Free Powerpoint Templates Fostering Hope: A Pediatrician’s Role in Caring for Children in Foster Care Hollie Edwards, MD Pediatric Grand Rounds November

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Fostering Hope: A Pediatrician’s Role in Caring for Children in Foster Care

Hollie Edwards, MDPediatric Grand RoundsNovember 6, 2015

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WHAT IS THE AVERAGE LENGTH OF STAY FOR A CHILD OR TEEN IN THE FOSTER CARE SYSTEM?

1 2 3 4

0% 0%0%0%

1. 5 years2. 3 years3. 1 year4. 6 months

A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR OFFICE THE DAY AFTER BEING PLACED WITH FOSTER PARENTS. YOU FIND OUT THAT

NEGLECT FROM THE BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION LED TO THE PLACEMENT. PATIENT APPEARS WELL ON

EXAM AND HAS NO KNOWN MEDICAL PROBLEMS. WHEN DO YOU NEED TO SEE HER BACK?

1 2 3 4

0% 0%0%0%

1. 1 year2. 6 months3. 2 months 4. 1 month

FOR A CHILD IN FOSTER CARE, WHO IS ABLE TO CONSENT FOR

MEDICAL PROCEDURES?

1 2 3 4 5 6

17% 17% 17%17%17%17%

1. Foster parents 2. Department of Social

Services (DSS)3. Birth parents4. 1 & 25. 2 & 36. All of the above

WHICH OF THE FOLLOWING SEQUELAE ARE TRUE CONCERNING

THE IMPACT OF TRAUMA ON A CHILD?

1 2 3 4 5 6

17% 17% 17%17%17%17%

1. Chronically elevated stress hormones

2. Development of permanent maladaptive behaviors

3. Altered development of prefrontal cortex and hippocampus

4. 1 & 25. 1 & 36. All of the above

DISCLOSURES

Neither myself nor Dr. Stephenson have any financial relationships to disclose.

OBJECTIVES

Gain overall knowledge about the process of the foster care system in America and the scope of the problem

Review existing recommendations related to the special healthcare needs of children in foster care

Become familiar with the sequelae of childhood trauma and adversity

Review frequently confused topics related to foster care and medicine

THE FOSTER CARE SYSTEM IN AMERICA

Temporary service Protection and shelter for children who

require out-of-home placement Opportunity for healing Ultimate goal- final placement in a stable,

safe, permanent, and secure living arrangement

SCOPE OF THE ISSUE

Each year, more than 3 million children are involved in investigations of abuse or neglect

Nearly 500,000 children are living in foster care on any given day

The federal government spends about $4.4 billion a year to maintain children in foster care

RACE STATISTICS

AGE STATISTICS

40% are teenagers 30% are under the age of 5 Median age entering system 6.7 years Median age currently in system 9.2 years

SOUTH CAROLINA DATA

COUNTY DATA

0-5yo 6-12yo 13-17yo 18+yo Total

Lexington 90 67 49 3 209

Richland 102 68 77 12 259

THE FOSTER CARE PROCESS

Report and Referral After Hours Reporting:

(803) 714-7444 Richland County DSS 24-Hour Hotline - protective services intake

Investigation Removal and Placement Service Planning Permanency Planning





REASONS FOR REFERRALS

Child maltreatment accounts for 70% Child neglect Sexual abuse Emotional abuse Physical abuse

Disruptive behaviors Voluntary placements, <1%

BIRTH PARENTS

79% have significantly impaired parenting skills* 31% with serious mental health problems 25% with active alcohol abuse 37% with active substance abuse 12% with cognitive impairment

*National Survey of Child and Adolescent Well-being (wave 1)








Investigation

Removal and Placement Service Planning Permanency Planning

REMOVAL IS TRAUMATIC

Even if the children came from bad circumstances, removal from family is emotionally traumatizing. This is the only world they have ever known.

