Foster Care

Description

Other Names

Children in the child welfare system

Diagnosis Coding

ICD-9

V60.81, Foster care (status)

313.89, Reactive attachment disorder



DSM-5 and ICD-10

Z62.21, Child in foster care

Z62.822, Parent-foster child conflict

F94.1, Reactive attachment disorder of childhood

F94.2, Disinhibited attachment disorder of childhood

Z62.21 is found under Factors influencing health status and contact with health services (Z codes), Problems related to upbringing (Z62), Upbringing away from parents (Z62.2), Child in welfare custody. F94.1 and F94.2 are found under Disorders of social functioning with onset specific to childhood and adolescence (F94). See ICD10Data.com for more details.

Description

Children and adolescents in the foster care system are a vulnerable population at high risk for developing physical, developmental, educational, and dental issues. Exposure to multiple adverse events, inadequate care in the family of origin, and previously undiagnosed health disorders further increases poor developmental trajectories. [Ringeisen: 2008] One study cites that 35-50% of children entering foster care have significant emotional and behavioral problems; 46% of those under age 6 have developmental problems; and 80% of those under age 3 years were exposed to maternal substance abuse in utero. [Stahmer: 2005]

Untreated conditions, especially emotional and behavioral ones related to traumatic experiences, are the most common reasons for foster placements to fail, leading to further disruptions in care, school, and community for the child. Traumatic experiences can include physical and sexual abuse, domestic and community violence, and/or witnessing parents or loved ones in life-threatening situations or abusing substances.

Primary care clinicians can collaborate with child welfare agencies to improve the physical and mental health of children in foster care and can engage families of origin and the foster families as a way to minimize the trauma of separation, identify health care needs, and initiate treatment. Close surveillance and continuity of care should continue as children transition between placements. The American Academy of Pediatrics has created Healthy Foster Care America (AAP) to assist primary care clinicians in meeting the health needs of children in foster care.

Prevalence

Every primary care clinician will face child maltreatment and the sequelae, including foster care placement. In 2011, at least 9 out of every 1,000 children in the U.S. suffered abuse. Of these children, 27.1 % were under 3 years old and 78% suffered neglect, 17.6% physical abuse, and 9.1% sexual abuse. [Administration: 2012] In 2012, there were 397,122 U.S. children in foster care – approximately one in every 185 children. Of these children, the median age at the time of entering foster care was 6.5 years. [Child: 2013]

Genetics

Although genetics do not play a direct role in causing children to be neglected, abused, or placed in foster care, heritable characteristics can lead to certain parental behaviors, attitudes, and limitations that lead to their children being placed there.

Prognosis

In 2012, more than 241,000 children exited foster care: [Child: 2013]
  • 51 percent were reunited with parent(s) or primary caretaker(s)
  • 21 percent were adopted
  • 8 percent went to live with another relative
  • 7 percent went to live with a guardian
  • 2 percent had other outcomes (includes transferal to another agency, running away, or death)
  • 10 percent were emancipated or "aged out” of the foster care system when they became too old (usually at age 18) to receive further services
One study found that adolescents who “age out” of the foster care system suffer serious lasting consequences: 1 in 4 will be incarcerated within 2 years of leaving foster care; 1 in 5 will become homeless sometime after age 18 years; and only 58% will graduate from high school (compared to the 87% national average). [Jim: 2007]

While little data exists on long-term outcomes for children who exit foster care before 18, the effects of child abuse and neglect often have long-lasting adverse consequences for survivors. The Adverse Childhood Experiences (ACE) Study demonstrated that child abuse, neglect, and other circumstances that disrupt the child-parent relationship are significantly associated with many leading causes of adult death, such as strokes, cancer, and heart disease, and are associated with heavy health service utilization. Stressful childhood experiences lead to higher rates of depression, suicide, cigarette smoking, diabetes, obesity, hypertension, and alcohol and substance abuse. [Felitti: 1998]

Roles Of The Medical Home

The primary care clinician and the medical home may provide one of the most stable adult influences in the life of a foster child. According to the American Academy of Pediatrics (AAP), the medical home serves as the focal point for the reduction of toxic stress and for the support of child and family resiliency. The medical home offers safety, access to resources, and continuous care for a child who has experienced trauma – Healthy Foster Care America (AAP).

Routine follow-up visits should be frequent as should opportunities for the child or adolescent to talk about their needs, fears, and desires. Acknowledging the anger, fear, sadness, and confusion associated with foster placement validates the child’s experience and can support their developing coping skills. Identifying and addressing cognitive distortions (e.g., “it's my fault,” “no one will ever want me,” or “I should have kept my dad from hurting my mom”) can make a huge difference for a child. Instilling hope and identifying strengths that will help them survive, and perhaps thrive, during the foster care experience is important.

The primary care clinician can provide families with guidance about the effects of toxic stress on development, behaviors, emotions, and learning especially during times of transition. The clinician can provide families emotional support, validation, and tools to optimize their responses to the challenging symptoms often seen in children and youth in foster care. By identifying toxic stress and related symptoms, the clinician can advocate for the child within the child welfare system. Interventions that promote a stable foster placement and a timely well-coordinated transition to a permanent home, including coordination of medical care, will mitigate deleterious effects on the child’s long-term development. Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) (PDF Document 3.6 MB) helps clinicians to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote more adaptive reactions to stress.

Practice Guidelines

Texas Department of State Health Services and others.
Psychotropic medication utilization parameters for foster children (CMAP).
Texas Department of State Health Services; (2007) http://www.dfps.state.tx.us/documents/about/pdf/2007-01_PsychotropicMe.... Accessed on 4/15/2014.
Guidelines for the clinical management of a child who is taking, or will be taking, a psychotropic drug. To be used in the treatment of foster children who receive services through Medicaid; Texas Children’s Medication Algorithm Project.

