in parent-child interaction, and that the verbal negotiation that may occur in abusive parent-child relationships protects linguistic growth in a way that a neglecting environment does not [74]. Therefore, when screening and referring maltreated children to rule out language delays, it is important to remember that child neglect is significantly more detrimental to language development than is child abuse.
Prenatal alcohol and drug exposure
It is estimated that nearly 80% of children in foster care are prenatally exposed to alcohol and/or other drugs [75]. PSE may be associated with subtle (or not so subtle) neurobehavioral impairments (ie, attention), which may in turn disrupt an infant’s ability to extract, process, or use linguistic information. Second, drug and/or alcohol abuse by parent(s) may cause impairments that may disrupt a parent’s ability to initiate and sustain the affective, social, and linguistic interaction with the infant that is critical to normal development. Third, in the child welfare system families in which parents use drugs are likely to be poor, homeless, and unstable, conditions that potentially result in an impoverished social-linguistic environment, which has a negative impacts on language growth and development [76,78].
The effects of prenatal alcohol exposure on language development are well documented. Studies have shown that children exposed to large amounts of alcohol in utero display communication deficits on measures of word comprehension, naming ability, grammar, pragmatics, and verbal learning, whether or not they present with characteristics of FAS [79,81]. Recent longitudinal prospective research on prenatal cocaine exposure and its effect on language supports the possibility that prenatal cocaine exposure is associated with subtle but stable negative effects on speech and language development during early childhood [82,84]. Children with prenatal cocaine exposure were more likely than controls to have mild receptive language delays and poorer expressive language abilities [83]. With increasing severity of prenatal cocaine exposure was an incremental decrement in expressive language function [84]. Further decrements in language function were found if the fetus was additionally exposed to alcohol [82], marijuana [83], or tobacco [83]. Language scores in children who were prenatally exposed to cocaine as well as controls also declined with time, suggesting that factors that were common to both groups, including low socioeconomic status, education, and poverty also have negative impacts on language development [83]. The quality and quantity of stimulation and support available to a child in the home environment and maternal vocabulary scores are positively related to child language outcomes in children who were cocaine exposed prenatally [83]. Therefore, although children placed in foster care tended to be more heavily exposed to cocaine prenatally than exposed children who remained in relative or maternal care, their language skills were found to be better at age 4 years than their counterparts who remained in the care of birth families, possibly because of a more stimulating environment for language development as shown by the higher Home Observation of the Environment (HOME) scores and verbal IQ scores of the adoptive-foster mothers [83]. Therefore, it is recommended that children who have confirmed exposure be thoroughly screened, and those with suspected delays be referred for further testing to confirm the presence of language delays as soon as possible, so that they be able to receive treatment and services accordingly.
Educational advocacy
Research indicates that foster children are less likely to perform at or better than grade level compared with their peers in the general population. Up to 55% of foster youth fail to obtain a high school diploma or acquire a General Education Diploma (GED), which affects their chances for success when transitioning out of foster care and seeking employment [85]. Negative educational impacts can be traced to a foster child’s early lack of fulfillment of basic needs (food, clothing, shelter, stimulation, and consistent parenting), multiple placement and school changes, higher rate of absenteeism, lack of a consistent advocate, numerous profound losses with resulting emotional problems, and the stigma and loneliness children often perceive related to their status as a foster child [86]. The PCP is in a prime position to identify potential factors that could negatively affect a child’s educational performance and to provide assistance to the caregiver on ways to promote better educational outcomes [87].
Children with established educational delays and those at risk for such delays because of the existence of a disability or developmental vulnerability have better educational outcomes if their needs are addressed as early as possible through early intervention services. Misdiagnoses and lack of genetic and educational background information are commonplace, but it is essential that PCPs acquire family, developmental, and educational histories that are as thorough as possible to make appropriate recommendations. PCPs should screen all foster children at the earliest possible age for potential developmental and learning disabilities. PCPs can identify and make appropriate referrals for conditions such as a learning disability, ADHD, or speech and language impediments that may have gone undetected and that could potentially affect the child’s future educational progress. If those conditions adversely interfere with the child’s educational progress, they could qualify a child for special education services [88]. In accordance with federal law, each state has developed a definition of those conditions and identifies which agency in the state is classified as the lead agency for infants and toddlers between the ages of birth and 3 years. In addition, many states have included as eligible for early intervention services children who are identified as at risk for certain conditions, such as those children who show developmental delays in the general areas of speech and language, large and fine motor skills, social and emotional behavior, and cognitive and/or adaptive skills, or who have vision or hearing losses [89].
