Children and adolescents living in foster care are a vulnerable population with unique healthcare needs. According to the U.S. Department of Health & Human Services (2012), in any given year, approximately 500,000 American children are living in foster care. It is estimated that, in 2011, approximately 247,000 children in the United States entered foster care and 240,000 exited care. Most children enter foster care because of neglect (50%-60%), physical abuse (20%-25%), and sexual abuse (10%-15%; U.S. Department of Health & Human Services, U.S. Department of Education, & U.S. Department of Justice, 2000). Children in foster care have distinct healthcare needs. However, more often than not, these children are receiving health care in a general pediatric or family practice clinic or practice, rather than a specialized clinic designed to meet their special needs. By virtue of their specialized education and training in pediatrics, and the variety of settings in which they interface with children, forensic nurses are in a unique position to advocate for children in foster care. Forensic nurses are involved with the assessment of children in foster care for concerns of child maltreatment (sexual abuse, physical abuse, and neglect), providing screening physical assessments for children entering into foster care, and working in settings designed to provide ongoing care to children. Moreover, it is hoped that, through reading this article, forensic nurses and advanced practice forensic nurses working with children in foster care will more fully understand their healthcare needs, and as a result, be in a better position to develop interventions to appropriately meet their unique needs.
Foster Care System
It is important for forensic nurses working in pediatrics to understand basic roles and processes unique to the foster care system. Decisions to remove children from their homes are never made lightly. These decisions are made by child protective services (CPS) and supported by the court when factors in homes are so deplorable that removal is the only way to insure their well-being and safety. Some parents may be unwilling or unable to provide a safe and healthy home for their children and voluntarily place their children in foster care.
The setting for foster care can vary based upon the availability of foster caregivers and the emotional or physical needs of the children requiring care. Foster care settings can include any of the following: kinship care, home-based foster care, treatment foster care, residential/group home, or inpatient admission (MacDonald & Turner, 2008). Kinship care is placement in a relative's home with CPS maintaining custody and is considered the optimal placement. Such arrangements are considered optimal as the children are living with a relative whom CPS has determined to be capable of safely caring for them; however, no financial assistance is provided by the state (Rubin et al., 2008). Home-based foster care is defined by placement in a home with at least one caregiving foster parent. Treatment foster care is a home-based foster home placement where foster parents have received additional training to better cope with foster children whose emotional or behavioral difficulties place them at increased risk for placement disruption (MacDonald & Turner, 2008). Children or teens may be placed in residential/group homes because of no available foster homes, specific behavioral concerns of the child, or the choice of the child (usually older teens). Inpatient treatment admission is reserved for those children with psychiatric/behavioral concerns in need of immediate intense treatment.
Federal legislation determines patterns of funding and regulatory guidelines for the care of children in foster care, but it is up to state social service agencies to implement the foster care program within each state (Szilagyi, 2012). Daily management of foster care may be delegated to county or private child welfare agencies. The Fostering Connections to Success and Increasing Adoptions Act of 2008 requires state child protective agencies, Medicaid departments, and pediatric health experts to work together to develop health systems for children in foster care (Hayek et al., 2013). Specifically, the legislation aims to improve healthcare coordination, promote the use of medical homes, mandate mental health assessments, and measure health outcomes. This legislation also mandates foster care agencies to identify appropriate kinship resources when children enter into foster care to support children being cared for by kinship providers versus foster parents.