American Academy of Child and Adolescent Psychiatry.
Practice parameter on the use of psychotropic medication in children and adolescents.
J Am Acad Child Adolesc Psychiatry. 2009;48(9):961-73. PubMed abstract / Full Text

American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care.
Health care of young children in foster care.
Pediatrics. 2002;109(3):536-41. PubMed abstract / Full Text

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text

Romanelli LH, Landsverk J, Levitt JM, Leslie LK, Hurley MM, Bellonci C, Gries LT, Pecora PJ, Jensen PS.
Best practices for mental health in child welfare: screening, assessment, and treatment guidelines.
Child Welfare. 2009;88(1):163-88. PubMed abstract

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract

Helpful Articles

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care provider's supporting role.

American Academy of Pediatrics.
Helping foster and adoptive families cope with trauma: A guide for pediatricians.
American Academy of Pediatrics; (2013) http://www.aap.org/traumaguide. Accessed on 4/10/2014.
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of new, more adaptive reactions to stress.

American Academy of Pediatrics, Task Force on Health Care for Children in Foster Care.
Fostering health: health care for children and adolescents in foster care, 2nd edition.
American Academy of Pediatrics; (2005) http://www2.aap.org/fostercare/FosteringHealth.html. Accessed on 4/10/2014.
Practice parameters for primary care, developmental and mental health care, and care when child abuse and neglect are involved; downloadable as pdf.

Clinical Assessment

Overview

Every child entering foster care should have a health screening evaluation before or shortly after placement. The examination should identify any medical, mental, or dental needs that require prompt attention or that should be considered in making placement decisions. [American: 2002] Within one month of the initial screen (or simultaneously with the screen), the child or adolescent should receive a comprehensive health assessment, preferably by the physician who will be providing the medical home. [American: 2002] The child’s caseworker, foster parents, and/or birth parents (if appropriate) should be present at visits and can help with acquiring medical records and history. Consent for routine and emergency medical care, as well as release of past medical records, should be obtained from the family per individual state regulations. Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB) has screening recommendations by age.

Screening

For Complications

Consider screening for developmental delays, vision, hearing, autism, effects of toxic stress, alcohol and substance abuse, depression, ADHD, other mental health disorders, risky sexual behavior, and learning disabilities. The Traumatic Event Questionnaire (TEQ) may be used to identify the types of traumatic events a child has experienced and the related symptoms. The Quick Traumatic Stress Screen for Ill or Injured Children (PDF Document 26 KB) is a brief interview guide for assessing symptoms related to trauma of any sort. The Safe Environment for Every Kid (SEEK) is a Parent Screening Questionnaire that targets risk factors related to child maltreatment. Free printable questionnaires in 4 languages can be found at SEEK Parent Screening Questionnaire (PSQ) (Univ. of MD).

Because many young children entering foster care come from settings in which substance abuse and sexual promiscuity are common, they should be considered to be at high risk for HIV infection, hepatitis, and other sexually transmitted infections. Laboratory tests for these conditions should be performed when appropriate. [American: 2002]

Presentations

Unless the family volunteers the information, it is possible that the primary care clinician will not know when a child has had an episode in foster care between office visits. If aware of a pending or completed placement, the primary care clinician can advocate to maintain continuity of care or collaborate if a new provider must be involved.

Comorbid Conditions

Children in foster care may manifest a number of disorders that could both contribute to, and result from, the experiences that led to them being in foster care:
  • Attachment disorder
  • Post-traumatic stress disorder (PTSD)
  • Depression, anxiety, and other mood disorders
  • Behavioral disorders such as Attention Deficit Hyperactivity Disorder (ADHD), oppositional-defiant disorder (ODD), and conduct disorder (CD)

Pearls & Alerts

Altered Responses

Traumatized children may have problems with self-regulation (sleep disturbances, eating problems, or toileting problems), and have symptoms of depression, anxiety, ADHD, aggression, self-injury, and anger that persist long after the child has been removed from the abusive or neglectful environment. In addition, despite the traumatic experienced there, children may develop symptoms related to separation from their home and other familiar environments – many children report this as the most traumatic aspect of entering foster care. Physicians can assist caregivers by helping them identify altered responses, formulate effective coping strategies, and mobilize available community resources. [Stirling: 2008]

Role as Confidant

Most children in foster care have been exposed to traumatic events beyond what is known or reported. The child may be willing to talk to their health provider about past events, such as other physical or sexual abuse, which they have not previously disclosed.

ADHD can Interfere with Mental Health Treatment

A high percentage of children in foster care are identified with ADHD symptoms. While some symptoms improve with set routines in a predictable home, a number of children struggle to engage in trauma-focused mental health treatment because of inattention, impulsivity, and hyperactivity. When appropriate, and in consultation with the child’s mental health therapist, consider proceeding with assessment for ADHD and when indicated, proceed with treatment even while the child is engaged in other psychotherapies.

Monitor for Suboptimal Care

Poor care can occur during placement changes or during visits with family of origin. In addition, placement changes can disrupt continuity of care by the foster parent and the primary care clinician, as well as school placement, which all can lead to increased emergency room use. [Rubin: 2004]

Reconstruct Immunization History

By communicating directly with previous medical providers or reviewing previous medical records (e.g., from schools or immunization registries), it is often possible to reconstruct the child’s immunization history. For some children, despite a thorough effort, little or no immunization information will be available. These children should be considered susceptible and immunized according to guidelines. [American: 2002]

History & Examination

At the initial visit, little, if any, medical and other history may be available. Suspicion that the child may have special health care needs that have been previously undiagnosed or untreated should be high. The child may have corrective lenses, hearing aids, dental retainers, inhalers, or medicines that did not accompany them into the foster care system or transition with them if they change foster placements. The history should include foster parent needs, normalizing activities for the child, other services the child may be receiving, school adaptation and function, and any behavioral or emotional issues.

