ARTICLES
continued
Assessing
the
Health
Status
of Children
Entering
Foster
Care
Robin Chernoff, MD*; Tern Combs-Orme, PhD; Christina Risley-Curtiss, PhD; and Alice Heisler, MDII
ABSTRACT. Objective. Most research on health
prob-lems of children in foster care has been cross-sectional,
resulting in overselection of children who have been in
care long-term and underrepresentation of children who are in care for a short time.
Methodology. This paper reports on the health of a
large cohort of children who had complete health exami-nations at the time of entry into foster care in a middle-size city during a 2-year period.
Results. Results indicate that >90% of the children
had an abnormality in atleast one body system, 25% failed the vision screen, and 15% failed the hearing screen. The children were also lighter and shorter than the norm.
Mental health screening revealed that 75% had a family
history of mental illness or drug or alcohol abuse. Of chil-dren older than 3 years of age, 15% admitted to or were suspect for suicidal ideation and 7% for homicidal ide-ation. Of the children younger than 5 years of age, 23% had
abnormal or suspect results on developmental screening
examinations. At the time of entry into foster care, 12% of the children required an antibiotic. More than half needed
urgent or nonurgent referrals for medical services and, for
children >3 years of age, more than half needed urgent or nonurgent referrals for dental and mental health services. Just 12% of the children required only routine follow-up care.
Conclusions. The high prevalence and broad range of
health needs of children at the time they enter foster care necessitate the design and implementation of better mod-els of health care delivery for children in foster care.
Pediatrics 199493:594-601; foster care, health status,
5cr-vice model.
ABBREVIATIONS. FCHP, Foster Care Health Program; PNP,
-
iatric nurse practitioner; ER, emergency room; EPSDT, Early Periodic Screening, Diagnosis and Treatment.After a decline in the early 1980s, foster care
place-ments are on the rise and >500 000 children are
pre-dicted to be in foster care by 1995.1 Factors that may
be contributing to this increase include more reports
From the *),O5ion of General Pediatrics, Department of Pediatrics, The Johns Hopkins School of Medicine, Baltimore, MD; the Department of Maternal and Child Health, The Johns Hopkins University School of Hy-giene and Public Health, Baltimore, MD; the §School of Social Work, An-zona State University, Tempe, AZ; and the IDivision of Behavioral and Developmental Pediatrics, Department of Pediatrics, University of Many-land School of Medicine, Baltimore, MD.
This work was presented in part at the annual meeting of the Society for Behavioral Pediatrics, Baltimone,MD, September 22, 1991.
Received for publication Mar 31, 1993; accepted Aug 18, 1993.
Reprint requests to (R.C.) Johns Hopkins Hospital, 600 N Wolfe St. Division of General Pediatrics, C.M.S.C. #144, Baltimore, MD 21287-3144. PEDIATRICS (ISSN 0031 4005). Copyright © 1994 by the American Acad-emy of Pediatrics.
of child abuse and neglect,2 perhaps related to
in-creased rates of drug abuse and family violence1;
in-creased numbers of neonates born with in utero drug
exposure3 or prenatal exposure to human
immuno-deficiency virus4; and increased numbers of homeless
women and children.”3 These risk factors overlap,
in-teract and are further related to poverty, poor
nutni-tion, inadequate health cane, and lack of psychosocial support.5
Children in foster care have special health care
needs arising from their preplacement experiences,
the trauma of separation from parents, and placement
in foster care and their peculiar legal circumstances.6
The Adoption Assistance and Child Welfare Act of
1980 (Pub L 96-272) mandates increased efforts to
keep children in their own homes when possible.
Thus it is likely that the proportion of foster children
with health problems will increase as only children
from the most seriously deteriorated situations are
brought into care.
To meet the multiple needs of these high-risk
chil-dren and to work most effectively with the foster cane
system, the American Academy of Pediatrics
Com-mittee on Early Childhood, Adoption and Dependent
Care7 and the Child Welfare League of America8
nec-ommend a complete health assessment for all
chil-dnen entering foster cane. The Academy also
encour-ages physicians to become familiar with both the
foster care system itself and the special needs of foster children.
