Health care of young children in foster care

Greater numbers of infants and young children with increasingly complicated and serious physical, mental health, and developmental problems are being placed in foster care. All children in foster care need to receive initial health screenings and comprehensive assessments of their medical, mental, dental health, and developmental status. Results of these assessments must be included in the court-approved social services plan and should be linked to the provision of individualized comprehensive care that is continuous and part of a medical home. Pediatricians have an important role in all aspects of the foster care system.     

Emergency department utilization by children in foster care.

OBJECTIVE: To examine emergency department (ED) utilization of children in foster care using nationally representative data. METHODS: Cross-sectional analysis of the National Survey of Child and Adolescent Well-Being, Wave 1, which provided data for children ages 1 to 14 years in foster care for 1 year between October 1999 and December 2000. We identified children as having used the ED based upon foster parent responses to the question, "In the last 12 months, has your child gone to an emergency room or urgent care center (UCC) for an illness or injury?" We examined child and family demographic variables that were associated with having used the ED. RESULTS: The sample included 559 children in foster care. Thirty-one percent (95% confidence interval = 26%, 36%) of foster children had visited the ED or UCC in the past 12 months. Multivariate logistic regression analysis revealed that out of all children in foster care, children who had a chronic condition, children of younger age, and children with younger foster caregivers were significantly more likely to have used the ED. CONCLUSION: A sizeable proportion of children in foster care use the ED, and subgroups of these children have particularly high rates of ED use. An important component of providing a medical home for children in foster care should involve coordination of care around ED visits for this vulnerable group of children.     

Mental health care utilization and expenditures by children in foster care

OBJECTIVE: To determine the percentage of children with mental health diagnoses and utilization and expenditures of mental health services among children in foster care compared with other children receiving Medicaid, including those with disabilities. DESIGN: Analysis of Medicaid claim and eligibility records in southwestern Pennsylvania for fiscal year 1995. POPULATION: A total of 39,500 children between ages 5 and 17 years continuously eligible for Medicaid in southwestern Pennsylvania were included in the analysis. MAIN OUTCOME MEASURES: Percentage of children with mental health diagnoses and mental and general health care utilization and expenditures classified by participation in foster care and Medicaid eligibility. RESULTS: Children in foster care were 3 to 10 times more likely to receive a mental health diagnosis, had 6.5 times more mental health claims, were 7.5 times more likely to be hospitalized for a mental health condition, and had mental health expenditures that were 11.5 times greater ($2082 vs $181) than children in the Aid to Families With Dependent Children (AFDC) program. Overall, utilization rates, expenditures, and prevalence of psychiatric conditions for children in foster care were comparable with those of children with disabilities. CONCLUSIONS: Children in foster care are significantly more likely to suffer from mental health conditions and use more mental health and general health services than AFDC children. Service use and expenditures are comparable with those of disabled children, suggesting that reimbursement rates and care management for children in foster care need to be reexamined.     

The foster care clinic: a community program to identify treatment needs of children in foster care

A community-based multiagency and multidisciplinary clinic was developed to perform comprehensive evaluations of preschool children in foster care. One hundred thirteen children, ages 1 month to 6 years old, were seen during the first 2 years. Forty-seven percent of the children were known to the social service agency from birth; however, the mean age at placement was 19 months. Fifty-seven percent of the children were in their first foster home at the time of their initial evaluation, but 17% has already been placed in three or more homes. Behavioral problems were found in 39% of the children, and chronic medical problems in 35%. Sixty-one percent of the children were delayed in one or more portions of the developmental assessment. Developmental delay was associated with older age. Sixty percent of the children with developmental delays were not involved in any community educational or therapeutic program, although they had been in foster care for a mean of 6 months. Because of the high mobility of this population, continuity of care by social workers, foster parents, and physicians is hard to achieve. The evaluation model developed by the clinic appears to facilitate the identification of children in need of additional services, enhances cooperation between various community agencies, and provides a constant site for monitoring the status and progress of children in foster care.     