Family History

If possible, obtain a history of mental illness from the family of origin. The foster family’s history and experience with special needs children is important in understanding how comfortable they are likely to be with managing any medical or mental health problems.

Pregnancy Or Perinatal History

Consider likelihood of substance abuse or smoking during pregnancy; prematurity related to poor prenatal care, poor nutrition, or stress related to domestic violence; postnatal exposure to neglect or substance abuse in the environment; and shaken baby syndrome.

Current & Past Medical History

If information is insufficient, the child welfare worker and parents (if possible) should be contacted to gather relevant history. Exercise, nutrition, and sleep hygiene should be reviewed. If possible, obtain information regarding seizures or previous head injuries or concussions. The concussions may be the result of the child’s participation in athletic endeavors. Immunization status should be confirmed.

Developmental & Educational Progress

Developmental screening is recommended for children under 6 years. Review any changes in school placement. If the child has an individualized education plan or a 504 plan for health accommodations at school, check if the plan has transitioned to the present school.

Maturational Progress

With adolescents, discuss sexual orientation, sexual activity, alcohol or drug use, tobacco use, prevention of sexually transmitted disease, and birth control. For children entering puberty, identify who is providing education and guidance.

Social & Family Functioning

Enquire about family relationships (both foster and family of origin), adjustment to foster care, peer relationships, adjustment to school, hobbies, education, or career plans. Asking caregivers about discipline techniques for these very emotionally and behaviorally challenging children may help identify caregivers at risk for punishing harshly. Goals for the child's permanent placement (e.g., reunification with parents, adoption, guardianship, or kinship placement) will guide who should be involved in health care planning and consent for treatment.

Physical Exam

General

An initial complete physical examination, including genital exam, is indicated. Inspect closely for signs of abuse, neglect, or maltreatment and report with photographic documentation when indicated.

Vital Signs

Baseline vital signs are important since children and adolescents exposed to toxic stress are at risk for developing hypertension or cardiac disease.

Growth Parameters

Plot growth, including BMI. Children on psychiatric medicines may experience weight loss or weight gain. Children on antipsychotic medicines are at risk for metabolic syndrome; BMI > 95th percentile or waist circumference > 90th percentile and Blood Pressure > 90th %.

Skin

Full exam is important to look for bruising or injury that may reflect abuse or self-harm.

Mouth/Teeth

Children in foster care are at increased risk for caries and poor dental hygiene.

Genitalia

Be sure you have identified yourself to the child or adolescent in your role as physician. Conduct the exam in a matter-of-fact way that normalizes the experience as a standard part of every comprehensive exam. Avoid using endearments such as “honey” or “sweetie.” Instead of interrogating, use statements such as “I don’t understand” or “can you help me understand, I wasn’t there so I don’t know.” During the exam, let the child use their own language, and do not correct or interrupt to give them more accurate terms when they are first describing an incident.

Extremities/Musculoskeletal

Examine for fractures or injury, present and past.

Neurologic Exam

Without adequate history, it may be unknown if the child or adolescent has had previous head injuries.

Testing

Sensory Testing

Hearing and vision screening. Traumatized children may dissociate and seem “not to hear.” They may be over- or under-reactive to sensory input.

Laboratory Testing

Depending on the clinical scenario, and access to and reliability of medical history, consider:
  • Hepatitis B screen
  • Hepatitis C screen
  • Hemoglobin
  • Lead level
  • Evaluation for metabolic syndrome
    • fasting serum triglyceride levels (>110mg/dL)
    • fasting HDL-cholesterol (<40mg/dL)
    • fasting glucose (>110mg/dL)
  • Chlamydia, gonorrhea, syphilis, and HIV testing if risk assessment is positive (Check state policy regarding who can give consent for testing.)
  • Pregnancy testing (Check state policy regarding who can give consent for testing.)
  • Purified protein derivative tuberculin (PDD) if 3 months or older

Imaging

Appropriate studies if suspicion of previously undiagnosed new or past fractures, including skull fractures or head injury.

Other Testing

The following screens may be useful:

Subspecialist Collaborations & Other Resources

If possible, learn of any medical specialists who have previously cared for the child and determine if follow-up visits are indicated. Because this is an opportunity to optimize medical care and services for children who were previously neglected and possibly under-served, a careful review of needs should be completed. For children under age 5, early intervention services may have been involved, or a referral for services may be indicated, if there are developmental delays. Children 3 through 5 may need special education services. For children with high levels of sensory sensitivities or hypo-responsiveness, an occupational therapy evaluation may be indicated. A referral for speech and language evaluation and treatment and physical therapy should be considered.

Children in foster care have a high incidence of psychiatric disorders, including PTSD. Efforts should be made to determine if the child or adolescent was receiving mental health services prior to removal from their home, and then, if possible, coordinate continuity of care. The child welfare worker should be able to provide access to a mental health assessments and treatment. Often there will be a forensic evaluation if the child or adolescent has experienced abuse. This may include a physical exam and a video-recorded interview that meets legally defined standards of care.

Early Intervention Programs (see Services below for relevant providers)

For children birth to age 5 who qualify for early intervention and/or special education preschool.

Preschool/Early Childhood Education (see Services below for relevant providers)

For children with developmental concerns.

Occupational Therapy, Pediatric (see Services below for relevant providers)

For children with evidence of sensory problems.

Speech/Language Therapy (see Services below for relevant providers)

For children with delayed language or speech development.

Psychiatrist, Child-18 (see Services below for relevant providers)

For children with evidence of mental health disorders, such as post-traumatic stress disorder (PTSD).

Head Start/Early Head Start (see Services below for relevant providers)

For infants and toddlers with disabilities or delays to learn many key skills and catch up in their development.