Currently little information exists concerning the
health status and needs of children at the time they
enter foster care. Several studies have documented
high rates of serious acute and chronic physical and
mental health problems in children in foster care.
However, most reports are based on children who are
seen weeks or months after entering care2; on a few
children’3”4; on record reviews15; on children placed
with relatives16; on a select group of children, such as
those who are human immunodeficiency
virus-positive;17 or are limited to assessments of mental
health only.12#{176}One study21 reported on a large-scale
program that systematically evaluated children with
suspected abuse and neglect. However, not all the
children in the sample entered foster care, and others
had been in foster cane for varying periods of time.
With two exceptions,13’14 this prior research on
chil-dren in foster care has been cross-sectional, resulting
in overselection of children who have been in care
long-term and underrepresentation of children who
In contrast to these cross-sectional studies of the
health needs of children in foster care, this paper
re-ports on the health of a large cohort of children at the
time of entry into foster care in a middle-size city
(Baltimore, MD) during a 2-year period (May 1989
through May 1991). Our objectives are: (1) to describe
the physical and mental health of children at the time
of entry into care; (2) to describe the number and
kinds of actions taken for identified health problems;
and (3) to contribute to ongoing efforts to develop
appropriate models for delivering health care services
to children in foster cane.
Program
METHODS
The Foster Care Health Program (FCHP), a cooperative project among the State of Maryland Department of Human Resources, the Baltimore City Department of Social Services, and the Univer-sity of Maryland Department of Pediatrics, Division of Behavioral and Developmental Pediatrics, was the result of a consent decree
effected in 1988 settling a class action law suit, L.J. v Massinga?- In
accordance with the consent decree requirements for health care of
foster children, the FCHP provided two levels of service. Level I
included a health assessment for all children within 5 days of entering foster care. Level 2 services included a comprehensive multidisciplinary assessment for children remaining in care at least 30 days to be completed within 60 days of placement. The goals at level I were to identify acute medical and mental health
problems, to treat contagious diseases, and to inform foster care
workers and foster parents of the children’s immediate and
ongo-ing health needs.
Level I services were provided in a health suite established on
the premises of the Baltimore City Department of Social Services.
Children were brought to the health suite for a complete screening
within 5 working days. Two pediatric nurse practitioners (PNPs), with a combined total of 25 years of experience with children in
Baltimore, examined the children. Their questions about treatment
or referral needs were answered by one of the supervising pedia-tncians (R.C. and A.H.), who also reviewed medical records
gen-erated at level I.
All children who were removed from their homes because of
physical or sexual abuse were first seen in an emergency room (ER) for appropriate documentation of their injuries. If abuse was
not suspected until after the child was seen in the health suite, the
child was referred to an ER for appropriate documentation,
speci-men collection, photographs, and official statements.
Children were excluded from the full level 1 service if they
were (1) healthy newborns with uncomplicated deliveries and
hospital courses, who were released directly from the hospital into
foster care; or (2) children who were placed directly into a
resi-dential treatment program in which evaluation by a physician was
part of the placement process. These children were not seen at the
health suite, but their records were reviewed and the children
were entered into the system for level 2 services.
Data were collected on all level I visits from May 1989 until
May 1991. For our sample, we used only first entries (within the sampling period) to avoid including a child in our sample twice.
We included only children with complete examinations to assure
the most complete data possible and to assure comparability of the
data for the entire sample. We included only children seen within
5 days of entry into foster care. The children seen later than 5 days included children who had been examined and treated in an ER or by a private physician, and children whose health status was influenced by their stay in foster care. Therefore, due to our
in-terest in the health status of children at entry into foster care, this
report was limited to the first level I visit of children seen for a complete examination within 5 days of entering foster care.
Data used in this report were from level I service only. They
were obtained in the normal course of service delivery as
stipu-lated in the contract between the University of Maryland Depart-ment of Pediatrics and the State of Maryland. All children were in the custody of the State of Maryland, and signed consents for medical care from the biological parents, or from the court, were
available. No additional data were collected for research purposes.
