CHAPTER 40

Health Care Needs of Children in Foster Care

Kelly Callahan, MD, MPT; ChrisAnna M. Mink, MD, FAAP; and Sara T. Stewart, MD, MPH, FAAP

The term foster care refers to the temporary placement of a child in the home of another caregiver or foster parent because of a threat to the child’s safety or well-being in the original home. Placement of a child in foster care results from an investigation of the child’s home environment by child protective services (CPS) and may be arranged via voluntary agreement of the parent or through court sanction. The foster parent may be related to the child (also known as kinship care) or may be a nonrelative. For children in voluntary placement, the biological parent retains the right to terminate the placement at any time. For those placed by legal sanction, a series of court hearings give parents, the child, and the CPS agency the opportunity to present their perspectives on the circumstances surrounding the allegations as well as their respective views on interventions to ensure the child has the best home environment.

Children in foster care may present to the primary care pediatrician soon after placement in foster care or after living with a foster parent for a long time. In either scenario, children in foster care often have a significant number of unmet medical and mental health needs because of complex psychological trauma and limited access to health care. These children have rates of medical and mental health disorders that are higher than those of children from equivalent socioeconomic backgrounds who are not in foster care. Thus, foster children should be considered part of the special needs patient population.

At the time of initial removal, the CPS worker may not be able to obtain a medical history or essential information about current medications for the child. Changes in foster care placement may interrupt continuity of care with a health professional, and frequent changes in assigned social services caseworkers can create barriers to communication among biological parents, foster parents, health professionals, and caseworkers.

Traditionally, those in the general medical community have lacked an appreciation for the complexity of the needs of this patient population. Additionally, in part because of low payment rates, it has been difficult to allot sufficient time in a “routine” office visit to complete the comprehensive evaluation these children require. For those children with identified mental health needs, often few psychiatric and psychological resources are available; this is particularly true for children younger than 5 years.

These unmet needs have long-lasting effects on the well-being of the children, even after exiting the foster care system, including into adulthood. Data have shown that the more adverse childhood experiences to which a child is exposed (eg, abuse, neglect, parental substance abuse, witnessing domestic violence; see Chapter 142), the higher the risk for heart disease, suicide, obesity, and other conditions in adulthood, including early death.

Because of their complex health care issues and vulnerability to fragmented care and adverse childhood experiences, foster children merit a medical home that provides comprehensive, multidisciplinary services and medical case management.

Epidemiology

At any point during a given year, 600,000 children in the United States spend time in foster care. Approximately 275,000 children enter the system annually. Reasons for placement, in descending order of prevalence, include neglect, physical abuse, psychological or emotional abuse, and sexual abuse. As a population, children in the foster care system come from home environments that experience high rates of poverty, parental mental illness, parental substance abuse, unemployment, adolescent parenthood, frequent involvement with the criminal justice system, and low levels of education. Foster children have high rates of exposure to domestic violence, and many are victims of neglect, physical abuse, and sexual abuse. Their biological parents often have limited parenting skills; the children experience inconsistent parenting behaviors along with minimal developmental stimulation and emotional support. All these factors combine to cause unpredictable, stressful, and unsafe home environments for these children, prompting their removal and placement into foster care. Children in foster care account for 25% to 41% of Medicaid expenditures despite representing less than 3% of all enrollees.

Foster children are of all ethnicities, but children of color are disproportionately represented. Children younger than 5 years comprise nearly one-half of the children in foster care, with those 11 to 15 years of age a distant second. In the past several decades, an increasing percentage of new entrants into foster care are infants younger than 1 year of age. Many of these infants are exposed to substances prenatally and are placed in foster care because of a combination of factors related to maternal drug use.

Approximately 70% of children leave foster care within 2 years of placement, with the average stay being 20 months. More than one-half of these children are reunited with their biological parent or primary caregiver. Six percent remain in foster care for more than 5 years, and approximately 35% of all children who leave foster care later reenter the system because of a new CPS report. Since the 1990s, the number of adoptions from foster care has increased to 20% of those leaving the child welfare system. An additional 8% of those leaving foster care emancipate out of the system by reaching 18 years of age without attaining permanent placement. Many of these teenagers later report being incarcerated or homeless at some point after emancipation. Twenty-five percent of the children in foster care will experience 3 or more placements, which results in further fragmentation of their health care and education. Multiple foster care placements are more common for those children with behavioral, emotional, or coping problems.

Clinical Presentation

Medical Issues

Children in the foster care system have been shown to have high rates of acute and chronic illness at the time of their initial medical evaluations after placement (Box 40.1). Thirty percent to 80% of children entering foster care have at least 1 medical concern, with one-third having a chronic illness. Common conditions include obesity, asthma, vision or hearing problems, neurologic disorders, gastrointestinal diseases, dental caries, and other inadequately managed chronic illnesses, such as eczema and anemia. Acute infections are also common, including respiratory tract infections, skin infections, otitis media, sexually transmitted infections (STIs), and intestinal infestations with parasites. Low immunization rates are a frequent occurrence.

Many children entering foster care have growth delay, with weight, height, or head circumference measurement less than the 5th percentile for their age. This may be caused by a combination of factors, including inadequate nutrition, environmental deprivation, prenatal alcohol exposure, genetic predisposition, and underlying illness (eg, HIV infection). Behaviors such as rumination and social withdrawal may manifest in children in environments that are chronically stressful or lack the necessary stimulation and support for a child. (For further discussion of failure to thrive, see Chapter 146.) Overweight (ie, body mass index [BMI] 85%–95% for age) and obesity (ie, BMI >95% for age) are also common among children in foster care. Depression, dysfunctional coping skills, and lack of family connectedness also contribute to suboptimal health.

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