Treatment & Management

Overview

Providing primary care for children in foster care presents several dilemmas for the clinician. First, the caregiver who accompanies the foster child may be the foster parent, the child welfare worker, or simply a transport provider. They may be most interested in resolving an immediate problem (e.g., the child needs to be calmer or go to sleep) and may not address long-term concerns or issues as most parents would. This places greater responsibility on the primary care clinician to consider and advocate for the child’s long-term needs and interests. Discontinuity of care and lack of access to medical records are often a challenge, since the foster parents may prefer not to (or are unable to) continue care with the child’s previous primary care clinician.

Another challenge is understanding who has legal authority to consent for care - the rules vary by state. When the state takes custody, the parents maintain legal guardianship unless the courts legally deprive them of parental rights. If birth parents are unavailable or uncooperative, an authorized committee or person within social services usually can provide medical consent for care. Depending on state regulations, foster parents may or may not be able to provide consent for certain medical interventions. Primary care physicians should receive (or seek) a copy of general medical consents from foster care agencies. [American: 2005]

Because of multiple risk factors, children in foster care often benefit from frequent visits as recommended: [Szilagyi: 2012]
  • Admission health screen within 72 hours of entry into the foster care system
  • Comprehensive health assessment within 30 days of entry
  • Follow-up health visit 60-90 days after entry
  • For infants under 6 months – monthly visits
  • An extra visit at 21 months

Pearls & Alerts

Motivational Interviewing for Adolescents

Motivational interviewing can be a valuable technique for approaching risk reduction counseling and contraception with adolescents. (Motivational Interviewing provides details of this technique.)

Share the Treatment Plan

Consider the health literacy of both the child and the foster parents when formulating and discussing the treatment plan. The plan also should be shared with the child’s caseworker and birth parents if appropriate.

Weigh Long-Term Goals with Medication Use

Multiple psychotropic medications are often prescribed to manage behavioral symptoms. This may be driven in part by relatively short-term goals that may not be in the long-term best interest of the child. Addressing the latter and collaborating with foster care programs to access services to help foster families manage symptoms non-pharmacologically may be useful.

Systems

Mental Health/Behavior

The primary care clinician may feel pressure to start, or continue and monitor use of, psychotropic medication(s) when they see 1) a child or adolescent as they transition from a residential setting where medicines were used, 2) a child in jeopardy of losing their foster placement or having school problems due to behavior, or 3) the caregivers and case workers are not able to provide an adequate past or present history. Disruptive behaviors, such as aggression, defiance, and temper tantrums, may indicate a reaction to traumatic events, which does not respond well to medicine. Poor sleep may contribute to moody behavior or poor attention span. Dissociation may look like oppositional behavior or the child ignoring directions. Taking the time to involve the relevant caregivers, obtain adequate information from the homes and the school, and clarify symptoms and diagnosis is in the child’s best interest. In addition to evaluating for trauma and assessing sleep, use the “BOLDER” approach to assessment: T-MAY (Treatment of Maladaptive Aggression in Youth) Toolkit (PDF Document 1.6 MB):

  • Behavior: In what ways does the child exhibit aggression?
  • Onset: When does it happen? What triggers it and why?
  • Location: Where do the symptoms occur - home/school?
  • Duration: How long does it last?
  • Exacerbates: What makes it worse?
  • Relief: What makes it better?
When parents or foster parents report significant behavioral or emotional problems with a child, the clinician should consider the capacity of the caregiver to manage the child’s behaviors without punishment that is emotionally or physically abusive. If the child and family cannot access immediate mental health services, a referral for respite care or, if punishment appears to be abusive, involvement of child protective services should be considered.

Agitation, anxiety, and poor attention are common responses to entering foster care and a new, unfamiliar home. Children and teens are often grieving the separation from their family and feeling confused by what has happened. These symptoms should be evaluated and followed to determine if they are transitory adjustments to foster care and/or recovery from exposure to past trauma, or if they represent a psychiatric disorder such as Attention Deficit Hyperactivity Disorder (ADHD), Depression, or post-traumatic stress disorder.

Evidence-based treatment recommendations for maladaptive aggression in youth were published in the June 2012 issue of Pediatrics. The T-MAY guidelines are as follows:

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Assists with diagnosis of mental health disorders, symptom and medication management particularly in complex cases with children who exhibit both medical and psychiatric disorders, and/or the coordination of mental health care.

Psychologist, Child-18 (see Services below for relevant providers)

Evaluates for learning disabilities, autism, or developmental disorders. May provide individual or family therapy. Some psychologists have additional training in trauma-informed or trauma-focused treatment.

Neuropsychology (see Services below for relevant providers)

Consider referral when a child has complex learning disorders associated with possible autism, intellectual disability, or brain injury.

Family Support Organizations (see Services below for relevant providers)

Many community mental health centers provide case management or respite care for children in their programs. When a child is in the custody of the state, there are sometimes financial restrictions on whether the local mental health center or the child welfare system should provide these services.

Crisis Intervention Mental Health (see Services below for relevant providers)

The Child Welfare system often contracts with specific providers for more intensive crisis and residential care and should be contacted when these services are needed.

Sexual Abuse Counseling (see Services below for relevant providers)

Provides prevention, intervention, and treatment services for children and families.

Pharmacy & Medications

Guidelines for treatments of ADHD, depression, or other psychiatric problems, which include information about choices and dosages of medications can be found in the Mental Health Practices in Child Welfare Guidelines Toolkit (PDF Document 1020 KB) and GLAD-PC: Guidelines for Adolescent Depression - Primary Care (REACH Institute).

If starting a psychiatric medicine, clearly identify the target symptoms and the potential side effects. See the patient frequently to monitor response, adjust dosage, or modify choice of medicine. Problems (such as sleep disturbances) that may exacerbate other issues should be considered for early treatment. Try to “start low” (one medicine at the lowest dose expected to be effective) and “go slow” (increasing dose or changing/adding medication) to allow response both to the medication(s) and the new home environment. Because the child and family may be extremely stressed by sleep deprivation, any sleep problems should be prioritized for intervention. With adequate sleep, many other problems can be more easily managed.