Effects of a foster parent training intervention on placement changes of children in foster care

Placement disruptions undermine efforts of child welfare agencies to promote safety, permanency, and child well-being. Child behavior problems significantly contribute to placement changes. The aims of this investigation were to examine the impact of a foster parent training and support intervention (KEEP) on placement changes and to determine whether the intervention mitigates placement disruption risks associated with children's placement histories. The sample included 700 families with children between ages 5 and 12 years, from a variety of ethnic backgrounds. Families were randomly assigned to the intervention or control condition. The number of prior placements was predictive of negative exits from current foster placements. The intervention increased chances of a positive exit (e.g., parent/child reunification) and mitigated the risk-enhancing effect of a history of multiple placements. Incorporating intervention approaches based on a parent management training model into child welfare services may improve placement outcomes for children in foster care.     

Improving resources for foster care.

The number of foster children and their psychological and medical morbidity are growing. To gain insight into how to recruit and retain foster homes, characteristics of 64 foster families were determined by interview. Foster parents had low-to-moderate incomes, were approaching middle age, had underutilized home space, and wanted more children. Most enjoyed foster care and planned to continue. Twenty-three percent of the 64 had half of all foster children in the study in their homes at interview and had cared for seven times as many children in the past, including 66% of all the teens and 83% of all the handicapped children who had been in the 64 homes. These "high providers" functioned like group homes for mentally handicapped individuals. Adapting the group-home concept to foster homes could improve care, especially for children with special needs.     

The experience of foster care: relationship between foster parent disciplinary approaches and aggression in a sample of young foster children

The relationship between disciplinary practices of 70 foster parents (kin and nonkin) and aggression in their 8-year-old foster children was examined. Aggressive behavior was assessed through child and foster parent reports, whereas disciplinary behavior was examined by asking foster parents how they would typically respond to five child misbehaviors. Kinship foster parents (64.8%) were significantly more likely than nonkinship foster parents (30.2%) to report that they would use harsh discipline (p < .01). No significant relationship was found between foster parent reports of child aggression and their reports of disciplinary behavior. However, foster parents who reported they would use harsher discipline were more likely to have children in their care who generated multiple aggressive solutions to social problems (odds ratio = 2.7, p < .01). The evidence suggesting that the disciplinary practices of foster parents may influence children's social aggression is discussed in relation to future research, policy, and interventions.     

Willingness of eye care practices to evaluate children and accept Medicaid.

BACKGROUND: The willingness of eye care providers to evaluate children or to accept Medicaid may be a barrier to care for those with an abnormal screen. OBJECTIVES: To determine the proportion of eye care practices that would provide diagnostic evaluation for children and accept Medicaid payment and to evaluate the influence of child age and practice characteristics on provision of care or acceptance of Medicaid. METHODS: We conducted a telephone survey of 364 eye care practices in Michigan, which were randomly selected from telephone directories of 26 rural and urban cities as defined by metropolitan statistical areas. RESULTS: The response rate was 93%. Most eye care practices, but more optometry-listed practices than ophthalmology-listed ones, would evaluate preschool-aged children (88% vs 73%; P <.01) or school-aged children only (11% vs 7%; P <.01). The proportion of practices willing to evaluate preschool-aged children was lower in urban cities compared with rural cities for optometry-listed (83% vs 96%; P <.01) and ophthalmology-listed practices (67% vs 93%; P <.01). Medicaid acceptance among practices that would evaluate children was higher among ophthalmology-listed than optometry-listed practices (74% vs 59%; P =.01) and did not vary by urban or rural status. Practice size was not associated with willingness to provide care for children. However, among practices that would provide care for children, larger practice size was associated with increased odds of Medicaid acceptance in both optometry-listed and ophthalmology-listed practices. CONCLUSIONS: These findings contradict the perception that eye care for children is unavailable. More work is needed to understand the relationship of this availability with the accessibility of eye care.     

