DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE:

DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE:

Challenges and Strategies

Megan Tardif Vanessa Lapointe Sue Khazaie

GOALS Brief Clinical Snapshot of young children in care Brief overview of findings and recommendations from

the Fraser Region Developmental Screening Project for Young Children in Foster Care.

Review of issues that arise when considering systematic developmental screening and monitoring of children in foster care, such as: selecting an appropriate screening measure; deciding how this measure should be administered

Overview of models for implementation that are presented in the related literature with links drawn to national, provincial and local efforts.

Participants' discussion about the challenges, models, and directions for addressing the need to monitor the developmental vulnerability of children in foster care

SOME STATISTICS Very little Canadian research on this

population

Over 76,000 foster children in Canada Approximately 500 000+ foster children in

USA, with 230 000 entering foster care every year (Antoine & Fisher, 2006)

Young children are the largest group of children living in out-of-home care

SOME STATISTICS

Most common reasons for placement in care:Neglect (30-59%)Parental incapacity including substance

abuse and mental illness (30-75%)Physical abuse (9-25%)Abandonment (9-23%)Sexual abuse (2-6%)

CONTRIBUTING FACTORS

Interactive Cycle

Parental Challenges

Child Factors

Environmental Stressors

Substance abuse

Mental Illness

Intellectual Limitations

Social isolation

Domestic violence

Poverty

Unemployment

Poor nutrition

Lack of social supports

Overcrowding

Difficult Temperament

Poor Self-Regulation

Behavioral issues

Intellectual & Developmental Limitations

ISSUES PREDATING PLACEMENT IN CARE Prenatal history

Poor prenatal care Prenatal exposure

Genetic conditions Transmission of parental challenges Developmental disabilities and other

exceptionalities

ISSUES PREDATING PLACEMENT IN CARE

Abuse and/or Neglect Physical, emotional, sexual abuse victims more likely

to receive mental health services than neglect victims where standard of care is not met despite the knowledge that neglect can be more detrimental to development (Pears & Fisher, 2005)

Developmental outcomes highly impacted by maltreatment, including peer interaction, self-control, internalizing behaviors, and hyperactivity (Buehler et al., 2000; Veloz & Fordham, 2005)

Children birth to 3 highest victimization rate of child maltreatment (US Department of Health and Human Services)


Placement in care of a relative Continuation of kinship ties

Lack of significant relationship with child prior to child entering care

Preparedness to parent Life stage Pre-existing issues

Substance abuse Parental substance abuse (biological parent) is one of

the strongest predictors of foster care placement instability (5-9x)– this instability exacerbates existing behavioral difficulties (Holland & Gorey, 2004)


Experience of poor parental strategies Deficient family management skills

Harsh and inconsistent discipline

Low levels of supervision and involvement in child’s life

Lack of appropriate prosocial reinforcement

(Leslie et al., 2005)

ISSUES ARISING WITH PLACEMENT IN CARE

Loss/trauma Birth parent(s)

Siblings (Leathers & Addams, 2005)

Consideration of age at placement Change in attachment classification (to secure)

more likely and more quickly in younger children (Stovall-McClough & Dozier, 2004)


Frequent changes in care providers # of transitions directly impacts development (Pears

& Fisher, 2005)

Exacerbates existing social and emotional concerns (Newton et al., 2000)

“…most any child who has already experienced a number of lifespan traumas and then the loss of their family of origin will only be further harmed by going through a series of developed and then lost relationships with foster parents and siblings.” (p. 117-188, Holland & Gorey, 2004)


Quality of care Discontinuity in or lack of service provision

(Pasztor et al., 2006) Physician Early Intervention Services Education

As children’s skills are tied to their environment, a move to foster care can therefore suppress child performance during a screening We may initially see a child experiencing

delays who then “catches up” with time in care

CLINICAL SNAPSHOT

Children in foster care have 3 to 7 times as many health conditions, emotional problems and developmental delays

Broken down by age, one American study found that children in foster care have the following incidences of developmental or emotional problems0 - 12 months – 76%1 – 3 years, 83%3 - 5 years, 92%

CLINICAL SNAPSHOT – MEDICAL ISSUES

Among the most medically fragile children Problems begin prenatally

Prenatal exposure; maternal substance use; poverty

82% of children in care (US) had at least one chronic medical condition; 29% had 3 or more

Much higher incidence of problems associated with prenatal exposure for the population of children in foster care

CLINICAL SNAPSHOT – MEDICAL ISSUES

40% are born prematurely or have low birth weight

Congenital infection rates are higher (HIV)