With school-age children, a high suspicion should be maintained for ADHD. Girls, in particular, may be considered socially disruptive or purposefully disobedient rather than suffering from impulsivity and working below their abilities due to ADHD, inattentive type. When starting treatment, stimulants are generally the first drug of choice; however, with risk of substance abuse or drug diversion, consider several non-stimulant drugs such as clonidine, quanfacine, and atomoxetine. These may have the added advantage of improving sleep disorders and not interfering with appetite. While stimulants are generally well tolerated, side effects of sleep problems, decreased appetite and weight loss, and rebound moodiness at the end of the day may limit their use.

For older children and teenagers, evaluation for depression and anxiety disorders is critical. While SSRIs are associated with increased risk of suicidal ideation, there are significant benefits in overall functioning and in decreasing actual suicide with SSRIs. Psychotherapy is the treatment of choice for a child or youth with anxiety or depression, and the primary care clinician should monitor response and notify the child’s therapist when there is inadequate progress. The atypical antipsychotics, such as risperidone, aripiprazole, and quetiapine are approved for mood stabilization in children and adolescents with bipolar disorder and for symptoms of agitation and aggression associated with autism. The atypical antipsychotics are nonspecific across the disorders for decreasing aggression, but the long-term side effects can be significant and demand monitoring. These medicines may provide short-term support while other services are being accessed - they should not replace intensive mental health care. The child welfare worker should collaborate with the primary care provider in making a referral for a mental health evaluation and/or treatment.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Assists with diagnosis of mental health disorders, helps with symptom and medication management - particularly with complex cases such as children with both medical and psychiatric disorders, and assists with the coordination of mental health care.

Nutrition/Growth/Bone

Previous height and weight records, which may be unavailable, may suggest neglect and/or ongoing stress experienced by the child. Eating and feeding topics are important to discuss – some children react to the lack of control in their lives through choices about eating or not eating. Cultural or family-specific food preferences and rituals may affect the child’s eating habits. Neglected children may hoard food, search through garbage, or eat until they vomit due to anxiety over past lack of access to food. Psychiatric medicines may decrease or increase appetite and affect weight gain or loss.

Subspecialist Collaborations & Other Resources

Nutrition/Dietary (see Services below for relevant providers)

May help devise dietary approaches and recommend foods that will optimize nutrition in the face of behavioral challenges.

Development (general)

Children in foster care have a high incidence of developmental delay; prompt referral for evaluation and/or early intervention should be considered whenever there is concern.

Subspecialist Collaborations & Other Resources

Developmental Evaluation (see Services below for relevant providers)

May be very useful in understanding the range of delays present and in formulating an intervention plan.

Developmental Pediatrics (see Services below for relevant providers)

May be very useful in understanding the range of delays present and in formulating an intervention plan, particularly if a Developmental Evaluation program is not available.

Early Intervention Programs (see Services below for relevant providers)

Often provide developmental evaluation, as well as programs to mitigate the causes and impact of developmental delays.

Sleep

Children and adolescents who have suffered trauma often show signs of stress through their sleep patterns. This is another common response to entering foster care or an unfamiliar, new home. Children and teens are often grieving the separation from their family and confused by what has happened. These symptoms should be evaluated and followed to determine if they are transitory adjustments to foster care and/or recovery from exposure to past trauma, or if they represent a psychiatric disorder such as Attention Deficit Hyperactivity Disorder (ADHD), Depression, or post-traumatic stress disorder. Sleep disturbance also may be due to psychiatric medicines, such as stimulants for ADHD or the sedating qualities of the atypical antipsychotics.

Subspecialist Collaborations & Other Resources

Pediatric Sleep Medicine (see Services below for relevant providers)

Consider referral if the sleep issues prove recalcitrant to primary care management or may be related to other anatomic or physiologic problems.

Maturation/Sexual/Reproductive

Regulations regarding testing for HIV vary from state to state. If a health care professional feels a minor has the capacity, the minor must consent for medical services related to reproductive health, sexually transmitted disease, HIV testing, and substance abuse. Adolescents in foster care have a greater risk for past and future participation in risky behaviors, including sexual encounters.

Transitions

Foster Care Quote
Nearly 24,000 adolescents age out of the foster care system annually, usually when they turn 18. [Child: 2013] As they do so, they face serious challenges including special healthcare needs that may not have been well addressed when they were young and that do not get better in adulthood. For most, lack of health care poses a substantial barrier. Even with health care, it can be difficult for aged-out foster youths to navigate the healthcare system or find medical practices that will accept their insurance coverage.

Primary caregivers can help transitioning patients by working collaboratively with child welfare workers and assisting youth in: [American: 2005]

  • Gathering medical records that list past health-care provider names, major illnesses and conditions, medications taken, immunizations, and family medical history.
  • Understanding their health issues including safe use of medication and knowing when to seek treatment. Making Healthy Choices: Guide for Youth in Foster Care on Psychotropic Medications (PDF Document 9.7 MB) may help youth to understand the use, limits of, and alternatives to psychotropic medication.
  • Understanding why their ongoing health care should be a priority.
  • Finding a new adult primary care physician as well as needed mental health, reproductive health, and dental services. See Finding Adult Health Care.
  • Understanding the importance of health insurance and working with the caseworker to identify post-foster care insurance options.
As of 2014, the Patient Protection and Affordable Care Act makes youth aging out of foster care eligible for Medicaid coverage until age 26, regardless of income. This is retroactive for young adults who used to be in foster care. Other state-specific health coverage opportunities may include low- cost health and mental health services through community health centers, student health centers, or other resource. Health Services Locators provides a list of free or low-cost government services and insurance options. Medicaid Programs by State leads to state-specific Medicaid enrollment information and Health Insurance Marketplace HealthCare.gov may be helpful to youth who no longer qualify for Medicaid.