The study was approved by the appropriate Human Volunteers
Research Committee of the University of Maryland.
Data Collection
Centralization of preplacement services made it possible to collect a considerable amount of information on children enter-ing foster care. Data sources included: interviews with the pro-tective service workers who brought the child, any family
mem-ber who accompanied the child, and the child; a review of
Department of Social Service Records; and physical and mental health examinations.
Physical Health
The child’s physical health status was determined by medical
history and physical examination. Historical information included
a history of chronic illness (broadly defined by case workers);
current use of medication; and, for children <6 years of age,
im-munization status, assessed using the standards mandated by the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) schedule? The EPSDT schedule is the standard used for all chil-dren on Medical Assistance in Maryland, including all children in foster care.
The physical examination began with measurements of height,
weight, and, for children <3 years of age, head circumference.
These measurements were plotted on the National Center for Health Statistics (NCHS) growth charts for boys and girls. The
examination included an examination of all body systems. For our
purposes, an abnormality in a specific body system on physical
examination might have been as ‘minor’ as evidence of past physi-cal abuse or a current upper respiratory tract infection, or as serious as an acute abdomen or wheezing. Dental problems in-cluded orthodontic problems, plaque, severe dental caries, and missing teeth.
Vision and hearing screenings were performed on children 3 years of age and older according to EPSDT standards, as noted in the Maryland Department of Health and Mental Hygiene Provider Manual23 and using their pass/fail criteria. Vision was screened with the E or Snellen vision charts. Visual acuity of 20/40 or worse in either eye was a failure. Hearing was screened using pure-tone audiometry with test frequencies and screening levels at 1000 Hz,
2000 Hz, and 4000 Hz at 20 dB for each ear separately. Failure to
respond to any of the tested frequencies in either ear constituted a suspect/positive finding. Laboratory tests for anemia and lead
were also performed. Anemia was defined as a spun capillary
hematocnit of 32. Children < 6years of age were also screened for
lead exposure with the samples, collected by capillector using
the appropriate technique, and processed by the Maryland State Laboratory.
Mental Health
It is particularly difficult to gather accurate and meaningful information on a child’s mental health status in the midst of place-ment in foster care. We therefore considered several measures of history and functioning as measures of mental health needs. We had history from the case worker regarding: (I) family history of
mental health problems or substance abuse, (2) the child’s history
of behavioral and emotional problems, and (3) placement
circum-stances that might suggest the need for immediate mental health intervention (eg, sexual abuse).
Children deemed to have a “history of behavior problems”
included those placed in care because of disruptive behavior as well as those identified by workers as having a known history of behavior problems, even if behavior problems were not a reason
for placement. Our measure of “history of sexual abuse” included
children who were placed because of sexual abuse; children who
had prior histories of sexual abuse; and those for whom there was
suspicion of abuse, even if sexual abuse was not a reason for this placement.
Using Simmons24 as a key reference, several clinicians at the University of Maryland (child psychologists, psychiatrists, and behavioral pediatricians) developed a mental status screening in-strument for use in the comprehensive assessment at level 2. It was
the PNPs throughout the interview and included the child’s
ap-pearance, orientation to time and place, mood, speech, and
thought processes and perceptions. Each item was judged to be
normal, abnormal, or suspect. In addition, the children were asked
whether they had ever thought about hurting or killing
them-selves or about hurting or killing others. An affirmative or
suspi-cious answer generated further questions on these issues.
For children younger than 5 years of age, the PNPs measured
developmental status with the Denver Developmental Screening
Test/s For children older than 6 years of age, school history was
reviewed for grade repetition or placement in special education.