Public schools have a federal requirement to seek out and serve students between the ages of birth and 21 years with suspected disabilities. Congress has enacted laws that mandate the educational rights of children with disabilities to ensure that they receive a free appropriate public education. The Federal Individuals with Disabilities Education Improvement Act (IDEIA) requires school districts and all educational agencies to protect the rights of disabled children. IDEIA defines eligibility for children who are within 1 or more of the following disability categories and who require special education and related services to make educational progress.
The following categories are disabilities that may qualify a child for special services if the disability negatively affects the child’s education [89]:
PCPs are in a position to support and collaborate with caregivers and school staff regarding a student’s medical condition. Chronic health conditions or disabilities can interfere with school attendance, participation, and achievement. Many students with stable conditions such as ADHD or mild intermittent asthma may require basic school nursing services, such as health care monitoring or medication administration. Advanced medical technology in conjunction with legislation (IDEIA mandates), has allowed a greater number of students with medical needs to attend school. Services once believed to be clearly outside the responsibility of schools are now legally mandated by state and federal statutes for all children who require these services. Schools should be able to assist with managing more complex medical regimens and/or treatments (eg, tracheostomy suctioning) to meet the child’s health-related needs. Medical equipment and devices allow more students to attend their neighborhood schools who previously were home or institutional-bound. PCPs can assist the school by providing comprehensive medical information as well as guidelines regarding the need for medical procedures or treatment during the school day. By identifying the criteria that could qualify a child for special education services, PCPs can support caregivers by writing letters to school districts stating their findings and offering recommendations. Supporting caregivers while they navigate through the public school educational bureaucracy is critical in ensuring that the child receives the appropriate services.
PCPs can monitor a child’s achievement trajectory during the annual medical check-up with discussions regarding overall school and behavioral functioning. If academic progress has been limited, the caregivers can be encouraged to request that the school district evaluate their child’s eligibility for special education services. Caregivers are allowed to request educational evaluations if they are the holder of the child’s educational rights. More often than not, educational rights are held by the birth parents. The formal appointment of an educational rights holder is often overlooked for youth who have experienced multiple placements and educational disruptions. The child’s educational rights holder is responsible for securing the support and resources needed by a struggling student. If a foster child is having academic difficulties, the PCP can inquire whether the student has an educational advocate and ensure that this person is aware of any medical implications and barriers to academic success. If a birth parent is unavailable, school districts have a legal responsibility to appoint a surrogate parent for the student to ensure that the student’s educational rights are protected [90].
Caregivers have the right to inspect and get copies of their foster child’s educational records, including securing any new assessment data that are being generated for an upcoming individualized education program (IEP) meeting. When a student is found to be eligible for special education services, an IEP team meets to develop an educational plan based on the child’s specific needs. The team includes the child’s caregivers, teachers, and other personnel responsible for implementing the IEP. The IEP is a written document that describes any accommodations, modifications, or related services a student needs to receive an appropriate education. It also lists goals and objectives that are used to measure a student’s progress and determine whether the program and placement are appropriate. Federal law provides that, before any initial IEP meeting (and at 3-year evaluations), students be assessed in their native language in all areas related to their suspected disability. If necessary, the school staff is required to provide interpretive services at IEP meetings so that caregivers can fully participate and be informed of the school’s findings. PCPs can give input before the IEP assessment by providing information of any health-related issues that might adversely affect the IEP assessment, such as a diagnosis of ADHD or medication side-effects, as well as addressing any restrictions or recommendations regarding their patient’s medical needs.