During the numerous transitions that children in foster care experience - whether during reunification with parents or primary caregivers, adoption, guardianship, or emancipation from foster care, the primary care provider can bring a whole-child perspective of health care for these youth and work with other caregivers to ensure comprehensive health services are maintained. [American: 2012] Helping Youth Transition to Adulthood: Guidance for Foster Parents (PDF Document 680 KB) may be helpful for foster parents involved in transitioning youth.

Subspecialist Collaborations & Other Resources

The following resources may be helpful for youth transitioning out of foster care:

Mentoring (see Services below for relevant providers)

Offer access to models of care and support in times of transitions.

Career Counseling (see Services below for relevant providers)

Provide career guidance and career coaching.

College Disability Centers (see Services below for relevant providers)

Coordinate academic modifications, adjustments, auxiliary aids, adaptive technologies, and resources for academic and life planning.

Community & Adult Education (see Services below for relevant providers)

Teach academics, English as a Second Language, preparation for post-secondary training or education, and skills for success in employment.

Emergency Financial Assistance (see Services below for relevant providers)

Provide emergency assistance, which helps homeless and low-income individuals and families work toward self sufficiency.

Financial Counseling (see Services below for relevant providers)

Offer services that help to increase the financial stability of low-to-moderate income households through obtaining a livable wage and learning basic financial principles.

Shelters, Homeless (see Services below for relevant providers)

Offer shelters, programs, and services that help homeless and low-income individuals and families work toward self sufficiency.

Prescription Funding (see Services below for relevant providers)

Provide funding for pharmaceutical needs.

Health Insurance/Funding, Transition (see Services below for relevant providers)

Provide support services usually include financial assistance, food stamps, child care, and eligibility to Medicaid, UPP, PCN, and CHIP.

Dental Care Expense Assistance (see Services below for relevant providers)

Offer free or low-cost emergency care, preventive (cleanings) and periodontal maintenance, restorative care (fillings, crowns, bridges), root canals, oral surgery, and dentures or partials.

Crisis Intervention Mental Health (see Services below for relevant providers)

Provide immediate help for an array of mental health issues, including drug and alcohol abuse.

Community Advocacy Agencies (see Services below for relevant providers)

Offer representation for an array of social, legal, and cultural issues.

Educational Advocacy (see Services below for relevant providers)

Provide services designed to increase the numbers of low-income students who graduate from high school and go on to attend college.

Outpatient Community Mental Health Agencies (see Services below for relevant providers)

Provide mental health and substance abuse services.

Disability/Diagnosis-Specific Advocacy (see Services below for relevant providers)

Offer education and support through facilitation of resources for specific health conditions.

Frequently Asked Questions

What can I do to help a patient in foster care with mental health or behavioral problems?

Psychoeducation for parents, foster parents, children, and youth is powerful and reassuring. To know “I am not crazy for feeling/behaving this way” is comforting whether for the child unable to sleep due to nightmares, the youth who is agitated and can’t sit still, or the parent frustrated because the child is up in the middle of the night eating food out of the garbage can.

Can I provide a meaningful intervention in a 15-minute visit for a patient who is depressed or traumatized?

Helping depressed adolescents: a menu of cognitive-behavioral procedures for primary care offers 7 types of basic cognitive-behavioral interventions that can be provided in a 15-minute office visit. These effective interventions build on the history taking already being done. Examples include clarifying a psychosocial problem, asking the child about their feelings surrounding it, and providing empathy. Another intervention is to coach patients in how to better present themselves so they receive the responses that they really desire. This may include teaching about the impact of body posture, eye contact, speech, and tone of voice and encouraging practice techniques.

Issues Related to Foster Care

Funding & Access to Care

Advocacy

Pharmacy & Medications

Prescription Assistance Programs

Resources

Information for Clinicians

Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) (PDF Document 3.6 MB)
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of adaptive reactions to stress; American Academy of Pediatrics.

Fostering Healthy Children Program
A program of the Utah Department of Health that works to ensure ongoing health, dental and mental health care needs are provided for children in DCFS custody in Utah.

Fostering Health Online Resource Library
The Online Resource Library includes Best Practice documents, streamlined forms for exchanging information and information about the American Academy of Pediatrics’ Standards of Care for the foster care population. Assembled by the North Carolina Pediatric Society.

California Evidence-Based Clearinghouse for Child Welfare
Easy access to research about screening, assessment tools, and treatment practices for children in foster care.

Policy Statement on Use of Alcohol/Drugs, Screening/Assessment of Children in Foster Care (AACAP/CWLA)
Screening and assessment information to help assure that children at risk receive appropriate use of drug and alcohol care; American Academy of Child and Adolescent Psychiatry and the Child Welfare League of America, 2003.

Healthy Foster Care America (AAP)
Resources for children and teens in foster care and foster parents; American Academy of Pediatrics.

Learning Center for Child and Adolescent Trauma (NCTSN)
Online courses and webinars focused on child welfare issues. See particularly the 0 to 6 Child Welfare series on the left menu; National Child Traumatic Stress Network.

National Scientific Council on the Developing Child
Information about toxic stress, the science of neglect, and much more; based at Harvard University.

Improving Outcomes for Youth Transitioning out of Foster Care (PDF Document 2.7 MB)
Suggestions for how to improve outcomes for youth transitioning out of foster care.

Tackling Toxic Stress (Harvard University)
A series of articles that re-thinks services for children and families based on the science of early childhood development and an understanding of the consequences of adverse early experiences and toxic stress; Center on Developing Child.