Actions Taken
In addition to referrals for routine medical care, consisting of
visits associated with the EPSDT recommended schedule of
well-child care, the PNPs made two other kinds of referrals. “Urgent”
referrals were to be acted on as soon as possible, but no later than
I week after the initial evaluation. This category included referrals
to ERs for recent, previously unsuspected, physical abuse; to
den-tists for severe dental disease; and to physicians for further
assess-ment of acute problems such as dysuria. “Nonurgent” referrals
required action within 2 to 4 weeks. These included referrals to
physicians to follow up ear infections, to evaluate the status of
chronic diseases, or to update immunizations; to dentists to repair decayed teeth; and to mental health centers to further assess the needs of children identified by history or screening as at high risk
for mental health problems. Criteria were established for referrals
for mental health services. Examples of urgent referrals would
include children with active suicidal ideation and children with a
history of recent sexual abuse. Examples of nonurgent referrals
would include children who received mental health services
be-fore entering foster care and children in whom there was evidence
of significant behavioral problems.
RESULTS Sample
Of the 2419 visits during the study, 237 were for
children reentering foster care during this 2-year
pe-nod, leaving 2182 (91 %) children receiving first level
1 visits. Of these, 1919 children (88%) were seen in the
health suite for a complete examination. We included
children whose examination took place within 5 days
of entering care: 1407 children, 73% of fully examined
first entries. This report is limited to the first level 1
visit of children seen for a complete examination
within 5 days of entering foster care.
TABLE 1. Demographics of Children in Foster Care
(n = 1407)
Variable Percent
Race
Black 84.3
White 14.2
Other 1.5
Male 51.2
Age in years*
0-.c:3 29.0
3-9Z7 20.7
7-<12 24.0
12-<19 26.3
Living arrangements before placement
Two parents 10.7
Single mother 39.9
Single father 2.9
Other relative 27.2
Mother and partner 8.9
Father and partner 0.9
Other caretaker 4.0
Unknown 5.0
*Mean age = 7.5 years.
Table 1 shows the distribution of the sample by
race, gender, age, and living arrangement before
en-tering foster care. The mean age of the sample was 7.5
years (range 3 days to 18.8 years). Although most
chil-dren were living with at least one parent before
en-tening foster care, >30% were in the care of relatives or other caretakers.
Table 2 shows the reasons for placement as noted
in social service records and according to Baltimore
City Department of Social Services criteria. Neglect
contributed to placement for about half of the
chil-dren, whereas physical abuse was cited for about one
fourth of them. Children placed because of parental
incapacity were from homes in which the parents
were physically on mentally unable to care for them
or were incarcerated. Children placed because of
“special needs” included those with a handicap on a
chronic condition that required additional attention
from a caregiver and close monitoring from medical
professionals. More than one reason for placement
was given for 46% of the children.
Physical Health
Tables 3 and 4 summarize the information on
physical health. Historical data from the case worker
or social service records show that 18% of the children
were taking some medication (on a chronic or an “as
needed” basis).
On physical examination, 92% of the children had
at least one abnormality noted in at least one body
system. Proportions with positive findings on
physi-cal examination by body system range from a high of
61 % of the children with abnormal skin examinations
to a low of 2% of the children with abnormal
neuro-logic examinations.
Vision and hearing screenings were performed on
>80% of the eligible children 3 years of age and older.
Of these, 25% failed the vision screen and 16% failed
the hearing test.
Growth parameters for children younger than 3
years of age revealed that three times the expected
number were at or below the 5th percentile for weight
and head circumference, and more than five times the
expected number of children were equal to or less
than the 5th percentile for height. For the whole
sample almost three times the expected number of
children were of short stature. We did not have
com-plete information on the children’s birth history and
could not take into account children who might have
been premature or small for gestational age.
TABLE 2. Reasons for Placement*
Reasons Number Percent
Neglect
Parental incapacity Physical abuse Abandonment
694 418 345 321
50.7 29.7 24.5 22.8
Child disruptive behavior
Sexual abuse
208
84
14.8
6.0
Child special need 58 4.1
* Figures exceed the total number of children because of multiple
TABLE 3. Physical Health of Children Entering Foster Care
Diagnosis/Problem Number* Percent
Historical data
Chronic illness 419
Current medication 249
Delayed immunization 194
(children <6 yr. n = 630)
34.6 17.7 30.8
*Of 1407 children unless otherwise noted.
