Transcript A Pediatrician`s Role in Caring For Children in Foster Care

Fostering Hope:
A Pediatrician’s Role in
Caring for Children in Foster
Care
Hollie Edwards, MD
Pediatric Grand Rounds
November 6,Free
2015
Powerpoint Templates
WHAT IS THE AVERAGE LENGTH OF
STAY FOR A CHILD OR TEEN IN THE
FOSTER CARE SYSTEM?
1.
2.
3.
4.
5 years
3 years
1 year
6 months
0%
1
0%
2
0%
3
0%
4
A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR
OFFICE THE DAY AFTER BEING PLACED WITH FOSTER
PARENTS. YOU FIND OUT THAT NEGLECT FROM THE
BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION
LED TO THE PLACEMENT. PATIENT APPEARS WELL ON
EXAM AND HAS NO KNOWN MEDICAL PROBLEMS.
WHEN DO YOU NEED TO SEE HER BACK?
1.
2.
3.
4.
1 year
6 months
2 months
1 month
0%
1
0%
2
0%
3
0%
4
FOR A CHILD IN FOSTER CARE, WHO IS
ABLE TO CONSENT FOR MEDICAL
PROCEDURES?
1.
2.
3.
4.
5.
6.
Foster parents
Department of Social
Services (DSS)
Birth parents
1&2
2&3
All of the above
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
WHICH OF THE FOLLOWING SEQUELAE
ARE TRUE CONCERNING THE IMPACT OF
TRAUMA ON A CHILD?
1.
2.
3.
4.
5.
6.
Chronically elevated stress
hormones
Development of permanent
maladaptive behaviors
Altered development of
prefrontal cortex and
hippocampus
1&2
1&3
All of the above
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
DISCLOSURES

Neither myself nor Dr. Stephenson have any
financial relationships to disclose.
OBJECTIVES
Gain overall knowledge about the process of the
foster care system in America and the scope of
the problem
 Review existing recommendations related to the
special healthcare needs of children in foster care
 Become familiar with the sequelae of childhood
trauma and adversity
 Review frequently confused topics related to
foster care and medicine

THE FOSTER CARE SYSTEM IN AMERICA
Temporary service
 Protection and shelter for children who require
out-of-home placement
 Opportunity for healing
 Ultimate goal- final placement in a stable, safe,
permanent, and secure living arrangement

SCOPE OF THE ISSUE
Each year, more than 3 million children are
involved in investigations of abuse or neglect
 Nearly 500,000 children are living in foster care
on any given day
 The federal government spends about $4.4 billion
a year to maintain children in foster care

RACE STATISTICS
AGE STATISTICS
40% are teenagers
 30% are under the age of 5
 Median age entering system 6.7 years
 Median age currently in system 9.2 years

SOUTH CAROLINA DATA
COUNTY DATA
0-5yo
6-12yo
13-17yo
18+yo
Total
Lexington
90
67
49
3
209
Richland
102
68
77
12
259
THE FOSTER CARE PROCESS

Report and Referral

After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
Investigation
 Removal and Placement
 Service Planning
 Permanency Planning

THE FOSTER CARE PROCESS
 Report

and Referral
After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
Investigation
 Removal and Placement
 Service Planning
 Permanency Planning

REASONS FOR REFERRALS

Child maltreatment accounts for 70%
Child neglect
 Sexual abuse
 Emotional abuse
 Physical abuse

Disruptive behaviors
 Voluntary placements, <1%

BIRTH PARENTS

79% have significantly impaired parenting skills*
31% with serious mental health problems
 25% with active alcohol abuse
 37% with active substance abuse
 12% with cognitive impairment

*National Survey of Child and Adolescent Well-being (wave 1)
THE FOSTER CARE PROCESS

Report and Referral

After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
 Investigation
Removal and Placement
 Service Planning
 Permanency Planning

THE FOSTER CARE PROCESS

Report and Referral

After Hours Reporting:


(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
Investigation
 Removal
and Placement
Service Planning
 Permanency Planning

REMOVAL IS TRAUMATIC

Even if the children came from bad
circumstances, removal from family is
emotionally traumatizing. This is the only world
they have ever known.
TYPES OF
FOSTER CARE
Family foster care
 Kinship foster care
 Pre-adoptive foster
care
 Congregate care