PCPs are in a position to make educational recommendations for their patients based on their expertise and knowledge of the patient. Suggesting intensive reading programs, summer school, and more direct instruction (teacher to student) have been effective in assisting children with educational difficulties. Tutoring, well-designed homework activities, and after school programs have also been shown to be beneficial for students struggling in school. PCPs can also contribute to the grade retention debate. Caregivers may seek out their PCP to advise whether grade retention would benefit their child. Despite evidence indicating that grade retention alone does not close the achievement gap for many foster youth, it may be beneficial in certain cases. Developmental and medical information can be factored in the decision-making process. A child with behavioral problems, developmental and academic delays, along with a height-age at the lower percentiles may benefit from repeating a grade. Some students simply need an additional year to achieve more physical, academic, and psychological development. For others, implementing an additional year of educational interventions, along with a coordinated system of comprehensive support and services designed to address the child’s academic, socioemotional, behavioral, and psychological needs, may serve to promote a healthy adjustment and educational achievement.
PCPs are encouraged to take an active role in assisting the school in understanding the medical needs of foster children and the implications of the medical conditions or disabilities on their education. Supportive PCPs can encourage foster parents to become active participants in shaping the education for their foster child, promoting linkages with the school and community, and encouraging realistic, but high, educational expectations for foster youth.
Mental health care
One of the most critical and challenging of the health disparities faced by children in the child welfare system is in the area of mental health. It is estimated that 50% of children in the child welfare system have mental health needs, a rate that is higher than the national average of 1 out of 7 [91,92]. Equally concerning is that the children in the child welfare system are disproportionately from minority and low socioeconomic backgrounds [93,94]. The PCP can play an important role in the recognition and management of the mental health needs of these vulnerable youth by providing and referring for much-needed prevention and early intervention services. Because of the shortage of child psychiatrists, PCPs are often the first and only clinical contact for many children.
The multiple insults of maltreatment, family risk factors, frequent placement changes, and severe emotional and behavioral problems underscore a critical need for clinical attention to this special population of children in the child welfare system. National estimates suggest that children in child welfare settings are receiving psychotropic medications at a rate between 2 and 3 times that of children treated in the community [95]. This estimate of increased psychotropic medication use in a landscape that is already known to be chaotic and poorly coordinated further mandates that continuity of care should be emphasized and formalized.
The AAP has recently highlighted the importance of increasing the competence of PCPs in the area of child mental health given the dearth of child psychiatrists [96]. Foster youth are an especially multimorbid population with significant needs and high service utilization often persisting into adulthood. One study found that more than half (54.4%) of adults placed in foster care as children had experienced at least 1 psychiatric symptom within the preceding 12-month period, and that 25% had significant posttraumatic stress disorder (PTSD) symptoms, a rate nearly double that of US war veterans [97,98]. However, 75% of youth in the child welfare system who meet stringent diagnostic criteria often do not receive mental health care within 12 months of a child abuse and neglect investigation [92,98]. The most common disorders for foster youth are anxiety disorders (including PTSD and generalized anxiety disorder), disruptive behavior disorders (including oppositional defiant disorder [ODD], conduct disorder [CD], and ADHD), depression, learning problems, and substance abuse [99,100]. Many of these disorders occur in the setting of other biologic and environmental stressors, such as in utero exposure to substances and profound abuse and neglect. Comorbidity of these disorders tends to be the rule and not the exception, with many youth having impairment in socioemotional and academic functioning that affects their ability to have stability in their placements.
Children within the child welfare system may be subjected to trauma before entry (ie, neglect; physical, sexual, and/or emotional abuse; intimate partner violence within a dysfunctional household), on entry (ie, separation and attachment disruption) as well as during placements. PTSD symptoms may manifest in various ways according to age. Infants tend to be in placements longer, have higher rates of reentry into foster care, and may be sensitive to disrupted attachments [101]. They may experience sleeping and feeding difficulties, fearfulness, and irritability, which can be manifestations of many conditions including PTSD. Older children may display aggression, impulsivity, and sexualized behaviors, which can be a manifestation of many conditions including PTSD, ADHD, and/or sexual abuse. PTSD behaviors are stressful and can lead to disrupted placements. A careful history and evaluation may help the clinician assess whether PTSD is contributing to the foster child’s symptoms.