Twenty-five children were found to be anemic
using a cutoff of 32 on a spun hematocnit.
Thirty-seven children had a history of elevated lead levels
before entering foster care. Although complete data
were not available on children screened by the FCHP,
at least four children were found to have class III lead
toxicity and were hospitalized for chelation therapy.
Mental Health
As Table 5 shows, most children showed some
in-dication of mental health problems or risk factors for
problems. We assessed a child to be at risk of mental
health problems in three ways. First, a child whose
family history included mental illness and/or drug
or alcohol abuse was determined to be at risk based
on that history. Second, children who had a history
of behavioral problems, mental health treatment, or
sexual abuse were judged to be at risk. Finally,
chil-dren whose behavior at the time of the interview
was suspect were considered to be at risk. Almost
75% of the children were at risk because of family
history of mental illness and/or drug or alcohol
abuse. Sexual abuse was known, or suspected, in
18% of the children.
Mental status screening was performed for about
77% of the eligible children 3 years and olden. Of
these, 15% either admitted to, or were suspect for,
suicidal ideation, and 7% admitted to, or were suspect
for, homicidal ideation.
Developmental assessments were obtained on 66%
of the eligible children 0 through 5 years of age. Based
on the interpretation of test results as described in the
Denver Developmental Screening Test manual, 23%
of the children who were tested had abnormal or
questionable test results. School placement data,
available on 80% of children 6 years of age and olden,
revealed that 40% had repeated a grade and >21%
were receiving special educational services.
Actions Taken
The FCHP was not designed to provide treatment
for illness and injury; referrals were made when
treat-ment was deemed necessary. Nevertheless, in cases
involving minor acute conditions, medications were
prescribed or recommended. An antibiotic was
pne-scnibed for 12% of children, and 21 % of children
re-ceived other treatments, including instructions for
nonprescription remedies (antipyretics, cold and
cough medicines, ointments, salves, lotions and
shampoos) or prescriptions for known medical
con-ditions (eg, asthma or anemia).
Table 6 shows the kinds of referrals made by the
PNPs. More than one third of all children required at
least one urgent referral, and more than two thirds
required at least one nonurgent referral. Of those
chil-dren needing urgent or nonungent referrals, almost
25% of the children were referred to three or more
services (not in table). Twelve percent of all children
required routine referrals only.
More than one haif of the children required urgent
or nonurgent referrals for primary medical care. Of
children ages 3 through 1 7 years, about half required
such referrals for dental care and for mental health
services. The proportion of children receiving mental
health referrals increased with age: 22% of children 3
through 6 years of age, 63% of children 7 through 12
years of age, and 77% of the teenagers required such
referrals. This increase is not surprising, because as
children age they are exposed for a longer period to
the problems that bring them into contact with the
foster care system (eg, neglect and abuse).
Children also were referred for urgent and
nonun-gent care to medical and surgical subspecialists and
for developmental assessments. Twelve children
were referred directly to a local ER (including a child
with an acute abdomen, several who were wheezing,
and several with active suicidal ideation); 93
adoles-cents were referred to gynecological/family planning
services; and 446 referrals were made to other medical
and surgical subspecialists.
DISCUSSION
This study explored the health needs of children
who received a complete screening within 5 days of
first entry into foster care during a 2-year period in
Baltimore. Although it is impossible to prove that our
selection process did not result in a biased sample, we
do not believe that it did. We can identify no
system-atic error that could have been introduced.
In this group of children, we found numerous
physical and mental health problems. Our PNPs, who
had extensive experience in Baltimore with
low-income children, were extremely capable in their
assessment of these children’s physical health. Our
findings, that 92% of the children had at least one
abnormality noted in at least one body system, may
seem high; however, it is important to recall that we
included both minor and major illnesses and
condi-tions. For example, skin problems included evidence
of current as well as prior infections, accidental or
inflicted trauma, impetigo, hives, diaper rash, birth
marks, or old surgical scars.
