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].
The following findings in young children are never normal:
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]