To fully comprehend the socioemotional issues confronting foster youth, it is important to understand the potential long-term consequences of exposure to various types of maltreatment. The ACE study has brought to attention the potential cumulative effect of childhood exposure to abuse (ie, emotional, physical, and sexual abuse) and household dysfunction (ie, parental substance abuse, mental illness, incarceration, domestic violence, separation, or divorce) on future medical and psychosocial problems such as illicit drug use, depressive disorders, and attempted suicide [43,102–104]. Detection of an adverse childhood risk factor can alert the PCP to investigate for additional risk factors, which can lead to earlier recognition, intervention, and provision of support and therapeutic services. Although PCPs may not be able to provide comprehensive mental health services for foster youth, they have an important role in the identification and referral process during the course of well-child visits and other interfaces in which caseworkers may seek medical clearance for youth before or shortly following placement. During the often rushed preplacement and postplacement assessment process, many youth are only seeing the PCP and not a psychiatrist, making this interface an essential point of contact for identifying underlying mental health issues. Establishing collaborative relationships with qualified mental health specialists with expertise in this population is critical for consultation as well as referral.
The 2009 CWLA guidelines recommend that mental health screenings occur at various intervals, with the first occurring within the first 72 hours of placement to triage for acute and immediate risk following entry. This initial evaluation is critical for early identification of youth presenting with immediate risk of harm to themselves or others, who are running away, or who are in need of mental health or substance abuse services. Additional objectives are to ascertain the child’s ability to function in various settings (eg, school, home, peer groups, community) [99]. If an acute risk is identified, the child should have an immediate referral to a qualified mental health provider. The acuity of the situation determines the level of care and treatment setting (eg, urgent care or outpatient setting).
The next evaluation should occur within 30 days of entry to the foster care system and should include evaluation of overall functioning and identification of children who may need ongoing services. CWLA recommends that this screening should be brief, low in cost, and simple [99]. These qualities enhance the likelihood for the screening to become part of the PCP’s routine care for foster youth. Youth who have a positive screen should be referred and linked to specialty mental health services for a comprehensive mental health assessment. Given the vulnerability of children in the child welfare system and the potential for these children to be retraumatized, the American Academy of Child and Adolescent Psychiatry (AACAP), CWLA, and AAP [96,99,101] recommend ongoing periodic mental health screening and assessments whether or not they are currently receiving mental health services [99].
Even for the experienced practitioner, evaluation for emotional and behavioral problems in young children can be challenging. In addition to the PCP’s face-to-face evaluation, utilization of validated screening tools can complement the general office assessment and assist in the decision-making process of referring for more specialized evaluations and interventions. The screening instrument should be easy to administer, score, and interpret for feasibility in a busy office setting. Caregivers should be able to fill out the questionnaire in a short period of time with the ease of scoring by any paraprofessional. For a listing of mental health assessment tools please refer to Ref. [105]. The following are a few examples of validated mental health screening and assessment tools that can be selected. Similar to the Ages and Stages Questionnaire (ASQ) used to screen for developmental delays, the ASQ-SE (social-emotional) tool for ages 6 to 60 months is simple to use and available in both English and Spanish. The Pediatric Symptom Checklist-35 items (PSC-35) for 4-year-olds to 16-year-olds, and the Strengths and Difficulties Questionnaire (SDQ) for 3-year-olds to 17-year-olds both screen for psychosocial problems as well as functional assessment in the area of attention. Both are available in various languages and are freely accessible. Identification of children at risk for depression can be difficult. Use of a screening tool prescored by the office staff could increase the PCP’s awareness that an in-depth, sensitive interview is required during the immediate visit. An example of a depression screening tool is the Child Depression Inventory (CDI) screen, appropriate for 7-year-olds to 17-year-olds, and available in both English and Spanish [105]. Children exhibiting symptoms of significant depression with complaints of insomnia, loss of appetite, inability to function with daily activities of living definitely require urgent referral to a psychiatrist, as do those who have suicidal ideation with or without developed plans.
Disruptive behavior disorders represent a cluster of disorders that include ODD, CD, and ADHD. ADHD is a common childhood disorder affecting between 5% and 10% of school-aged children [100] and is seen more frequently among foster youth because many of them have histories of biologic and environmental risk factors. The Conner’s Behavioral Checklist, which can help differentiate between the disruptive behavior disorders, is a useful screening inventory that can be sent to school to be completed by teachers.