Although the children’s mental health needs were
not assessed using a standardized instrument, we
felt comfortable with our method of systematic
ob-senvations and a series of questions. Our purpose
was not to diagnose mental illness, but to identify
children at an early stage who might require mental
health intervention. Consistent with this purpose,
we sought a process that would be highly sensitive;
specificity was less important. The PNPs worked
closely with the consulting pediatricians when there
were questions about the physical or mental health
examination.
More than half of the children in the sample needed
urgent on nonungent referrals for medical services.
For children >3 years of age, more than half needed
Number* Percent 1288 857 405 322 193 151 146 118 113 101 86 57 32 32 205 138 533 61 107 73 106 201 91.5 60.9 28.8 22.9 13.7 10.7 10.4 8.4 8.0 7.2 6.1 4.1 2.3 2.3 25.3 15.9 37.9 15.4 27.2 18.8 7.7 14.6
* Of 1407 children unless otherwise noted. Children may not have been screened because they were too young, because they were uncooperative, or because of time constraints.
Number* Percent 281 728 482 1049 509 255 115 54 80 166 312 20.0 51.7 34.3 74.6 36.2 18.1 14.8 6.9 22.7 21.4 40.2 TABLE 4. Physical Health of Children Entering Foster Care
Diagnosis/Problem
Physical examination Any abnormal systems
Skin Nose Mouth Ears Scalp Genital Eyes Abdomen Lungs Extremity Head Heart Neurological
Vision problems (n = 808)
Hearing problems (n = 867)
Dental problems
Growth measures:
Children 0-2 y (n = 408)
Weight 5th %ile
Height 5th %ile
Head circumference 5th %ile
Children 0-18 y
Weight 5th %ile Height 5th %ile
TABLE 5. Mental Health of Children_Entering Foster Care
Diagnosis/Problem
Historical data Family history of
Mental illness Drug abuse Alcohol abuse Any of the above
History of behavioral problems History of sexual abuse
Mental status screen
Suicidal ideation (n = 775)
Homicidal ideation (n = 775) Abnormal/suspect DDSTt (n = 352) Special education (n = 777)
Grade repetition (n = 777)
* Of 1407 children unless otherwise noted. t Denver Developmental Screening Test.
about the same number for mental health services.
Our rates of referral may seem higher than would be
the case for another population of children with
simi-lan extensive health problems, particularly if those
children were seen at a primary cane model
assess-ment facility. A liberal stance toward referral for this
population was the result of our knowledge that we
would not be providing primary care for these
chil-dren; that most children did not have primary
pro-viders; and, that many would leave foster care
with-out having their health needs further addressed and
followed up if we did not refer them at the time they
entered care.
Our findings, that these children have many health
problems, are consistent with the findings of several
cross-sectional studies of children in foster cane.9’10”5’26
Several researchers10’13”5’16 also have noted that
chil-dren in foster cane have significantly more health
problems than poor children in general. Halfon et al,27
however, found that utilization of health cane services
by children in foster care in California did not differ
substantially from other Medi-Cal covered children
except for mental health service utilization. Despite
this inconsistency, there is widespread agreement
that this is a high-risk group of children with multiple
health problems. An important issue, therefore, is
who is responsible for meeting the health needs of
foster children?
Before we try to answer this, several limitations of
our study should be noted. At the time a child entered
foster care, medical history data were based on
ne-ports from protective service workers, who
fre-quently did not have access to information from a
family member. Historical data also may have been
incomplete due to the adversarial nature of many
coop-TABLE 6. Referrals for Services for Children at Entry into Foster Care
Referrals Number* Percent
Referralst
Urgent 551 39.2
Nonurgent 990 70.4
Routine only 167 11.9
Types of referrals for urgent or nonurgent care
Medical care 752 53.4
Dental (n = 999) 482 48.2
Mental health (n = 999) 552 55.2
*n = 1407
1 Urgent and nonurgent categories are not mutually exclusive.
eration from birth parents. Even when the child and
family were well known to protective services,
medi-cal information in the social service records was often
inadequate. No attempt was made to verify the
ac-curacy of historical information and in some cases no
historical data were available (eg, abandonment).