TYPES OF FOSTER CARE

Family foster care Kinship foster care Pre-adoptive foster

care Congregate care

SOUTH CAROLINA PLACEMENT




Investigation Removal and Placement

Service Planning Permanency Planning




Investigation Removal and Placement Service Planning

Permanency Planning

PERMANENCY PLANNING

Options for permanent placing Reunification Adoption Guardianship to relative Emancipation from foster care system

Mandated court reviews Guardian ad litem

FOSTER CARE TEAM

Department of Social Services (DSS) Caseworkers Foster parents Birth parents Guardian ad litem Pediatricians

PEDIATRICIANS ARE A CRITICAL PART OF THE FOSTER CARE TEAM…

OVERALL GOALS FOR PEDIATRICIANS

Be a medical home Help child welfare agencies, foster families,

and birth families minimize the trauma of placement separation

Improve the child’s health and development during the period of foster care

HIGH RISK POPULATION

In 1995, a Government Accounting Office Report stated that children in foster care are “sicker than homeless children and children living in the poorest section of inner cities.”

o Compared with children from the same socioeconomic background, they have much higher rates of serious emotional and behavioral problems, chronic physical disabilities, birth defects, developmental delays, and poor school achievement.

BARRIERS TO GOOD HEALTH OUTCOMES

Lack of a medical home Lack of medical records Inadequate and delayed assessment of

needs upon entry into system Lack of follow-through in addressing

identified needs Lack of access to other health services Diffusion of authority and responsibility Health providers’ lack of knowledge about

child welfare and legal systems

NATIONAL INVOLVEMENT

AAP Council on Foster Care, Adoption, and Kinship Care

Healthy Foster Care America Child Welfare League of America (CWLA)

AAP RECOMMENDATIONS

Health screening within 72 hours of placement into foster care

A comprehensive evaluation within 30 days of placement

Follow-up health visit within 60 to 90 days of placement

Continuity of care Monthly for infants from birth to age 6 months Every 3 months for children age 6 to 24 months Twice a year for children and teens between 24

months and 21 years of age

INITIAL HEALTH SCREENING

Review the circumstances that led to placement

Monitor adjustment to foster care home

Inquire about the agency’s plans for permanency

INITIAL HEALTH SCREENING

Immunization status Review patient’s medical history Assess developmental or school progress Complete physical exam

Height, weight, head circumference All body surfaces should be unclothed Genital and anal examination

Laboratory tests when appropriate

GENERAL TIPS FOR HEALTH CARE PROFESSIONALS

Use respectful language Don’t label children or families Use the term “child in foster

care” instead of “foster child” After each visit, contact the DSS

caseworker Provide a copy of the health

summary to the caseworker and foster parent

COMPREHENSIVE EXAM

Physical health Oral health Relational health Developmental health (if under 6yo) Educational health (if over 5yo) Mental/behavioral health

PHYSICAL HEALTH

About 50% have chronic medical problems Asthma Iron deficiency anemia Obesity or FTT Enuresis and encopresis Visual and hearing loss Neurological disorders Genetic disorders Infection (STI, TB) Increased lead levels

ORAL HEALTH

Approximately 35% enter foster care with significant dental and oral health problems

Common problems: bottle tooth decay in

young children multiple dental caries in

older children AAP recommends that

every child and teen entering foster care have a dental evaluation within 30 days of placement

RELATIONAL HEALTH

Children and teens often enter foster care without a model for normal, healthy family relationships

They need to learn some of the basic principles of being a part of a healthy family

Overall, foster care is intended to allow children to develop a sense of belonging

DEVELOPMENTAL HEALTH

6x more likely to have developmental problems

60% of children <6yo enter foster care with developmental delay in at least one domain

Use validated developmental screen Referrals for PT, OT, ST May be a role for developmental pediatric

specialists

EDUCATIONAL HEALTH

Kindergarteners in foster care have half the vocabulary of their peers

Nearly half are involved in special education and of these children, half have significant behavioral problems that lead to high rates of school suspensions and missed educational opportunities

8% of young adults completed a bachelors degree compared to the general population of 24%

MENTAL/BEHAVIORAL HEALTH

30% of children in foster care vs. 4% of general population have emotional issues