Shaken baby syndrome and physical abuse

Failure to thriveMost common medical conditions

include: asthma, anemia, vision and hearing problems, and hyperphagia

CLINICAL SNAPSHOT – MENTAL HEALTH ISSUES While up to 50% of children in one study

reportedly had mental health needs, very few of them actually accessed the appropriate services due to lack of identification and/or barriers to service accessibility within the system (Leslie at al, 2000)

Other studies place the incidence of clinically diagnosable mental health issues for children in foster care at up to 90%

CLINICAL SNAPSHOT – MENTAL HEALTH ISSUES “Placement in foster care often follows an

experience of profound neglect, severe or prolonged …abuse, exposure to violence, or grossly disturbed or noncontingent input from a psychiatrically impaired or substance abusing parent. Many children have had multiple caregivers, either before or while in foster care. In the youngest cohort of children entering foster care, these adverse events occur during the most formative time for the development of self-regulation and attachment, the primary developmental task of infancy and early childhood.” (Vig et al., 2005)

CLINICAL SNAPSHOT – MENTAL HEALTH ISSUES Placement in foster care associated with

higher rates of behavior issues/disorders (Flynn & Biro, 1998)

Most common root cause of mental health problems for children in foster care is attachment disorders

These are children who have often endured multiple losses of their primary attachment figure(s)

CLINICAL SNAPSHOT – MENTAL HEALTH ISSUES

Regulatory disorders are also very common “inability to establish regular patterns in

sleep or eating, and/or to modulate emotion, attention, activity level, or aggression.

Result in significant behavioral issues


Higher incidence of sleep disorders Higher incidence of PTSD

Expect hyperarousal, hypervigilance, difficulty concentrating, developmental regression

Often over diagnosed as having ADHD when the real problem is attachment, trauma or regulatory based.

CLINICAL SNAPSHOT – MENTAL HEALTH ISSUES Exposure to higher levels of cortisol in

extremely critical period of brain development

Higher levels of cortisol created by many of the issues that predate placement in care and arise with placement in care (neglect, maltreatment, attachment, loss, trauma, etc.)

More recently, evidence that certain therapeutic interventions can actually counteract the effects of this early exposure to higher than normal levels of cortisol (e.g. Fisher et al., 2007; see also Gunnar, M. and colleagues)


Mental health services are typically more difficult to access than physical health services (Pasztor et al., 2006)

CLINICAL SNAPSHOT – DEVELOPMENTAL CHALLENGES Decreased levels of educational success

41% repeat grade 43% in Special Education (3-4x) Frequent changes in educational setting (2x) (Flynn & Biro, 1998)

CLINICAL SNAPSHOT – DEVELOPMENTAL CHALLENGES

Prevalence of developmental delay 13-80% compared to 4%-10% in general population (Halfon et al., 1995; Horowitz, Simms & Farrington, 1994; Leslie et al., 2002)

Decreased language development across all ages but worsens as as enter preschool years (up to 63% will have delays) (Halfon et al, 1995; Silver et al, 1999)

63% cognitive delays and 46% motor delays (Leslie et al, 2002)

CLINICAL SNAPSHOT

Early Interventionist PerspectiveOften start with regulation difficulties;

possibly related to prenatal factorsDifficulty with self-soothingMore likely to have extreme and sudden

changes in their emotional state (++ “unexplained” crying, tantrums)

Catch up may happen with developmental delays but social and emotional difficulties often last

DEVELOPMENTAL SCREENING PROJECT RESOURCE GROUP

Dana Brynelsen Provincial Advisor, Infant Development ProgramLorraine Aitken Provincial Advisor, Supported Child Dev. ProgramJanet Donald Office of the Child and Youth OfficerChristine Scott Director, Simon Fraser Society for Community

Living MCFD Staff:Bruce McNeill Director of Child Welfare

Deputy Director of AdoptionSusan Waldron Manager of Practice DevelopmentPat Scriven Adoption ConsultantCarol Arkinstall Guardianship ConsultantPatricia Ghobrial Guardianship ConsultantDiane Swansburg Residential Resources ConsultantSue Khazaie Early Development Consultant

FRASER REGION DEVELOPMENTAL SCREENING PROJECT FOR YOUNG CHILDREN IN FOSTER CARE

1. Targeted children-in-care in the Fraser Region in March 2005

• not recently screened & not currently receiving services

2. Foster/birth parents completed developmental screening inventories:

Ages and Stages Questionnaire (ASQ)

Ages and Stages Questionnaire: Socioemotional (ASQ:SE)• Parent administered• Valid and reliable estimates of children’s developmental

status• Commonly used to monitor high-risk populations• Several domains

ASQ: fine motor, gross motor, communication, problem solving, personal-social

ASQ:SE: Self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people)

