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.
Medical evaluation of a child in foster care
The pediatrician often will need to assess a child’s healthcare needs with little or no available health history. Guidelines for the appropriate care of the foster child are available in the AAP document Fostering Health: Health Care for Children and Adolescents in Foster Care (available at bit.ly/AAP-fostering-health)9 and the Child Welfare League of America (CWLA) Standards of Excellence for Health Care Services for Children in Out-of-Home Care (bit.ly/CWLA-standards-excellence).nIn general, the foster child should have 3 visits over the first 3 months (Table3,8). The pediatrician will need to support and educate the foster child, caregivers, and child welfare workers throughout the entire process as well as continue to monitor for any signs of abuse and neglect.
Within 30 days, the foster child should undergo a comprehensive assessment wherein the pediatrician is able to review all health records including developmental and mental health assessments. The pediatrician should assess how well the child is adapting to foster care and perform any appropriate screenings and developmental assessments. Approximately 60 to 90 days after placement, the child should be seen again to review health, mental health, and developmental issues as well as assess how well the child is adapting to his or her new environment.3
There are also several extra visits in addition to the general guidelines outlined in Bright Futures.10 Infants should be seen monthly between their regularly scheduled preventive visits for the first 6 months of life as well as have an additional visit at 21 months. From age 2 to 21 months, it is recommended that the foster child be seen every 6 months. The pediatrician is monitoring growth and development, assessing adjustment to placement, and monitoring any chronic medical problems as well as being alert for the development of any mental health issues.8
The pediatrician should consider a full mental health evaluation, but that may not be available in all communities. Instead, he or she could consider using an age-appropriate screening tool such as the Strengths and Difficulties Questionaire11,12 or the Early Childhood Screening Assessment.13 The AAP has a mental health toolkit (bit.ly/AAP-mental-health-toolkit) that discusses many of the available tools. Another tool for the pediatrician is the list of evidence-based mental health services for children in foster care published by the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org/).
Adolescents as a special population
Adolescents in foster care are at increased risk of poor educational outcomes with significantly higher dropout rates compared with other low-income and minority populations. Additionally, only 50% of foster children graduate from high school, and many of these are with an equivalency certificate.3
Because of potential exposures to substance abuse, physical and sexual abuse, violence, and neglect, youth in foster care have a number of risk factors associated with sexually transmitted infections (STI). In fact, foster youth appear to be at increased risk of documented STIs (females, Trichomonas; males both gonorrhea and chlamydia) compared with children not in foster care.14