Foster Care
Moira Szilagyi
I. Description of the problem. Foster care is government subsidized and regulated temporary care for children who have been removed from their families for reasons of abuse and neglect. The goals of foster care are health, safety, and permanent caretaking for children. The main types of care are family foster care, placement with relatives (kinship care), and residential group care. For brevity, the term foster care will be used for all three types of care.
A. Epidemiology. (See Table 96-1.)
B. Contributory factors. Children entering foster care have typically endured multiple and chronic adverse life experiences, including abuse and neglect, inconsistent and chaotic parenting from multiple caregivers, severe emotional and financial deprivation, and limited access to appropriate services. Removal from their families and all that is familiar is often a traumatizing event and the uncertainty inherent in the foster care system may further erode a child’s sense of well-being. The impact of foster care on individual children depends on their personal strengths and coping skills, prior life experiences, developmental abilities, and the availability of protective environmental factors.
II. Identifying problems.
A. General issues.
1. The periodicity schedule of the American Academy of Pediatrics (AAP) for child health supervision may need to be adjusted to reflect the more intensive support and monitoring necessary because of the many junctures in foster care that may adversely affect a child’s health and well-being. A checklist that includes the crucial aspects of the health assessment and healthcare for children in foster care is available through the AAP (www.aap.org/advocacy/HFCA).
2. Intensive healthcare management to guarantee access to an appropriate array of developmental, mental health care, medical, and dental services is essential to good health outcomes for children in foster care.
3. The single greatest health need of children in foster care is for mental health care services and support.
B. Specific issues. Healthcare practitioners should consider children in foster care as a population with special healthcare needs.
1. Primary pediatric care. Children in foster care should have a “medical home.” The AAP recommends visits
Monthly until 6 months of age, particularly if born prematurely
Every 3 months from 6 to 24 months of age
Every 6 months from 24 months to 21 years
Primary care clinicians should address the adjustment of the child to the foster care placement, emotional and behavioral issues, school functioning, and the capacities of all the child’s families to meet the child’s needs. As thorough a history should be taken as possible to include information about the child’s reason for placement, legal status, and the names and roles of the child welfare workers who are responsible for the child (e.g., foster parents, caseworker, law guardian). On physical examination, it is important to follow-up growth parameters, skin findings, and vision, hearing, dental, musculoskeletal, and neurological assessment. Clear communication and collaboration with the other professionals involved in the child’s care is essential. Frequent follow-up visits and a high index of suspicion for emotional and psychological problems are fundamental to providing appropriate healthcare for this population.
Mental health is the most significant health concern for children and adolescents in foster care. Children in foster care may have to deal with issues of separation and loss and may feel unloved or abandoned by their parents or experience anger, anxiety, and depression. It may help children to describe their parents as unable, rather than unwilling, to care for them. Children with a history of maltreatment may have extreme behaviors and difficulty trusting others. Clinicians can play a valuable
role by supporting and educating foster parents and engaging the child in a consistent and caring manner during more frequent office visits.
Table 96-1. Dimensions of foster care
Relevance
A total of 542,000 children are in foster care (an increase of 90% since 1982); 130,000 freed for adoption, about half of whom are in preadoptive placement
Types of care
72% in regular (including kinship) care
18% in group or residential care
8% in other arrangements
Age of foster children
4% infants
24% 1-5 years of age
24% 6-10 years of age
41% teenagers
Race; ethnicity of foster children
37% white, non-Hispanic
38% African American, non-Hispanic
17% Latino
6% Other
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