Although some PCPs may be comfortable treating some of the more common psychiatric diagnoses, (eg, uncomplicated ADHD), given the multimorbid characteristics of the foster youth, it is recommended that those who have positive screenings receive a comprehensive mental health assessment conducted by a qualified mental health provider. In some cases it may be helpful to include the mental health provider as part of a multidisciplinary team that provides a comprehensive assessment including medical, dental, and developmental evaluations. PCPs who are not working as part of a multidisciplinary team need to collaborate with mental health partners in their community. It is critical for the PCP to use the child’s caseworker and/or the agency as a source of collateral information and a partner to facilitate the referral and linkage process.
Because of the significant prevalence of mental health disorders in the foster care population, many child welfare agencies have adopted the philosophy that addressing the well-being of these children requires multimodal service plans that require partnership and collaboration with mental health partners. The pediatric provider is a key component in this process.
Psychosocial issues
A little extra understanding and sensitivity on the part of clinicians to the unique needs of foster children and caregivers can make a big difference. The following are important areas to keep in mind and are ways of expressing your understanding of their situation.
Be sensitive to issues of loss, vulnerability, lack of control, and anxiety about the future, which are the Achilles’ heels of children in foster care. Be aware that many situations that seem unrelated to a child’s separation from birth parents or change in placement may trigger these uncomfortable feelings. For example, a change in teachers or schools or the loss of a pet can elicit a major emotional reaction that, in turn, can exacerbate a medical condition such as asthma. A foster child may view a hospitalization as a repeat of the abandonment by his birth family or other caregivers. Because so many foster children have low self-esteem, excessive guilt, and believe they are to blame for their situation, they may view a painful medical procedure or a hospitalization as a form of punishment. Being cognizant of these possible connections can allow the PCP to help the child and foster parents to understand the context of the child’s reactions and possible manifestations of grief and loss, thereby normalizing their feelings and behaviors. Providing as much anticipatory guidance and preparing the child for medical procedures and hospitalizations with their input to the greatest extent possible helps to increase their feelings of control. Giving extra reassurance to the child that it is normal to be frightened and that they will be returning to their caregiver may help alleviate many fears.
The PCP can help caregivers understand that behaviors such as cursing, hitting, sulking, and regression in toilet training may appear during transitions that are critical periods of vulnerability as well as an opportunity for the child and new caregivers. These behaviors can be interpreted to the foster parent as normal child development in these situations. If a child’s behaviors are challenging, referring for immediate intervention can help prevent escalation. Pathologizing the child’s behaviors and misattributions is less likely to occur with supportive interpretations and interventions. The PCP can explain these facts to foster parents with the reassurance that, with time, consistent parenting, and appropriate mental health transition services, these behaviors are likely to diminish. Diagnosing and/or medicating a child or taking a child off psychotropic medication during transitions may be inappropriate. In the same way, visits with birth parents may evoke loyalty conflicts in the children and result in the manifestation of difficult behaviors, even exacerbation of the child’s medical problems. Unless there is suspected child abuse or neglect or fear of serious harm to the child, these visits need to continue as part of the family reunification plan. Foster parents often request that the PCP write a letter to the court stating that these visits be discontinued, but caution should be exercised.
Be aware of the model of cumulative risk; that it is not any single risk factor, but the number of adverse risk factors in a child’s environment that interact with one another to affect the development and behavior of children. Although foster parents cannot change certain risk factors (eg, mental illness and substance abuse of birth parents, a child’s PSE, multiple past placements and/or abuse), they can be a source of protective factors for the child. They can ensure that the child receives coordinated and comprehensive medical and mental health care, consistent and nurturing care from them, and that the child’s school situation is stabilized. These protective factors can interrupt the negative trajectory so often experienced by foster children. Be careful about what you say to foster parents, children’s caseworkers, and school personnel, as well as what you write, because both follow the child. If you suspect a diagnosis such as FAS, ADHD, or autism, refer to specialists if you cannot rule out these diagnoses yourself. Avoid making dire predictions about the outcomes for the child based on 1 risk factor such as PSE, because not only is such a prediction inaccurate, it makes foster parents feel helpless instead of focusing on positive interventions. Using correct terminology (ie, birth parent vs real parent, children with PSE instead of drug babies) is less stigmatizing and is respectful of the child, birth parent, and foster/adoptive parent.