Assessing mental health needs presents additional
problems. Previous research,13”5’19’27 as well as our
own experience with children in foster care, lead us
to believe that these children are at extremely high
risk for mental health problems. The circumstances
leading to foster care placement, as well as the trauma
of placement,28 would contribute to higher rates of
numerous mental health and behavior problems.
When mental health is assessed at the time of entry
into foster care, the child may or may not be
mani-festing his or her ongoing level of functioning.
Lon-gitudmnal studies of children in foster cane are needed
to understand the relationship between the children’s
mental health needs at the time of placement and their
long-term mental health morbidity.
The FCHP was designed as a service project with
the research component added secondarily. Because
we evaluated a large number of children in foster care
and our results are similar to studies in comparable
populations, we believe that our findings are of
in-tenest and probably genenalizable to similar
popula-tions of children in foster care. We did not compare
the health needs of our sample to those of any other
group of children because it is difficult to find an
ap-propniate comparison group. We cannot say whether
the number of health problems is comparatively high,
but we suspect that this is the case.
IMPLICATIONS
When children enter foster care, the responsibility
for their health and welfare passes to the State. By
removing children from their homes, the State is
de-daring that it can cane for these children better than
they were cared for by their parents. The
responsi-bility for providing excellent care begins as soon as
the child is removed from his or hen home. Data on
the prevalence and range of health needs of children
at the time they enter foster care, therefore, have clear
implications for pediatricians as they examine
chil-dren entering foster care; for foster parents as they
care for these children; and for case workers who are
attempting to develop and implement care plans. Our
objective in this report was not only to describe the
health needs of children at the time they enter foster
care but also to contribute to ongoing efforts to
de-velop effective models for delivering health care
ser-vices to children in foster cane. These data call
atten-tion to issues that should be considered as states, in
response to litigation and to Child Welfare League of
America standards,8 design and implement new
models of health care delivery to this population. We
make the following five recommendations from our
experience:
1 . Effort should be made at the time of removal of the
child to complete a health assessment as quickly as possible.
It is clear from our findings and those of Hochstadt et
al,’3 that many of the physical and mental health
prob-lems experienced by children in foster care are present
and can be recognized at the time of placement.
More-over, like others,’ we found that 20 to 25% of children
who are placed in foster care will return home within
30 days and thus will not be available for later
as-sessment. In 1987, the American Academy of
Pediat-nics recommended that “health care interventions,
treatments and referrals should not be delayed in
an-ticipation of a brief placement.”7’P’5 Thus, the
exami-nation that is conducted at entry should be seen as a
“window of opportunity” to rapidly identify, treat,
and refer this high-risk population of children.
Failure to identify and to address medical and
men-tal health problems early not only may adversely
af-fect the foster child’s quality of life, but also may lead
to increased difficulties in adjustment to placement,
serious behavior problems and resultant placement
moves, and may compromise the family’s permanent
union when the child returns home.
2. The health examination should cover as many areas as possible. The issue of how comprehensive the initial
examination should be is a complicated one. On the
one hand, because these children are known to have
a high prevalence of medical and mental health
prob-lems, it is important for the assessment to be as
com-prehensive as possible. On the other hand, the
trau-matic circumstances at placement may limit the
number of procedures that the child can tolerate. We
believe that our decision to do as much as possible in
the original examination was a wise one. Had we
elected to do only a brief physical examination, we
might have missed children who had vision or
hear-ing deficits, were anemic, had lead toxicity, or had
medical, dental, or mental health needs that required
immediate attention.