FRASER REGION DEVELOPMENTAL SCREENING PROJECT FOR YOUNG CHILDREN IN FOSTER CARE

3. Screening results computed

4. Follow-up visit from experienced interventionist• Referrals for further assessment• Referrals for developmental supports

TARGET SAMPLE

14%

21%

3%

62%

already receiving services

over age five

no longer in care/moved

received packages

Children in Foster Care in Fraser Region, March 2005 N = 454

TARGET SAMPLEDATA COLLECTION CHALLENGES

14%

20%

3%

20%2%

18%

2%2%

19%

already receiving services

over age five

no longer in care/moved

already receiving services(after)

over age five (after)

no longer in care/moved(after)

recently received services(after)

insufficient information tocontact (after)

Completed packages

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RESULTS% of sample at-risk

58%

5%

37% At-risk

Borderline scores/foster parentconcern

Not at-risk

“INTENSITY” OF RISK

Scope of Risk

32%

26%5%

37%

At-risk in 2 or more domains

At-risk in 1 domain

Borderline scores/fosterparent concern

Not at-risk

DOMAIN OF RISK

Prevalence of Risk By Domain

0

5

10

15

20

25

30

35

Communication Gross Motor Fine Motor Problem Solving Personal-Social Social-emotional

Domain

%

FOLLOW-UP AND HOME VISITS Foster parents with children receiving at-risk

scores were contacted within 4 weeks Follow-up visit arranged 55 children flagged for follow-up

19 home visits completed 3 children with borderline scores had notable

improvement so no home visit required 26 already receiving services when contacted for

home visit 7 no longer in care, moved, over age 5,no longer

concerns/received services

FOLLOW-UP AND HOME VISITS Experienced early interventionist that worked

in the geographical area where flagged foster child resided visited the involved family

Reviewed screening results Established concerns Discussed/facilitated appropriate referrals Provided suggestions to encourage further

development in at-risk areas

Intervention plan devised, completed and returned to social worker

FOLLOW-UP AND HOME VISITS 19 home visits completed

14 children for whom referrals for developmental supports were made or recommended

These 14 children had 34 referrals for early development services/supports made and an additional 10 recommendations for services and supports

4 additional families received telephone consultation

PROJECT RECOMMENDATIONS

1. Systematic developmental screening and surveillance program to be developed and implemented for all young children in foster care

Appropriate tool Face-to-face Foster parent training to include information about

screening, referral and community services Time lines for screening and referral Immediate and regular involvement with a

pediatrician


2. Once identified, timely early intervention services and therapy without wait times for children in care. These services and supports should be portable with the child.


3. Information should be tracked and readily available regarding a child’s:

Developmental status Services and supports involved Foster parent information Guardianship and resource worker information

Recommendations from Literature

The American Academy of Pediatrics and the Child Welfare League of America have published guidelines relevant to the health supervision of children in care. Among these are:

Initial medical visit within 24 hours of placement A comprehensive follow-up visit within 30 days of

placement Routine screening for development, mental health,

dental health and sexually transmitted infections In Canada, there remains no practice guidelines

specifically designed to meet the health care needs of children and youth in foster care. (Paediatrics & Child Health, 2008)

Fraser Region Early Childhood Screening Program Year 1 – Children in Care

Partnership between Fraser Health and Ministry of Children and Family Development

Fraser Health started with the dollars for vision screening program for 3 year olds

Linked this to hearing, dental and developmental screening at 18 months and 3 years

Year 1 are piloting this program for children in foster care

In the first 4 months, there have been 40 children screened in the Region

Overall 69% of children required referral for further evaluation in at least one facet of the screening

(Early Childhood Screening Program May 2008)

Every Child Matters:“Looked After Children” - UK Developed after the 2003 Victoria Climbié inquiry 108 recommendations were made by Lord Laming

Every Child Matters:“Looked After Children” - UK At the heart of the recommendations was interagency

coordination and communication Care for children in care is managed within each

Primary Care Trust (PCT) The Children Act 2004 gives a particular role to Local

Authorities in setting up the arrangements to secure co-operation among local partners, such as Primary Care Trusts, Youth Offending Teams, the Police Service, District Councils and others

Children are systematically tracked, screened and monitored over time

Thanks to: Elaine Offler, CHN Maple Ridge and Pam Munro, RN, BScN, MSN Clinical Nurse Specialist Community Child and Youth Health Promotion and Prevention Fraser Health

Documents

DEVELOPMENTAL SCREENING AND MONITORING OF CHILDREN IN FOSTER CARE: