Prevalence and Nature of Health Problems

Neglect, abandonment, and abuse are common reasons for foster care placement. The physical and psychological consequences of physical abuse, sexual abuse, and neglect, as well as the trauma of being removed from the home, engender physical, emotional, and developmental problems. In addition, other risk factors associated with poor physical and mental health such as lack of medical care, poverty, homelessness, violence in the home, parental substance abuse, parental mental illness, and premature birth are often present.

The prevalence of health problems among children in foster care has been studied using different outcome measures and timing with respect to foster care placement. Chernoff et al evaluated the health status of 1407 children at the time of entry into care and found that 12% required routine follow-up only, whereas the remaining 88% required at least one referral for further medical, dental, or mental health care. Among the children referred for additional services, almost 25% required three or more referrals. The prevalence of chronic conditions among foster children has been estimated at between 30% and 80%, ^, and an estimated 25% of foster children have three or more chronic conditions. The health problems of foster children are multiple and complex, and they affect physical, mental and developmental health.

Chernoff et al found that 92% of children examined at a specialized clinic at the time of entry into foster care had at least one abnormality on physical examination. A medical problem was identified on history, physical examination, or screening tests among 60% of foster children examined at a San Francisco Child Protection Center. Studies have shown that respiratory problems such as asthma and upper respiratory infections as well as allergic and infectious skin conditions were among the most common physical health problems for children entering care. ^, Dental caries, pediculosis, anemia, delayed immunizations, and failed vision and hearing screens are also common. A disproportionate number of foster children are below the fifth percentile for height, weight, and head circumference. Children in foster care must be evaluated for signs of inflicted injury. Risk factors for vertically or sexually transmitted infections must also be assessed. Adolescents in foster care are more likely to engage in high-risk sexual behaviors compared with a group of adolescents not in care.

Estimates for the prevalence of developmental problems among foster children have ranged from 20% to 60%. Lack of stimulation, exposure to violence, trauma, and lack of a stable caregiver negatively affect child development. Because brain growth and development are active in infancy and childhood, children’s brains are vulnerable to environmental risk factors. Biological risk factors for developmental delay such as perinatal drug exposure, prematurity, and nutritional deficiencies can also be present. Neglected and abused children often fail to establish solid attachment to a caretaker. Attachment disorders can manifest with behaviors such as hiding food, self stimulation, and indiscrimination toward adults . Gross and fine motor skills as well as speech can also be compromised. Lack of stimulation makes it difficult to develop vocabulary and communication skills. The effect of trauma and neglect on brain development can also lead to behavioral difficulties including hypervigilence, hyperactivity, impulsiveness, apathy, and sleep disorders. School difficulties are prevalent among older children in care. In Chernoff et al’s cohort, 40% of school-aged children repeated a grade.

Research and practice have shown that foster children have a high prevalence of mental health and behavioral problems. In Pilowsky’s review of the literature from 1974 to 1994, prevalence estimates for mental health problems among foster children ranged from 29% to 96%. Experiences prior to foster care placement including abuse, neglect, and witnessing violence place children at risk for mental health problems. The experience of being removed from the home, separation from siblings, changing schools, as well as placement changes can also be traumatic. Chernoff et al found that close to 75% of their cohort of children entering care had a family history of mental illness. Traumatic experiences can result in anxiety, hypervigilence, and posttraumatic stress disorder. Depression, conduct disorder, attention deficit disorder, and oppositional defiant disorder can also be present. Chernoff et al found that 15% of children older than 3 years had suicidal ideation and 7% had homicidal ideation at the time of entry into care.

In addition to the physical and mental health problems experienced during childhood, children in foster care are at risk for long-term adverse outcomes. Foster children are at increased risk of unemployment, criminal conviction, substance abuse, lower educational attainment, homelessness, and poor mental health in adulthood. In a British cohort, adults with a history of foster care were more likely to perceive their health as poor compared with controls. A review of outcomes for youth leaving care showed that 18% to 42% had a history of incarceration.

The prevalent physical and mental health care problems of foster children are costly. A California study of Medi-Cal claims revealed a 70% greater cost per eligible child for foster children compared with other Medi-Cal eligible children. A Pennsylvania study found that expenditures for the mental health care of foster children were 11.5 times greater than those of Medicaid eligible controls, and a Florida study found that behavioral health care costs for foster children were over eight times higher than for Medicaid-enrolled nonfoster children. In addition to short-term direct health care costs, long-term physical and mental health problems also engender health care costs. As discussed previously, foster children are at risk for outcomes such as criminal conviction and substance abuse in adulthood, and ensuing indirect costs exist. Loss of productivity and loss of tax revenues also engender costs to society. The human costs of emotional and physical suffering are immeasurable.

Barriers to Health Care

The prevalence of short- and long-term health problems among foster children, as well as the high human and societal costs, delineates the need for optimal health care delivery. However, multiple barriers hinder the fulfillment of foster children’s health care needs. Despite their high need for quality coordinated and comprehensive services, foster children are underserved. A 1995 review of health services for children 36 months of age and younger in foster placement in New York, California, and Pennsylvania found that less than half had all of their health care needs met, and 19% and 32% had none or only some of the health care needs met, respectively. In addition, 12% of children in foster placement received no routine health care and 34% received no immunizations. Leslie et al studied a national U.S. sample of children ages 2 to 15 in foster care and found that a quarter of children in need of mental health services had not received them after approximately 12 months in out-of-home care. Furthermore, the need for services was not the only factor predicting whether services were obtained; young children and African American children were less likely to receive mental health services. A national study of U.S. child welfare agencies found that 57% of the agencies sampled did not provide comprehensive physical, mental, and developmental evaluations for all children entering foster care. Recent studies highlight concerning trends in the prescription of psychotropic medications for foster children. Among foster children receiving psychotropic medication in Texas, 41.3% were dispensed psychotropic medications from three or more drug classes at the same time. Furthermore, 22.2% of foster youth with concomitant psychotropic medications were prescribed two or more drugs in the same drug class. A national study of psychotropic medication use among foster youth with autism spectrum disorder found not only that foster youth were twice as likely to receive concomitant psychotropic medications compared with children on Social Security Income (SSI) but also that there was marked variation in psychotropic medication use across states.

Placement instability impedes optimal health and health care. Placement changes jeopardize the continuity of care and have been associated with poor behavioral and mental health outcomes. A study of foster children’s use of the emergency department showed that children with multiple placements were more reliant on the emergency department for ambulatory care. Rubin et al categorized children according to baseline risk for placement instability and studied the relationship between actual placement stability during the first 18 months in care and behavioral outcomes. Across all levels of baseline risk for placement instability, children with unstable placement after 18 months in care were at twice the odds for behavioral problems compared with children who achieved stable placement. Qualitative evidence also exists that placement instability is detrimental. Focus groups of adolescents who had at least 1 year in foster care reported that changes in foster homes had the most influence on mental health, and a participant likened foster care to “being tossed around like a little ball.”

Another barrier to optimal health care is a lack of information regarding children’s past medical histories. Fragmented health care from multiple providers can compound the difficulty of obtaining medical records. Lack of information can lead to the omission or duplication of health care interventions such as immunizations and screening. ^, Sharing of information among social services, physicians, foster parents, biological parents, and children is an additional challenge and can lead to miscommunication. ^, The health care needs of foster children are complex and the resources and training necessary to meet these needs are not always available. Many health care providers do not receive training specific to foster children. Providers caring for foster children require more time to address the complex needs of this population. ^, Foster parents often receive limited information about health care. A qualitative study revealed that foster parents had difficulty accessing services and had not been adequately informed of their foster child’s health care needs. Lack of financial and health care resources also impede the fulfillment of foster children’s health care needs. ^,

Policies and Guidelines

Guidelines and policies have been established in response to the complex health care needs of foster children and the obstacles impeding the provision of optimal care. U.S. federal policies address issues such as permanency, benefits, funding, performance tracking, and transitions out of care. The first federal foster care program was established in 1961 with the Aid to Families with Dependent Children Foster care program. This program, under Title IV-A of the Social Security Act, provided funds to care for children who could not safely remain with their families. However, there was little monitoring of children’s care in the child welfare system, and federal laws made finding permanent homes fiscally disadvantageous. The 1980 Adoption Assistance and Child Welfare Act (AACWA) under Title IV-E of the Social Security Act stipulated that “reasonable efforts” be made to prevent out of home placement and to reunify foster children with their families. Another change brought about by the AACWA was that foster children were made eligible for federal adoption assistance payments and Medicaid. Permanency was one of the focuses of the 1997 Adoption and Safe Families Act (ASFA). The ASFA stipulated that permanency hearings were required after no more than 12 months in care and that, with specified exceptions, termination of parental rights be initiated for children in care for 15 of the last 22 months. The safety of foster children was also addressed, requiring, for example, that states develop standards for the health of children in care and that foster homes be fully licensed in order to obtain federal funding. The ASFA identified kinship care as an option for permanent placement. The ASFA also required the Department of Health and Human Services to track and annually report on state performance.

Guidelines for the evaluation and treatment of the physical, developmental, and mental health care needs have been established by The Child Welfare League of America and the American Academy of Pediatrics (AAP). The AAP’s District II Task Force on Health Care for Children in Foster Care published a reference manual detailing guidelines for the health care of foster children.

The AAP recommends that health care services for foster children be comprised of the following components: initial health screening, comprehensive health assessment, developmental and mental health evaluation, and ongoing monitoring of health status. The Task Force on Health Care for Children in Foster Care recommends that the initial health screening be completed within 24 hours of removal with the goal of identifying health problems requiring immediate intervention. The initial health screen should include vital signs, anthropometric measurements, examination of all body surfaces unclothed for signs of abuse, inspection of the external genitalia and anus, as well as identification of acute illness and infectious diseases such as pediculosis. ^, It is important to evaluate the stability of chronic illness and to ensure that necessary medications are prescribed. ^, The initial evaluation should also include screening for developmental and mental health problems including suicidal ideation.