3. More energy should be invested jn developing
sys-tems for documenting and communicating the health
Many studies of the health of children in foster care
have alluded to the serious problem of the lack of
available health information.’13’29’#{176} We have
previ-ously noted that the transiency children experience
before entering foster care, as well as their poor health care histories, and the often adversarial relationship
between the foster care agency and the parents can
result in a lack of historical data at the initial
screen-ing.6 The health care provider who examines the
fos-ten child at placement is seriously hampered by this
paucity of information. In some cases children may
have problems that go undetected and may not
re-ceive the therapy or follow-up required. In other
cases, children may suffer unnecessary tests,
thena-pies, or immunizations.
In addition to wider use of existing methods of
col-lecting data, such as the Health Passport,31 new
meth-ods may be required. For example, Starfield and
col-leagues32 are developing a system for eliciting health
histories by self-report from preadolescent and older
children. The model of a centralized unit that requests
medical records and prepares a computerized
medi-cal passport suggested by Chadwick et a133 is also
appealing.
4. Consideration should be given to providing mental
health services for all children entering foster care. Our
findings, and those of virtually every other
investi-gator who has investigated the mental health needs of
children in foster care,’3’19’ support the proposal that
all children in foster care deserve a comprehensive
mental health evaluation. In our population, based on
family history, history of behavior problems, reasons
for placement, and mental status screening during the
initial assessment, most children >3 years of age were
referred for mental health services after the level I
examination.
We recommend providing mental health services
for all children entering foster care in spite of the fact
that there is currently no evidence that therapy is
ef-fective in this population of children. Nevertheless,
we believe that it might be therapeutically useful for
all school-aged children in foster care to be referred
for short-term group therapy. This therapy could be
used for supportive purposes during the transition
into foster care and could also serve to identify those
children who need further diagnostic work and more
intensive mental health services.
We also support the recommendation of Klee et a135
that a broad spectrum of mental health care services
should be available to children in foster care. These
services should include day treatment programs,
in-fant mental health services, therapeutic nursery
ser-vices, infant and toddler development programs, and
school-age and adolescent programs. In addition,
as-sessment tools used for children entering foster cane
need to be sensitive to, and normed for, children in
crisis.
5. A system must be organized to track the children’s
health needs. Follow-up of referrals should occur whether
the child remains in foster care, returns to his or her home,
or is placed with relatives. In this high-risk population,
a large majority of the children required a nonroutine
referral. A system designed to evaluate the health
needs of children in foster cane is optimized when
there is an integrated system to track compliance with
follow-up and referrals while a child is in care.
In addition, screening children at placement creates
a dilemma-if the child returns home, does the
agency retain responsibility for following up on any
health problems that are detected? We believe so, and
we support the recommendation of the Child Welfare
League of America8 that referrals for all needed health
and mental health services should be made when a
child is discharged from foster cane to ensure
conti-nuity of health care. Others have gone further to
recommend extending eligibility and benefits for at
least I year after the child exits foster care. We suggest
that when placing a child with a relative or birth
par-ent the court, with the agency’s assistance, require the
caretaker to follow through on all health
recommen-dations and referrals. Many families will have
diffi-culty doing so without assistance. A computer system
designed to help track compliance with health
refer-rals would be useful while a child is in foster care and
for a period after the child returns home. While it may
seem financially expedient for the state to disclaim
responsibility upon return of the child to his or her
home, the long-term costs of such abdication may be
very high.
ACKNOWLEDGMENTS
This work was supported in part by support for Tern Combs-Orme by project number MCH-000106 from the Maternal and Child Health Bureau (Title V. Social Security Act), Health Re-sources and Services Administration, Department of Health and Human Services.
The authors thank Charlene Davis, Earlene Boone, Darlene Col-bert, and Emily Gonzales for their invaluable assistance.
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OUR BRIEF MOMENT OF CERTITUDE
You will all remember it, even though it lasted for only a brief period, the span
of time between the final examinations and the first week of internship. It was that
best of all possible times in our lives, the moment when we knew absolutely
everything about everything. And, for most of us, certainly for me, it was the last
moment of its kind in a professional lifetime.
Ever since, it has been one confusing ignorance after another..
Thomas L. The Fragile Species. New York: Charles Scribners; 1992.