CPS caseworkers play an integral role within the foster care system. It is a difficult job requiring multiple skills but, in reality, is often an entry-level job requiring no more than 2 years of college education in some agencies (Szilagyi, 2012). Caseworkers function as case managers for biological families, and it is their responsibility to develop case plans that parents must complete, demonstrating their ability to safely and adequately care for their children. It is the responsibility of caseworkers to assist biological parents in securing whatever services or resources are needed to complete their case plans (housing, parenting education, mental health treatment, substance abuse treatment). Caseworkers must also coordinate services for the children (educational, health, developmental, and mental health) and support the foster parent in the care of the children. Caseworkers must also be knowledgeable regarding their state legal system particularly family court and the juvenile justice system. Caseworkers, with the input of their CPS supervisors, make the initial decision to remove children from their homes to insure their safety. It then becomes the responsibility of caseworkers to prepare court petitions within 72 hours of the child's removal from the home and to document the reasons for removal. Caseworkers must return to court at designated intervals to document the need for ongoing placement of children and discuss their own efforts to aid parents toward reunification (Landers, Snyder, & Zhou, 2013).
The legal system also plays a pivotal role in the foster care system. Once children enter foster care, it becomes the responsibility of family court judges to decide if children remain in foster care after hearing the information presented to them in court by CPS and parents. Family court judges are also responsible for ordering the services (case plan), which biological parents must meet to reunify with their children, and then rehearing cases at set intervals to determine the needs for continued foster care, returning to biological homes, or alternative permanency arrangements. Court decisions for permanency are difficult decisions made based on the input of attorneys, all caregivers, guardian ad litems, child welfare agencies, mental health professionals, and the children (if age and development allow; Szilagyi, 2012). Permanency decisions essentially sever all parental rights of biological parents and allow children to be legally adopted. Children in foster care are represented by a guardian ad litem at all court hearings (Szilagyi, 2012). The guardian ad litem may or may not be an attorney and is appointed by the court. The guardian ad litem is a neutral party who meets with parents, children, and other involved parties to form an opinion regarding what is best for the children and presents this opinion to the court.
Foster parents are essential to the foster care system. Foster parents come from all walks of life but are more likely to be married, to be in lower middle class, have at least a high school education, to be employed, and have children of their own (Szilagyi, 2012). An increasing number of same sex partners are fostering children, and some individuals foster with the hope of ultimately adopting children. Foster parents are trained, monitored, and annually recertified by child welfare agencies. Reimbursement for foster parenting varies but often times only covers approximately two thirds of the cost of parenting children.
Most children in foster care have visits with the biological parent(s) or other family members while in care. Visitation usually begins with supervision by the caseworker in a neutral setting and then transition to a community setting or the parent's home initially supervised and then progresses to unsupervised visits (Szilagyi, 2012). Visits with the parents may be difficult for a variety of reasons including inconsistent visits or visit no-shows by the parents, which reinforce feelings of rejection, children not feeling safe because of a history of abuse/neglect, and parental inability to focus on the child during the visit. Separation at the end of each visit may be difficult for the child. Foster parents may notice behavioral concerns when children are preparing for or returning from a parental visit.
The ultimate initial goal is reunification of children with their biological parents. To this end, CPS will work closely with biological families while the child is in foster care, develop a case plan for the parents, and assist the parents in working to complete the case plan. The time line for reunification varies and is dependent upon parental ability to show compliance with the case plan; unfortunately, there are times when reunification is never possible. Despite efforts to prevent foster care disruptions, some children will be moved to multiple foster homes or foster settings during a single placement in foster care.
Healthcare Needs
There are many factors that make children in foster care a vulnerable population. First of all, nurses need to consider the reason(s) why the child has been placed into foster care in the first place. Many children and adolescents in foster care have been exposed to multiple traumas before placement in foster care. Most children in foster care have experienced one or more forms of child maltreatment including neglect, physical abuse, sexual abuse, and emotional abuse. Other traumatic exposures that may result in foster care placement are a lack of medical care, poverty, homelessness, violence in the home, parental substance abuse, and parental mental illness (Lewis, Beckwith, Fortin, & Goldberg, 2011). Despite experiencing significant trauma in their biological homes, the act of removal from the home is almost always traumatic for children. They lose contact with family and friends and frequently must change schools. They often feel abandoned (Baker, Mehta, & Chong, 2013). It is essential for pediatric forensic nurses to have an understanding of trauma and its effects on children to better advocate for the healthcare needs of children in foster care.