5x more likely to have behavioral problems 16x more likely to carry a psychiatric

diagnosis 8x more likely to be on psychotropic

medications Consider referrals to mental health care

professionals with expertise in trauma, post-traumatic stress disorder, grief, and separation issues

o Largest unmet health need for children and teens in foster care

HOW PEDIATRICIANS CAN HELP FOSTER PARENTS

Explain health status Help access services Give advice on parenting Teach foster parents how

to cope with child’s history of trauma


Explain health status Help access services

Give advice on parenting

Teach foster parents how to cope with child’s history of trauma

STRESSORS

Change in visitation with parents Change in school or child care settings Separation from siblings Parents going to rehab or jail Court dates Another child entering/leaving the foster

home Being freed for adoption


Explain health status Help access services Give advice on parenting

Teach foster parents how to cope with child’s history of trauma

THE IMPACT OF CHILDHOOD TRAUMA

Trauma experiences such as maltreatment, violence exposure, poverty, and impaired caregiving lead to chronic elevations in stress hormones

As pediatricians, it is crucial to understand the impact of trauma on the developing brain and its translation into largely predictable emotions and behaviors

We must be able to reframe behaviors for foster parents in ways that might be helpful to them in parenting the child

PEDIATRICIANS ROLE IN CHILDHOOD TRAUMA: “TRAUMA INFORMED CARE”

Identify traumatized child

Educate families about toxic stress and the possible biological, behavioral, and social manifestations of early childhood trauma

Empower families to respond to child’s behavior in a manner that acknowledges past trauma, but promotes the learning of new, more adaptive reactions to stress

COMMON BEHAVIORS

Poor affect regulation Impulsive Hyperactive Limited attention span Inflexible Dissociation Poor self concept Act younger than they are Insecure attachment

Indiscriminately friendly Avoidant, ambivalent

Do not know difference between anger and sadness

REASONS FOR THESE COMMON BEHAVIORS

These children have developed different ways of perceiving and reacting to their world, ways that often prove maladaptive in a more normal environment

Altered neuroendocrine development

ADVICE FOR FOSTER PARENTS

Do not take these behaviors personally Help child understand your facial expression or tone Avoid yelling and aggression Come down to child’s eye level Validate their feelings Develop breathing techniques, relaxation skills, or

exercises that the child can do when getting upset Praise the child for expressing feelings or calming

down Be aware of your own emotional responses to child’s

behaviors With time, patience, and practice, the child’s brain

and body will learn more adaptive ways to respond to a new, safer environment

SPECIAL ISSUES

TRANSITIONING OUT OF FOSTER CARE AND IN TO ADULTHOOD

Importance of mentorship Major decisions Need copy of:

medical records including meds, immunizations, full history, birth, medical, and family history

emergency contact info legal form with POA health insurance card contact info for former doc, dentist, counselor birth certificate and SS card high school diploma or GED photo ID

MEDICAL CONSENT

Legal guardianship remains with birth parents unless freed for adoption

Whenever possible, the birth parents should make all important decisions and grant consent on behalf of their child

DSS also has the ability to consent for routine medical treatment

Foster parents do not have the authority to provide consent for medical procedures

When freed for adoption, birth parents no longer have any legal rights

CONFIDENTIALITY

Medical information may be shared with caseworkers and foster parents

Need to check with foster care agency before releasing information to birth parents

Once freed for adoption, may not share information with birth parents

Attorneys and court-appointed special advocates only have access to medical information through subpoena or written consent

ADVOCACY OPPORTUNITIES

Volunteering in agencies that serve children or teens in foster care

Becoming a mentor Teaching independent living skills Advocating for services and policies at the

federal and state level Starting a “backpack” program so that

children in foster care have items for school Donating to a fund that pays to enroll

children in foster care in extracurricular activities

CONCLUSIONS

The foster care system aims to uphold the health and well-being of children and teens in foster care, keep them safe, and promote stability

It is our job as pediatricians to provide high quality health services, health care coordination, and advocacy on their behalf

It is crucial to understand the impact of trauma on the developing brain and its translation into largely predictable emotions and behaviors

We must be able to reframe behaviors for foster parents in ways that might be helpful to them in parenting the child

WHAT IS THE AVERAGE LENGTH OF STAY FOR A CHILD OR TEEN IN THE FOSTER CARE SYSTEM?

