Filling medical gaps in foster care
With more than a half million children in foster care every day in the United States, chances are that some of these vulnerable kids are your patients. How you meet their many healthcare needs can make a great difference in their lives.
Nearly all children in foster care have some sort of family dysfunction.3 Significant numbers of foster children suffer from at least 1 mental health disorder, and nearly two-thirds continue to suffer some form of neglect. Depression, social problems, anxiety, and posttraumatic stress disorder are commonly experienced by patients in foster care.2
Additionally, in 1 study nearly half of children in foster care demonstrated observable, clinical signs of mental health problems. Unfortunately, large numbers of these patients did not receive mental health services.5
The pediatrician is often asked to prescribe psychotropic medications for behavior problems, and he or she will certainly have patients on these medications. One challenge for the pediatrician is knowing whether these medications are appropriate or not, with increasing concerns of polypharmacy. Compared with children enrolled in Medicaid, psychotropic medications are 3 times more likely to be prescribed to children in foster care.3 This is particularly concerning given the patients’ needing but not receiving mental health services.
The most common drugs prescribed include antidepressants, attention-deficit/hyperactivity disorder drugs, and antipsychotic agents.6 Significant numbers of children are noted to start these medications before the age of 6 years, and there is not yet good data for long-term outcomes.7
When prescribing these medications, the pediatrician should keep the following general principles in mind:8
Begin treatment with a single agent at the lowest starting dose.
Increase dosing gradually with careful monitoring for adverse effects.
Single-agent therapy is generally the goal when possible.
The symptoms the pediatrician sees such as hyperactivity or inattention may be a result of trauma, neglect, abuse, anxiety, or depression rather than manifestations of an inattention hyperactivity disorder.
Always consider referral for a mental health evaluation any child in foster care with symptoms.
Foster children sometimes move frequently, which can inhibit their educational achievement. Whether from frequently changing schools and the resultant challenges or having credits not transferred between school systems, there are many barriers to a productive education. In 1 study, only 50% of children graduated high school while another showed that 89% achieved a GED, but at a rate 6 times that of other children. Poor educational attainment can further these children’s vulnerability and impact their future educational attainment as well as adult quality of life.2
Both missed and abnormal screenings are common among children in the foster care system. Whereas missed preventive visits often occur before entry into the foster care system, foster children often continue to fail to meet routine health maintenance benchmarks while in foster care. Examples of the chronic health conditions and failed screenings include:1
Failed vision screening.
Failed hearing screening.
Poor oral health with lack of dental screening and existing dental caries.
Failure to obtain screening for anemia and lead exposure.
Missing growth parameters such as growth failure, low height, and decreased head circumference.
Both underweight and increasingly obese.