SOUTH CAROLINA PLACEMENT
THE FOSTER CARE PROCESS

Report and Referral

After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
Investigation
 Removal and Placement

 Service

Planning
Permanency Planning
THE FOSTER CARE PROCESS

Report and Referral

After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline protective services intake
Investigation
 Removal and Placement
 Service Planning

 Permanency
Planning
PERMANENCY PLANNING

Options for permanent placing
Reunification
 Adoption
 Guardianship to relative
 Emancipation from foster care system

Mandated court reviews
 Guardian ad litem

FOSTER CARE TEAM
Department of Social Services (DSS)
 Caseworkers
 Foster parents
 Birth parents
 Guardian ad litem
 Pediatricians

PEDIATRICIANS ARE A CRITICAL PART OF
THE FOSTER CARE TEAM…
OVERALL GOALS FOR PEDIATRICIANS
Be a medical home
 Help child welfare agencies, foster families, and
birth families minimize the trauma of placement
separation
 Improve the child’s health and development
during the period of foster care

HIGH RISK POPULATION

In 1995, a Government Accounting Office Report
stated that children in foster care are “sicker
than homeless children and children living in the
poorest section of inner cities.”
o Compared with children
from the same
socioeconomic background,
they have much higher
rates of serious emotional
and behavioral problems,
chronic physical
disabilities, birth defects,
developmental delays, and
poor school achievement.
BARRIERS TO GOOD HEALTH OUTCOMES
Lack of a medical home
 Lack of medical records
 Inadequate and delayed assessment of needs
upon entry into system
 Lack of follow-through in addressing identified
needs
 Lack of access to other health services
 Diffusion of authority and responsibility
 Health providers’ lack of knowledge about child
welfare and legal systems

NATIONAL INVOLVEMENT
AAP Council on Foster Care, Adoption, and
Kinship Care
 Healthy Foster Care America
 Child Welfare League of America (CWLA)

AAP RECOMMENDATIONS
Health screening within 72 hours of placement
into foster care
 A comprehensive evaluation within 30 days of
placement
 Follow-up health visit within 60 to 90 days of
placement
 Continuity of care

Monthly for infants from birth to age 6 months
 Every 3 months for children age 6 to 24 months
 Twice a year for children and teens between 24
months and 21 years of age

INITIAL HEALTH SCREENING

Review the circumstances that led to placement

Monitor adjustment to foster care home

Inquire about the agency’s plans for permanency
INITIAL HEALTH SCREENING
Immunization status
 Review patient’s medical history
 Assess developmental or school progress
 Complete physical exam





Height, weight, head circumference
All body surfaces should be unclothed
Genital and anal examination
Laboratory tests when appropriate
GENERAL TIPS FOR HEALTH
CARE PROFESSIONALS
Use respectful language
 Don’t label children or families
 Use the term “child in foster care”
instead of “foster child”
 After each visit, contact the DSS
caseworker
 Provide a copy of the health
summary to the caseworker and
foster parent

COMPREHENSIVE EXAM
Physical health
 Oral health
 Relational health
 Developmental health (if under 6yo)
 Educational health (if over 5yo)
 Mental/behavioral health

PHYSICAL HEALTH

About 50% have chronic medical problems









Asthma
Iron deficiency anemia
Obesity or FTT
Enuresis and encopresis
Visual and hearing loss
Neurological disorders
Genetic disorders
Infection (STI, TB)
Increased lead levels
ORAL HEALTH


Approximately 35% enter
foster care with significant
dental and oral health
problems
Common problems:
bottle tooth decay in young
children
 multiple dental caries in
older children


AAP recommends that
every child and teen
entering foster care have a
dental evaluation within 30
days of placement
RELATIONAL HEALTH
Children and teens often enter foster care
without a model for normal, healthy family
relationships
 They need to learn some of the basic principles of
being a part of a healthy family
 Overall, foster care is intended to allow children
to develop a sense of belonging

DEVELOPMENTAL HEALTH
6x more likely to have developmental problems
 60% of children <6yo enter foster care with
developmental delay in at least one domain
 Use validated developmental screen
 Referrals for PT, OT, ST
 May be a role for developmental pediatric
specialists

EDUCATIONAL HEALTH
Kindergarteners in foster care have half the
vocabulary of their peers
 Nearly half are involved in special education and
of these children, half have significant behavioral
problems that lead to high rates of school
suspensions and missed educational
opportunities
 8% of young adults completed a bachelors degree
compared to the general population of 24%