1 2 3 4

0% 0%0%0%

1. 5 years2. 3 years3. 1 year4. 6 months

A HEALTHY 6 YEAR OLD FEMALE PRESENTS TO YOUR OFFICE THE DAY AFTER BEING PLACED WITH FOSTER PARENTS. YOU FIND OUT THAT

NEGLECT FROM THE BIRTH PARENTS SECONDARY TO ALCOHOL ADDICTION LED TO THE PLACEMENT. PATIENT APPEARS WELL ON

EXAM AND HAS NO KNOWN MEDICAL PROBLEMS. WHEN DO YOU NEED TO SEE HER BACK?

1 2 3 4

0% 0%0%0%

1. 1 year2. 6 months3. 2 months 4. 1 month

FOR A CHILD IN FOSTER CARE, WHO IS ABLE TO CONSENT FOR

MEDICAL PROCEDURES?

1 2 3 4 5 6

17% 17% 17%17%17%17%

1. Foster parents 2. Department of Social

Services (DSS)3. Birth parents4. 1 & 25. 2 & 36. All of the above

WHICH OF THE FOLLOWING SEQUELAE ARE TRUE CONCERNING

THE IMPACT OF TRAUMA ON A CHILD?

1 2 3 4 5 6

17% 17% 17%17%17%17%

1. Chronically elevated stress hormones

2. Development of permanent maladaptive behaviors

3. Altered development of prefrontal cortex and hippocampus

4. 1 & 25. 1 & 36. All of the above

REFERENCES Ahrens, KR. et al. Youth in foster care with adult mentors during adolescence have improved

adult outcomes. Pediatrics 2008; 121 (2): e246-e252.

“Foster Care.” American Academy of Pediatrics. Web. <www.aap.org/fostercare>.

“Smart Spending.” Casey Family Programs. Web. <http://www.casey.org/smarter-spending/>.

Committee on early childhood, adoption, and dependent care. Health care of young children in foster care. Pediatrics 2002; 109 (3): 536-540.

Greiner, MV. et al. Foster caregivers’ perspectives on the medical challenges of children placed in their care: Implications for pediatricians caring for children in foster care. Clinical Pediatrics 2015. epub ahead of print.

American Academy of Pediatrics District II New York State Task Force on Health Care for Children in Foster Care. Fostering Health: Health care for children and adolescents in foster care. Elk Grove Village, IL: American Academy of Pediatrics; 2005.

Szilagyi, M. The pediatrician and the child in foster care. Pediatrics in Review 1998; 19 (2): 39-50.

Jee, SH. et al. Foster care issues in general pediatrics. Current Opinion in Pediatrics 2008; 20 (6): 724-728.

Bruskas, D. Children in foster care: a vulnerable population at risk. Journal of Child and Adolescent Psychiatric Nursing 2008; 21 (2): 70-77.

Task Force on Health Care for Children in Foster Care. Fostering health: Health care for children and adolescents in foster care, 2nd addition. New York: American Academy of Pediatrics, 2005. Print.

Leslie, LK. Et al. Comprehensive Assessments for children entering foster care: A national perspective. Pediatrics 2003; 112 (1): 134-142.

Halfon, N. et al. Health status of children in foster care. The experience of the Center for the Vulnerable Child. Arch Pediatr Adolesc Med. 1995; 149 (4): 386-392.

Chernoff, R. et al. Assessing the health status of children entering the foster care system. Pediatrics. 1994; 93 (4): 594-601.

American Academy of Pediatrics and Dave Thomas Foundation for Adoption. Helping Foster and Adoptive families cope with trauma: A guide for pediatricians. Elk Grove Village, IL: American Academy of Pediatrics; 2013.

Schor, E. The foster care system and health status of foster children. Pediatrics 1982; 69 (5): 521-528.

QUESTIONS??

(THIS EXCLUDES DR STALLWORTH)

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Free Powerpoint Templates Fostering Hope: A Pediatrician’s Role in Caring for Children in Foster Care Hollie Edwards, MD Pediatric Grand Rounds November