Transcript is foster care good for your health?

Health Problems of Children in
Out of Home Care – Results from
a Health Screening Clinic
Dr Dimitra Tzioumi
Dr Dania Nathanson
Child Protection Unit
Sydney Children’s Hospital
Children in Out of Home Care
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Australian Statistics
Health Screening Clinic setup
Results of screening at 1 year
Literature findings
Recommendations
Australian Statistics
• In 2004-2005, 12,531 children entered care
• At 30 June 2005, there were 23,695
(4.9/1000) children (0-17years) in care
• Approx 38% under 5yrs (13% under 1yr),
27% 5-9yrs, 27% 10-14yrs, 8% 15-17yrs
• Indigenous children overrepresented – 6
times
Children in Care & Health
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Vulnerable group of children
High health needs
Unrecognised health needs
Unmet health needs
• Recent interest to address these needs
Health Screening Clinic for
Children in Out of Home Care
• Local initiative between the Children’s
Hospital child protection service and
the local office of the Department of
Community Services (DOCS)
• Clinic started February 2005
• Clinic accepted referrals only from
DOCS
The clinic setup
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Multidisciplinary clinic
Medical and psychosocial staff
Pre-assessment health questionnaires
Comprehensive physical examination
Hearing assessments – audiology
Developmental screening
Report to DOCS
Recommendations
The Clinic Results
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101 children
Age range: 3m to 14yrs
50% (50) were under 5yrs
43% girls, 57% boys
Time in care ranged from 1 week to 6
years
• 46% were in their first placement
Health Problems -1
• Immunisations – 67% up to date
• Vision – 21% (17/81) failed screen and
referred
» 5 Squint
» 10 Poor Visual Acuity
» 1 Floater
14(14%) pre-existing eye conditions
Health Problems -2
• Dental – 27% caries
• Hearing - 27% (21/77) failed hearing test
» 6 ENT referrals
» 1 sensorineural hearing loss
» 2 required ‘grommets’ (ventilation tubes)
Health Problems - 3
• Development
– 65% of under 5s failed screen
– 2 autistic behaviours
• Speech Delay
– 52% of under 5s
– 16% of over 5s
• Growth
– Small stature – 9%
– Overweight / Obese– 4%
Health Problems - 4
• Infections – 14 (14%)
– Respiratory – URTI, ear
– Skin –impetigo, infected eczema, warts,
fungal
• Skin – 24 (24%)
– Eczema
– Scars
– Nappy rash
– Impetigo
– ?psoriasis
Health Problems - 5
Recurrent Urinary Tract
infections *
Investigation for
seizures
Orthopaedic problems
Constipation
Recurrent vulvovaginitis
BIRP referrals
Allergic rhinitis
Asthma*
Enuresis
Snoring
Preauricular skin tag
Iron deficiency *
High arched palates
Health Problems -6
• Behavioural and Emotional health
– Most significant issue in 60%
• Significant mental health issues
– Depression
– Suicidal thoughts
– Significant grief and loss issues requiring
counselling
– Post Traumatic Stress Disorder
– Gender identity issues
Emotional Health Problems
Attachment
issues
Grief and loss
Separation
issues
Reactions to
contact visits
Parentification *
Aggression
Poor self esteem
Poor social skills
Rage
Food hoarding
and overeating
Sexualised
behaviour
Stealing and
lying
Drug and alcohol
School expulsion
Placement
breakdown
Health needs of children in Out
of Home Care -Evidence from the
literature
Children at risk for poor health
• High prevalence of abuse and neglect
• Poverty and social disadvantage
• Biological weighting with parents with
mental health and drug and alcohol
problems
*Egelund and Brunnquell, 1979
Children at risk for poor health
• Rosenfeld 1997 – risk factors for
learning and behavioural problems,
teenage pregnancy and/or mental health
problems.
– Risk defined as poverty, perinatal stress,
maternal education, family discord, parental
alcoholism or addiction, parental mental
illness etc.
– 4 risk factors at age 2yrs increase risk of
poor outcomes
– On average, foster kids had more than 14
risk factors
*J Am Acad Child Adolesc Psychiatry
Risks to Physical Health
• Antenatal – drug exposure, poor
maternal nutrition, poor antenatal care
• Postnatal – poor nutrition, medical
neglect, psychosocial deprivation,
inadequate preventive health such as
immunisations
*Simms, 2000, Pediatrics
Risks to Development
• Neglect has profound and long lasting
effect on all aspects of development
• Particularly speech and language skills
although has global effects
*Am Acad of Pediatrics, 2000
Risks to Mental Health
• Likely to have formed attachments to
mentally ill, substance abusing or
emotionally unavailable parents
• Effects of abuse and neglect
• Trauma of forced separation from
parents
• Demand for rapid adjustment to
separation
• Unstable and temporary situation
Risks to Mental Health cont..
• Social isolation – new schools, friends,
neighborhood
• Sense of rejection and abandonment
• Irrational beliefs about reasons for
placement
• Resentment towards adults who control
life
• Concern about relationship between
foster and biological parents
Health on entering Care
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13% had normal examination
25% failed vision screen
15% failed hearing screen
20% dental caries
33% under-immunised
20-60% under 5s with developmental delays
35-85% significant emotional or behavioural
problems
*Chernoff (1994) Pediatrics *Takayama (1998) Pediatrics
Health status in Care
• Being in care does NOT ameliorate these
health problems
• Poor uptake of immunisations
• Inadequate dental care
• Up to 60% developmental difficulties
• 45-76% chronic medical conditions
• 84% developmental or psychological
problems
*Takayama (1998) Pediatrics
Barriers to health care -1
• Poor transfer of health information
– Minimal medical history available
– Frequent placements
– New health care providers
– Often no ‘bluebooks’
– Often no medicare cards
– Changes in caseworker
*Am Acad Ped (2002)
Barriers to health care - 2
• Lack of advocate – too many adults
involved, none takes responsibility
• Issue of consent and confidentiality and
privacy
• Funding
• Resources
• (In)Experience of health professionals
Barriers to health care -3
• Tendency to rely on carers to report ill
health
– relying on carer/caseworker identifies only
about 30% of children with developmental
delay
– Carer report identified 33% with emotional,
behavioural or developmental problems cf
to 84% on careful assessment
*Simms et al (2000) Pediatrics * Halfon et al (1995) Arch Ped Adol Med
HEALTH OF CHILDREN IN OUT
OF HOME CARE
FUTURE DIRECTIONS
Health Care for Children in Out-of-Home Care
Recommendations
• Routine health assessments on entry into
care
• Ongoing monitoring of health needs
• Timely access to therapeutic services
• Transferable health records
• Health care coordination between agencies
• Adequate government funding
* RACP guidelines
CREATE Health Report Card -2006
Recommended Actions
• Health Care Planning must include:
– Maintaining and accessing health records
– Initial health screening and assessment
– Ongoing planning and review (6-12 month
reviews)
• Service collaboration at local level
• Monitoring and review – data collection
• Research into the health needs of
children in OOHC