MENTAL/BEHAVIORAL
HEALTH
o Largest unmet health need for
children and teens in foster
care
30% of children in foster care vs. 4% of general
population have emotional issues
 5x more likely to have behavioral problems
 16x more likely to carry a psychiatric diagnosis
 8x more likely to be on psychotropic medications
 Consider referrals to mental health care
professionals with expertise in trauma, posttraumatic stress disorder, grief, and separation
issues

HOW PEDIATRICIANS CAN HELP FOSTER
PARENTS
Explain health status
 Help access services
 Give advice on parenting
 Teach foster parents how to
cope with child’s history of
trauma

HOW PEDIATRICIANS CAN HELP FOSTER
PARENTS
Explain health status
 Help access services

 Give
advice on
parenting

Teach foster parents how to
cope with child’s history of
trauma
STRESSORS
Change in visitation with parents
 Change in school or child care settings
 Separation from siblings
 Parents going to rehab or jail
 Court dates
 Another child entering/leaving the foster home
 Being freed for adoption

HOW PEDIATRICIANS CAN HELP FOSTER
PARENTS
Explain health status
 Help access services
 Give advice on parenting

 Teach
foster
parents how to
cope with child’s
history of trauma
THE IMPACT OF CHILDHOOD TRAUMA
Trauma experiences such as maltreatment,
violence exposure, poverty, and impaired
caregiving lead to chronic elevations in stress
hormones
 As pediatricians, it is crucial to understand the
impact of trauma on the developing brain and its
translation into largely predictable emotions and
behaviors
 We must be able to reframe behaviors for foster
parents in ways that might be helpful to them in
parenting the child

PEDIATRICIANS ROLE IN CHILDHOOD
TRAUMA: “TRAUMA INFORMED CARE”



Identify traumatized child
Educate families about toxic stress and the
possible biological, behavioral, and social
manifestations of early childhood trauma
Empower families to respond to child’s behavior
in a manner that acknowledges past trauma, but
promotes the learning of new, more adaptive
reactions to stress
COMMON BEHAVIORS
Poor affect regulation
 Impulsive
 Hyperactive
 Limited attention span
 Inflexible
 Dissociation
 Poor self concept
 Act younger than they are
 Insecure attachment




Indiscriminately friendly
Avoidant, ambivalent
Do not know difference between anger and
sadness
REASONS FOR THESE COMMON BEHAVIORS
These children have developed different ways of
perceiving and reacting to their world, ways that
often prove maladaptive in a more normal
environment
 Altered neuroendocrine development

ADVICE FOR FOSTER PARENTS









Do not take these behaviors personally
Help child understand your facial expression or tone
Avoid yelling and aggression
Come down to child’s eye level
Validate their feelings
Develop breathing techniques, relaxation skills, or
exercises that the child can do when getting upset
Praise the child for expressing feelings or calming
down
Be aware of your own emotional responses to child’s
behaviors
With time, patience, and practice, the child’s brain
and body will learn more adaptive ways to respond to
a new, safer environment
SPECIAL ISSUES
TRANSITIONING OUT OF FOSTER CARE AND
IN TO ADULTHOOD
Importance of mentorship
 Major decisions
 Need copy of:









medical records including meds, immunizations, full
history, birth, medical, and family history
emergency contact info
legal form with POA
health insurance card
contact info for former doc, dentist, counselor
birth certificate and SS card
high school diploma or GED
photo ID
MEDICAL CONSENT
Legal guardianship remains with birth parents
unless freed for adoption
 Whenever possible, the birth parents should
make all important decisions and grant consent
on behalf of their child
 DSS also has the ability to consent for routine
medical treatment
 Foster parents do not have the authority to
provide consent for medical procedures
 When freed for adoption, birth parents no longer
have any legal rights

CONFIDENTIALITY
Medical information may be shared
with caseworkers and foster parents
 Need to check with foster care agency
before releasing information to birth
parents
 Once freed for adoption, may not
share information with birth parents
 Attorneys and court-appointed special
advocates only have access to medical
information through subpoena or
written consent

ADVOCACY
OPPORTUNITIES
Volunteering in agencies that serve children or
teens in foster care
 Becoming a mentor
 Teaching independent living skills
 Advocating for services and policies at the federal
and state level
 Starting a “backpack” program so that children
in foster care have items for school
 Donating to a fund that pays to enroll children in
foster care in extracurricular activities