Another factor increasing the vulnerability of children in foster care is caregiver lack of knowledge regarding past medical, psychological, and educational concerns. This lack of knowledge is complicated by placement instability. Placement instability is a serious concern for children in foster care and contributes to negative physical and emotional consequences. Changes in foster care placements result in a discontinuity of medical and mental health care, education, and potential relationship building. Placement disruptions result in children cycling through multiple caregivers who may know very little about the child's past medical/educational histories and impedes the healthcare providers' ability to really get to know the child and determine their needs. A disproportionate amount of healthcare services are sought from emergency departments by caregivers who have little information about new foster children (MeKonnen, Noonan, & Rubin, 2009).
The healthcare needs of children in foster care are complex with many having one or more chronic health conditions of which the foster caregiver may be unaware. Nearly half of all children in foster care have chronic medical problems, and up to 80% have serious emotional problems (MeKonnen et al., 2009; Pecora, Jensen, Romanelli, Jackson, & Ortiz, 2009). Common medical problems for children in foster care include respiratory problems (asthma), allergic and infectious skin conditions, dental caries, pediculosis, anemia, delayed immunizations, and impaired hearing and vision (Lewis et al., 2011; Rubin et al., 2008). Nutritional disorders are also common health problems with overweight or obesity occurring more frequently in children in foster care than failure to thrive (Schneiderman, Arnold-Clark, Smith, Duan, & Fuentes, 2013a; Steele & Buchi, 2008). However, a disproportionate number of foster children are below the fifth percentile for height, weight, and head circumference (Lewis et al., 2011). Children experiencing failure to thrive tend to be younger (less than 5 years old) and especially less than 2 years old (Steele & Buchi, 2008). Overweight and obesity, problems concerning a significant proportion of the American population, are more commonly found in children in foster care than in the general population (Schneiderman, Smith, Arnold-Clark, Fuentes, & Duan, 2013b). Schneiderman et al., in a study of children in foster care, found that children aged 2 years and younger were not likely to be overweight or obese, but foster children aged 2-19 years were more likely to be overweight or obese when compared with those who are not in care. Foster children between the ages 2 and 5 years who were overweight or obese upon entry into care were significantly less likely to be overweight or obese after 12 months in care. However, foster children aged 6 years and older remained overweight or obese after 12 months in care. This is likely reflective of the psychological effects of experiencing abuse and neglect, which cannot be immediately wiped away by placement into foster care. In addition, children in foster care are at increased risk for depression and anxiety, which is linked with overweight/obesity in the general population (Dockray, Susman, & Dorn, 2009). It is interesting to note that Schneiderman et al. (2013a) found that children placed into foster care because of parental substance abuse were more likely to remain at a normal weight or no longer be overweight/obese after 12 months in foster care when compared with children entering care for other reasons. These researchers also found that children placed in group homes had a higher prevalence of obesity than children placed in other types of out-of-home placements.
Acute dental conditions, primarily caries, are frequently noted in children entering foster care (Lewis et al., 2011; Steele & Buchi, 2008). This concern is compounded by the fact that access to dental care does not consistently improve for children while in care. Furthermore, it is suggested that children in foster care are nine times more likely to have a diagnostic or preventative dental visit than a restorative visit, suggesting that dental follow-through is less than optimal (Melbye, Huebner, Chi, Hinderberger, & Milgron, 2013).
Developmental delay is a common problem for children in foster care (Stahmer et al., 2005). There are a variety of environmental and biological factors placing these children at risk for developmental delay. Environmental factors occurring in the home of origin influencing child development may include lack of a stable, loving caregiver able to provide appropriate stimulation and ensure consistent school attendance; exposure to abuse and neglect with its resulting physical and psychological trauma; exposure to domestic violence; and parental substance abuse. Biological risk factors include intrauterine drug exposure, prematurity, and early critical nutritional deficiencies (Lewis et al., 2011).