The comprehensive health assessment for foster children should be completed within 1 month of placement per AAP recommendations. ^, The goal of the comprehensive evaluation is to identify physical, developmental and mental health problems and to develop a treatment plan for the child. All available medical and social information should be reviewed. The complete review of systems should include the child’s adaptation to the new living environment. A thorough physical examination should include an evaluation of the child’s dentition. Clinical and laboratory screening tests should be completed as recommended by the AAP. The need for sexually transmitted infection testing and pregnancy prevention counseling should be assessed. The AAP committee on Pediatric AIDS published guidelines for the identification and treatment of HIV for infants, children, and adolescents in foster care. Establishing immunization status can be complicated by the unavailability of prior medical records. The Task Force on Health Care for Children in Foster Care recommends that if, despite every effort, the immunization record cannot be located after 60 days after placement, immunizations should be administered according to the AAP catch-up schedules. The comprehensive evaluation should result in an individualized treatment plan and referral to the necessary health services.

Comprehensive mental health and development assessments are also recommended within 30 days of placement. ^, Fine and gross motor skills, language, cognition, and social skills should be evaluated. Evaluation of suicidal ideation, affect, substance abuse, risky sexual behaviors, and prior history of trauma should be included in the mental health assessment. Finally, ongoing monitoring of health status is important not only to deliver routine pediatric care, but also to detect problems that were not apparent on initial evaluation and to assess adjustment to foster care. ^,

Models of Foster Care and Health Care Delivery

Different models of foster care have been studied with respect to their impact on health outcomes. In light of the increasing number of foster children in kinship care, ^, the advantages and disadvantages of placing children with relatives or caretakers with close family ties as opposed to with nonrelative foster parents have been debated. It has been suggested that relative caretakers receive less support and follow-up from social services. Kinship care has also been associated with delayed reunification and fewer health care services compared with nonrelative foster placements. Relative caretakers are more likely to be older, single, in poor health, and of lower socioeconomic status compared with nonrelative foster parents. ^, Stability has been highlighted as an advantage of kinship care. Research suggests that children placed with relatives are less likely to change placements. ^, Children placed with relatives experience less change in culture, religion, and family values and are more likely to remain in the same neighborhood. Studies have associated kinship care with improved behavioral outcomes. ^, A national study controlling for placement stability, reunification, and baseline risk and using the Child Behavioral Checklist as an outcome measure estimated that 32% of children in early kinship care had behavioral problems 3 years after initial placement compared with 46% of children in nonrelative foster care.

Other models of foster care include group placements and therapeutic foster homes, which can be useful for children with significant behavioral or emotional problems. Private organizations have developed foster care programs. For example, the Casey Family Programs are privately funded foster care programs offering enhanced services such as summer camps and counseling, lighter caseloads for case workers, and college scholarships for children in care. When compared with youth serviced by public foster care, graduates of the Casey Family Programs had a lower prevalence of depression, anxiety, and substance abuse on interviews conducted 1 to 13 years after leaving care.

Various solutions for the improvement of delivery and coordination of care for foster children have been proposed. The AAP recommends that child welfare agencies ensure transfer of medical information among health professionals and highlights the importance of communication between providers, child protection agencies, foster parents, and biological parents. Medical passports and electronic records have been proposed to facilitate communication and continuity of care. Different models of care have been used to service foster children, and their feasibility varies according to the local structure of the child protective services agency and available resources. Specialized clinics for foster children, clinics based in child protective agencies, and community-based care have been described. ^, A Connecticut study comparing community-based care to a specialized multidisciplinary program found that foster children serviced by the latter were more likely to be identified with mental health and developmental problems, to be referred for services, and to receive services when referred.

Older Children in Foster Care

Youth aging out of the foster require special consideration. This population is at increased risk for homelessness, lower educational attainment, poor mental health, substance abuse, and criminal justice system involvement. In a Midwestern U.S. study of emancipated foster youths, more than half were uninsured. Policies to address the needs of this population include the Foster Care Independence Act of 1999. ^, This act established the John H. Chafee Foster Care Independence Program, which provides funding for independent living activities and gives states the option to extend Medicaid coverage to age 21 for emancipated foster youth. Continued efforts to improve education, health care access, housing, and transition to independent living are needed for this high-risk population.

Directions for Future Research

A high prevalence of physical, mental, and developmental health problems among foster children has been established. New problems such as HIV have emerged since the initial studies conducted in the 1970s, underscoring the need for ongoing health status assessment for the population of foster children. Continued monitoring of health care delivery as well as of the effectiveness of policies, guidelines, and interventions aimed at improving access to care are also warranted. Further evaluation of health outcomes associated with models of foster care and health care is needed. Despite current policies and guidelines, multiple barriers to health care delivery to foster children remain, as does a need for research on the effectiveness of existing and novel solutions.

Given the growing number of children in care as well as their susceptibility to a range of health problems, many professionals will encounter the challenges and rewards of caring for foster children. The prevalence of unmet health care needs among foster children and the multiple barriers to adequate care summon advocates for individual children as well as for the foster care population as a whole.