CONCLUSIONS
The foster care system aims to uphold the health
and well-being of children and teens in foster
care, keep them safe, and promote stability
 It is our job as pediatricians to provide high
quality health services, health care coordination,
and advocacy on their behalf
 It is crucial to understand the impact of trauma
on the developing brain and its translation into
largely predictable emotions and behaviors
 We must be able to reframe behaviors for foster
parents in ways that might be helpful to them in
parenting the child

WHAT IS THE AVERAGE LENGTH OF
STAY FOR A CHILD OR TEEN IN THE
FOSTER CARE SYSTEM?
1.
2.
3.
4.
5 years
3 years
1 year
6 months
0%
1
0%
2
0%
3
0%
4
A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR
OFFICE THE DAY AFTER BEING PLACED WITH FOSTER
PARENTS. YOU FIND OUT THAT NEGLECT FROM THE
BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION
LED TO THE PLACEMENT. PATIENT APPEARS WELL ON
EXAM AND HAS NO KNOWN MEDICAL PROBLEMS.
WHEN DO YOU NEED TO SEE HER BACK?
1.
2.
3.
4.
1 year
6 months
2 months
1 month
0%
1
0%
2
0%
3
0%
4
FOR A CHILD IN FOSTER CARE, WHO IS
ABLE TO CONSENT FOR MEDICAL
PROCEDURES?
1.
2.
3.
4.
5.
6.
Foster parents
Department of Social
Services (DSS)
Birth parents
1&2
2&3
All of the above
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
WHICH OF THE FOLLOWING SEQUELAE
ARE TRUE CONCERNING THE IMPACT OF
TRAUMA ON A CHILD?
1.
2.
3.
4.
5.
6.
Chronically elevated stress
hormones
Development of permanent
maladaptive behaviors
Altered development of
prefrontal cortex and
hippocampus
1&2
1&3
All of the above
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
REFERENCES

Ahrens, KR. et al. Youth in foster care with adult mentors during adolescence have improved adult
outcomes. Pediatrics 2008; 121 (2): e246-e252.

“Foster Care.” American Academy of Pediatrics. Web. <www.aap.org/fostercare>.

“Smart Spending.” Casey Family Programs. Web. <http://www.casey.org/smarter-spending/>.












Committee on early childhood, adoption, and dependent care. Health care of young children in foster care.
Pediatrics 2002; 109 (3): 536-540.
Greiner, MV. et al. Foster caregivers’ perspectives on the medical challenges of children placed in their
care: Implications for pediatricians caring for children in foster care. Clinical Pediatrics 2015. epub ahead
of print.
American Academy of Pediatrics District II New York State Task Force on Health Care for Children in
Foster Care. Fostering Health: Health care for children and adolescents in foster care. Elk Grove Village,
IL: American Academy of Pediatrics; 2005.
Szilagyi, M. The pediatrician and the child in foster care. Pediatrics in Review 1998; 19 (2): 39-50.
Jee, SH. et al. Foster care issues in general pediatrics. Current Opinion in Pediatrics 2008; 20 (6): 724728.
Bruskas, D. Children in foster care: a vulnerable population at risk. Journal of Child and Adolescent
Psychiatric Nursing 2008; 21 (2): 70-77.
Task Force on Health Care for Children in Foster Care. Fostering health: Health care for children and
adolescents in foster care, 2nd addition. New York: American Academy of Pediatrics, 2005. Print.
Leslie, LK. Et al. Comprehensive Assessments for children entering foster care: A national perspective.
Pediatrics 2003; 112 (1): 134-142.
Halfon, N. et al. Health status of children in foster care. The experience of the Center for the Vulnerable
Child. Arch Pediatr Adolesc Med. 1995; 149 (4): 386-392.
Chernoff, R. et al. Assessing the health status of children entering the foster care system. Pediatrics.
1994; 93 (4): 594-601.
American Academy of Pediatrics and Dave Thomas Foundation for Adoption. Helping Foster and
Adoptive families cope with trauma: A guide for pediatricians. Elk Grove Village, IL: American Academy
of Pediatrics; 2013.
Schor, E. The foster care system and health status of foster children. Pediatrics 1982; 69 (5): 521-528.
QUESTIONS??
(THIS EXCLUDES DR STALLWORTH)