The foster parent
Many of the parents fostering and adopting are single parents, parents accepting transracial placements, and/or parents who are gay and lesbian, either as singles or couples. Some of the foster children themselves are lesbian, gay, bisexual, transsexual, or questioning. There are issues unique to these populations, and it is important to be familiar with them. It is also important to respect these nontraditional forms of families, and to focus on their strengths and parenting. If a PCP is uncomfortable with the family’s lifestyle, then the best approach is to refer to a colleague who is willing, comfortable, and knowledgeable.
The unique and changing role of foster parents and the related stresses are often not given sufficient attention by providers, including PCPs. Foster parents traditionally have had to deal, with minimal supports, with their ambiguous and often temporary role in the child’s life, as well as frequent intrusion by agency representatives. The foster family’s grief reactions when a child is reunified or replaced are not given the necessary attention [106]. Concurrent planning, wherein the foster parent makes a commitment to adopt if family reunification is not successful, now poses additional challenges because so many of these families are interested in adopting, but reluctantly decide to foster as an avenue to becoming parents. If a child is reunified, the foster parents’ grief may be magnified by their thwarted goal of adoption as well as prior losses such as the inability to have a birth child. Even in a brief visit, the PCP can help recognize and normalize the grieving process of foster parents and also validate the critical service they are providing to the child and the community [107]. Referrals for counseling can be made when the grief is extended; negatively affects the child and foster parent’s mental and physical health and the ability of the foster parent to wish the children well as they leave; and if the foster parent’s ability to attach to a subsequent placed child is impaired.
Most foster parents try hard to provide the children in their care with loving, consistent substitute parenting. However, there are always exceptions: foster parents who are indifferent, unresponsive, fail to follow through on medical appointments, abusive, mentally ill, and/or addicted. Although it is not possible for the PCP to do a comprehensive assessment of the caregiving environment, clues that there are significant problems that could be affecting the child need exploration and follow-up. Contacting the child’s caseworker, referring to community resources such as public health nurses, and having the child in for more frequent follow-up are ways to provide a safety net for the foster child. However, if abuse or neglect is suspected, a child abuse report is mandated.
Cultural sensitivity
The PCP should be aware of the importance of cultural issues in approaching, assessing, and treating foster children and their caregivers. For example, there may be differences in how health and mental health treatment are viewed, how much and what kinds of information are communicated or considered private, and the ways discipline is administered. Issues related to culture and socioeconomic status enter into every aspect of life of the foster child (eg, the age at which they are toilet trained, the languages they speak, how education is viewed and educators approached). Frequently, the children may be of different cultures, races, ethnicities, socioeconomic status, and religions than the caregiver, posing some unique challenges. Although PCPs can be familiar with a variety of cultural practices and values, each family is different, and a PCP cannot become an expert about every culture. What is critical is that a PCP shows interest in and inquires nonjudgmentally about the different values and beliefs of a child and/or caregiver when an issue is affecting the child’s health and functioning. The family members can then explain their viewpoints and ways of life, feel understood, and this information can be integrated into the assessment and treatment planning.
Summary
Raising a foster child can be complex because of the myriad of challenges these youth present and the daunting bureaucracies the caregivers must navigate to secure appropriate services for their children. The PCP can be an important protective factor for the foster child and can provide a safety net of evaluations, services, follow-up, and referrals for specialized interventions. PCPs must take part in enrolling foster children within their busy practices even though providing care to them may be challenging and the reimbursements cannot begin to compensate for the time and effort involved. PCPs must attend to the children’s needs and advocate for services within a system in which many of the children are subjected to frequent moves; changes in health care providers, teachers, and caseworkers; and lack any sustaining adult figures to stand by them while they go through this unfamiliar and frightening journey. PCPs can encourage foster parents to become active participants in shaping the development, education, and psychosocial growth for their foster child. A supportive health care provider can be a positive influence on a foster child’s resiliency and future.
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