Addressing the developmental and mental health needs of young children in foster care

Research over the past two decades has consistently documented the high rates of young children entering the child protective services/child welfare system with developmental and mental health problems. There is an emerging evidence base for the role of early intervention services in improving outcomes for children with developmental and mental health problems in the general population that heavily relies on accurate and appropriate screening and assessment practices. The Child Welfare League of America, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry have all published guidelines concerning the importance of comprehensive assessments and appropriate referral to early intervention services for children entering out-of-home care. Recent federal legislation (P.L. 108-36) calls for increased collaboration between child welfare and public agencies to address the developmental and mental health needs of young children in foster care. This paper provides a framework for health, developmental, and mental health professionals seeking to partner with child welfare to develop and implement programs addressing these critical issues.     

Relationship between reason for placement and medical findings among children in foster care

OBJECTIVE: To determine the reasons for placement of children in foster care, the prevalence of medical findings during initial placement, and the relationship between reason for placement and medical findings. The association between placement reasons and parental substance abuse also was explored. METHODS: Population-based analysis of medical records of 749 children examined at the Child Protection Center in San Francisco from October 1, 1991, to December 31, 1992. Health evaluations consisted of a clearance examination of children during entry into foster care and a comprehensive examination 3 weeks later. Reasons for foster placement included abandonment, neglect, no available caretaker, physical abuse, sexual abuse, and failed placement. RESULTS: Nearly 50% of children in our study were < 6 years of age. Neglect (30%), physical abuse (25%), and no available caretaker (24%) were the most frequent placement reasons, followed by abandonment (9%), failed placement (7%), and sexual abuse (5%). Substance abuse was documented in 30% of parents, 51% when the placement reason was neglect. Medical findings were identified in 60% of children. Among 0 to 6-year-olds, 27% had upper respiratory illnesses, 23% had developmental delay, and 21% had skin conditions; for children 7 to 12 years of age, 32% failed vision screening, 12% had dental caries, and 11% had upper respiratory illnesses; and among 13- to 18-year-olds, 31% failed vision screening and 12% had positive tuberculin skin tests. For younger children, skin conditions were associated with neglect, no available care taker, and failed placement, and developmental delay with neglect and abandonment. For adolescents, history of psychiatric illness was associated with neglect and failed placement. Marks of abuse for all age groups were limited to children who had been physically abused. Three or more diagnoses were identified for approximately 20% of children who had been neglected or abandoned or had failed placement, compared with 10% of children who had been either physically or sexually abused. CONCLUSIONS: Specific medical findings associated with reasons for placement provide health professionals with additional information to assess more accurately the health care needs of children entering foster care. As important, screening tests revealed high rates of vision problems and exposures to tuberculosis, warranting earlier and more comprehensive screening. Finally, children who have endured variations of neglect or failed placement may have more health problems than anticipated previously.     

Comparison of preventive care in Medicaid managed care and Medicaid fee for service in institutions and private practices.

OBJECTIVE: To compare preventive screening for children in Medicaid managed care (MMC) with children in Medicaid fee for service (M-FFS) in private and institutional settings. METHODS: The sample included randomly selected institutions and private practice physicians in New York City. Within setting, children in MMC and M-FFS were sampled randomly and charts reviewed for immunizations and lead and anemia screening. RESULTS: In both institutions and private practices, children enrolled in MMC appeared more likely to be up-to-date than their M-FFS counterparts for immunizations (institution, P <.01; private practice, P <.05), lead screening (institution, P <.01; private practice, P <.01), and anemia screening (institution, P <.01; private practice, P <.01). However, children in MMC had more visits (P <.01) and were followed up for a longer time (P <.01). After controlling for these variables, effects of MMC diminished and only remained significant for screening among private physicians. When considering 10 different attributes of managed care plans, no clear pattern of association with better preventive care services was observed. CONCLUSION: The positive effect of managed care on preventive care services was largely explained by more visits and longer follow-up time; however, there were differences between institutions and private practices, with enrollment in MMC associated with some positive effect on screenings in private practices.