Helpful Articles

American Academy of Pediatrics.
Helping foster and adoptive families cope with trauma: A guide for pediatricians.
American Academy of Pediatrics; (2013) http://www.aap.org/traumaguide. Accessed on 4/10/2014.
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of new, more adaptive reactions to stress.

American Academy of Pediatrics, Task Force on Health Care for Children in Foster Care.
Fostering health: health care for children and adolescents in foster care, 2nd edition.
American Academy of Pediatrics; (2005) http://www2.aap.org/fostercare/FosteringHealth.html. Accessed on 4/10/2014.
Practice parameters for primary care, developmental and mental health care, and care when child abuse and neglect are involved; downloadable as pdf.

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care provider's supporting role.

Clinical Tools

Assessment Tools/Scales

Adversities – Beliefs - Consequences (ABC) Worksheet (PDF Document 115 KB)
Helps identify the impact of thoughts and feelings, as related to adversity, on the future; adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

M-CHAT-R/F Screen (PDF Document 1 KB)
Parent-completed questionnaire designed to identify children at risk of autism. A copyrighted instrument available for free download in different languages for clinical, research, and educational purposes.

Ages and Stages Questionnaire: Developmental (ASQ-3) (Brookes)
Parent-completed questionnaire of about 30 age-related questions that screens for developmental delays between one month and 5½ years. Available for purchase from Brookes Publishing Company.

Ages and Stages Questionnaire: Social-Emotional (ASQ:SE-2) (Brookes)
Parent-completed questionnaire; series of 19 age-specific questionnaires screening communication, gross motor, fine motor, problem-solving, and personal adaptive skills; results in pass/fail score for domains. Available for a fee from Brookes Publishing Company.

Bright Futures in Practice: Mental Health—Volume II, Tool Kit (Bright Futures)
A comprehensive selections of downloadable mental health tools for health professionals and families; American Academy of Pediatrics.

SEEK Parent Screening Questionnaire (PSQ) (Univ. of MD)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions; free to download in English, Chinese, Spanish, and Vietnamese.

Patient Education & Instructions

SEEK Parent Handouts
Information for parents about depression, substance abuse, discipline, stress, intimate partner violence, and food insecurity. Includes lists of national hotlines and other resources. Customizable space to include local resources; University of Maryland School of Medicine.

Toolkits

GLAD-PC: Guidelines for Adolescent Depression - Primary Care (REACH Institute)
Comprehensive set of guidelines addressing issues in screening, diagnosis, and treatment of depression in adolescents age 10-21 - includes an extensive toolkit; Resource for Advancing Children's Health.

Mental Health Practices in Child Welfare Guidelines Toolkit (PDF Document 1020 KB)
Comprehensive, 153-page guide, including ratings of the evidence behind its recommendations. Published by the Annie E. Casey Foundation, based on Mental Health Practice Guidelines for Child Welfare: Context for Reform: A Special Issue of Child Welfare Journal (Vol. 88, No. 1).

Health Care Toolbox
Assessment, intervention, and training tools focused on helping children and families cope with illness and injury; Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia.

Other

Four Steps to Reframing Worksheet (PDF Document 94 KB)
A tool for children that helps breakdown problems into smaller steps. Adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Children in Foster Care (How Kids Develop)
Information for parents and professionals about how to identify healthy development, typical reactions and adjustment issues for children in foster care, and when to be alert that a problem needs further investigation and intervention; developed by the First 5 Commission of San Diego.

Time for Reform: Aging Out and On Their Own
Challenges of adolescents aging out of foster care systems with no permanent home or support; Pew Charitable Trusts.

Time for Reform: Preventing Youth From Aging Out On Their Own
Recommendations for policy-level changes to enhance the success of those transitioning out of foster care; Pew Charitable Trusts.

Improving Outcomes for Youth Transitioning out of Foster Care (PDF Document 2.7 MB)
Suggestions for how to improve outcomes for youth transitioning out of foster care.

Helping Youth Transition to Adulthood: Guidance for Foster Parents (PDF Document 680 KB)
Discusses the critical role of foster parents, laws, and programs supporting transitioning youth.

Support National & Local

Foster Care Alumni of America
Aims to connect the alumni community and to transform policy and practice, ensuring opportunity for people in and from foster care.

Foster Care to Success
Non-profit organization that provides scholarships, grants, living stipends, mentoring, and academic coaches for youth in foster care heading to college. Serves 3,500 people annually.

Services for Patients & Families

Career Counseling

See all Career Counseling services providers (117) in our database.

College Disability Centers

See all College Disability Centers services providers (17) in our database.

Community & Adult Education

See all Community & Adult Education services providers (180) in our database.

Community Advocacy Agencies

See all Community Advocacy Agencies services providers (39) in our database.

Crisis Intervention Mental Health

See all Crisis Intervention Mental Health services providers (87) in our database.

Dental Care Expense Assistance

See all Dental Care Expense Assistance services providers (13) in our database.

Developmental Evaluation

See all Developmental Evaluation services providers (55) in our database.

Developmental Pediatrics

See all Developmental Pediatrics services providers (5) in our database.

Disability/Diagnosis-Specific Advocacy

See all Disability/Diagnosis-Specific Advocacy services providers (111) in our database.

Early Intervention Programs

See all Early Intervention Programs services providers (52) in our database.

Educational Advocacy

See all Educational Advocacy services providers (40) in our database.

Emergency Financial Assistance

See all Emergency Financial Assistance services providers (22) in our database.

Family Support Organizations

See all Family Support Organizations services providers (7) in our database.

Financial Counseling

See all Financial Counseling services providers (42) in our database.

Foster Care

See all Foster Care services providers (68) in our database.

Head Start/Early Head Start

See all Head Start/Early Head Start services providers (57) in our database.

Health Insurance/Funding, Transition

See all Health Insurance/Funding, Transition services providers (42) in our database.

Mentoring

See all Mentoring services providers (81) in our database.

Neuropsychology

See all Neuropsychology services providers (33) in our database.

Nutrition/Dietary

See all Nutrition/Dietary services providers (53) in our database.

Occupational Therapy, Pediatric

See all Occupational Therapy, Pediatric services providers (42) in our database.

Outpatient Community Mental Health Agencies

See all Outpatient Community Mental Health Agencies services providers (75) in our database.

Pediatric Sleep Medicine

See all Pediatric Sleep Medicine services providers (3) in our database.

Preschool/Early Childhood Education

See all Preschool/Early Childhood Education services providers (80) in our database.

Prescription Funding

See all Prescription Funding services providers (38) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (28) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

Sexual Abuse Counseling

See all Sexual Abuse Counseling services providers (27) in our database.

Shelters, Homeless

See all Shelters, Homeless services providers (41) in our database.

Speech/Language Therapy

See all Speech/Language Therapy services providers (80) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Author: Kristina Hindert, MD - 4/2014
Contributing Author: Julie Steele, FNP, DNP - 4/2014
Content Last Updated: 12/2015

Bibliography

Administration on Children, Youth, and Families.
Child maltreatment 2011 (ACYF).
U.S. Department of Health and Human Services; (2012) http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2011. Accessed on 4/15/2014.

American Academy of Child and Adolescent Psychiatry.
Practice parameter on the use of psychotropic medication in children and adolescents.
J Am Acad Child Adolesc Psychiatry. 2009;48(9):961-73. PubMed abstract / Full Text
Evidence-based information about the appropriate and safe use of psychotropic medications in children and adolescents with psychiatric disorders; emphasizes the best practice principles that underlie medication prescribing.

American Academy of Pediatrics.
Helping foster and adoptive families cope with trauma: A guide for pediatricians.
American Academy of Pediatrics; (2013) http://www.aap.org/traumaguide. Accessed on 4/10/2014.
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of new, more adaptive reactions to stress.

American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care.
Health care of young children in foster care.
Pediatrics. 2002;109(3):536-41. PubMed abstract / Full Text
Practice parameters for primary health care, developmental and mental health care, child abuse and neglect, and health care management of young children in foster care.

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text
Identifies challenges and recommendations for youth aging out of foster care.

American Academy of Pediatrics, Task Force on Health Care for Children in Foster Care.
Fostering health: health care for children and adolescents in foster care, 2nd edition.
American Academy of Pediatrics; (2005) http://www2.aap.org/fostercare/FosteringHealth.html. Accessed on 4/10/2014.
Practice parameters for primary care, developmental and mental health care, and care when child abuse and neglect are involved; downloadable as pdf.

Child Welfare Information Gateway.
Foster care statistics 2013.
U.S. Dept. of Health and Human Services; (2013) http://www.acf.hhs.gov/sites/default/files/cb/afcarsreport20.pdf. Accessed on April 2014.
Sx pages of statistics about foster care.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Am J Prev Med. 1998;14(4):245-58. PubMed abstract
Describes the relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Jim Casey Youth Opportunity Initiative.
Time for reform: aging out and on their own.
Pew Charitable Trusts. 2007. / http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Foster_...
Challenges of adolescents aging out of foster care systems with no permanent home or support; Pew Charitable Trusts.

Ringeisen H, Casanueva C, Urato M, Cross T.
Special health care needs among children in the child welfare system.
Pediatrics. 2008;122(1):e232-41. PubMed abstract
Presents levels of special health care need among children in the child welfare system and how these needs may affect children's functioning.

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract
Summary of guidelines developed at the 2007 Best Practices for Mental Health Child Welfare Consensus Conference related to parent engagement and youth empowerment.

Romanelli LH, Landsverk J, Levitt JM, Leslie LK, Hurley MM, Bellonci C, Gries LT, Pecora PJ, Jensen PS.
Best practices for mental health in child welfare: screening, assessment, and treatment guidelines.
Child Welfare. 2009;88(1):163-88. PubMed abstract
Summary of guidelines developed at The 2007 Best Practices for Mental Health Child Welfare Consensus Conference in 3 key areas: screening and assessment, psychosocial interventions, and psychopharmacologic treatment.

Rubin DM, Alessandrini EA, Feudtner C, Localio AR, Hadley T.
Placement changes and emergency department visits in the first year of foster care.
Pediatrics. 2004;114(3):e354-60. PubMed abstract
Evaluates the temporal relationship between Emergency Dept. visits and placement changes and underscores the need for better health care management for foster children, particularly in the period after placement changes.

Stahmer AC, Leslie LK, Hurlburt M, Barth RP, Webb MB, Landsverk J, Zhang J.
Developmental and behavioral needs and service use for young children in child welfare.
Pediatrics. 2005;116(4):891-900. PubMed abstract / Full Text
Determines the level of developmental and behavioral need in young children entering child welfare (CW), estimates early intervention services use, and examines variation in need and service use based on age and level of involvement with CW.

Stirling J Jr, Amaya-Jackson L, Amaya-Jackson L.
Understanding the behavioral and emotional consequences of child abuse.
Pediatrics. 2008;122(3):667-73. PubMed abstract / Full Text
Assists caregivers by helping them recognize the abused or neglected child's altered responses, formulate more effective coping strategies, and mobilize available community resources.

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care provider's supporting role.

Texas Department of State Health Services and others.
Psychotropic medication utilization parameters for foster children (CMAP).
Texas Department of State Health Services; (2007) http://www.dfps.state.tx.us/documents/about/pdf/2007-01_PsychotropicMe.... Accessed on 4/15/2014.
Guidelines for the clinical management of a child who is taking, or will be taking, a psychotropic drug. To be used in the treatment of foster children who receive services through Medicaid; Texas Children’s Medication Algorithm Project.