Children and adolescents in foster care, as well as adults who were formerly placed in foster care, have disproportionately high rates of emotional and behavioral problems (Bertram, Narendorf, & McMillen, 2013; Pecora et al., 2009). Most likely, these problems are related to traumatic life experiences. Adolescents in foster care are significantly more likely than the general population to be diagnosed with at least one lifetime DSM-IV psychiatric diagnosis (63%-46%) and to have three or more lifetime diagnoses (23%-15%; Pecora et al., 2009). The most common lifetime diagnoses for children and adolescents in foster care are oppositional defiant disorder, conduct disorder, major depressive disorder, panic attack, and attention deficit hyperactivity disorder. The most commonly diagnosed DSM-IV psychiatric disorders found in adolescents in foster care within the past year are major depressive disorder, major depressive episode, posttraumatic stress disorder (PTSD), intermittent explosive disorder, and conduct disorders (Pecora et al., 2009). Young adults formerly in foster care are at a significantly higher risk for PTSD, anxiety disorders, depression, and drug dependency.
Adolescents often engage in risky behaviors (see Table 1). However, adolescents in foster care engage in more high-risk behaviors than adolescents not in care (Lewis et al., 2011; Mekonnen et al., 2009). Their experiences of maltreatment, instability, and family dysfunction coupled with high rates of poverty, poor health, developmental delays, mental health problems, and educational weaknesses increase their vulnerability to engage in health-risk behaviors (Leslie et al., 2010). Leslie et al. compared health-risk behaviors in young adolescents (aged 12-14 years) in foster care with young adolescents not in foster care and found that 28.5% of young adolescents in foster care reported engaging in sexual intercourse compared with 17% not in care. Suicidal ideation or self-harm was nearly double among young adolescents in foster care, and they were also more likely to get into fights; carry a weapon; and use tobacco, alcohol, and marijuana when compared with young adolescents not in foster care (Leslie et al., 2012). It is imperative that adolescents in foster care are screened for high-risk behaviors. Numerous studies have validated a relationship between involvement in the child welfare system or placement in foster care and delinquent behaviors or involvement with the youth criminal justice system (Snyder, Espiritu, Huizinga, Loeber, & Petechuk, 2003; Thornberry, Huizinga, & Loeber, 2004; Widom, 2003). Male adolescents in foster care who have been physically abused are at extremely high risk to engage in delinquent behaviors (Grogan-Kaylor, Ruffolo, Ortega, & Clarke, 2008).
Older teens are faced with the often daunting problem of reaching the age of majority and aging out of foster care (Jee, Tonniges, & Szilagyi, 2008). Many adolescents are ill-equipped for this change and the loss of financial and social support previously provided by the foster care system. Multiple studies have stated that youth aging out of foster care are three to seven times more likely to have a chronic physical and/or mental health problem and are only about half as likely to have health insurance when compared with youth who have never been in foster care (American Academy of Pediatrics [AAP], 2012). However, as a result of the Patient Protection and Affordable Care Act of 2010 beginning in 2014, all youth aging out of foster care will be eligible for Medicaid coverage until the age of 26 years, regardless of income (American Academy of Pediatrics [AAP], 2012). Forensic nurses working in pediatric settings need to assist adolescents reaching the age of majority to transition to an adult healthcare provider and make sure that linkages to all appropriate adult specialty care providers are established to meet their physical and mental health needs.
A pressing healthcare need of children entering into foster care is the management of psychotropic medications. An increasing number of children and adolescents are being treated with one or multiple psychotropic medications at the time of entering into foster care. Often times, the linkage with prescribing psychiatrists is lost upon entering into foster care because of fragmented communication. A national survey (Raghavan et al., 2005) found that 13.5% of children in foster care were using psychotropic medication, which is two to three times the rate of children in the general population. This can be attributed to the discontinuity of care for children in foster care and the lack of resources for quality assessment and diagnosis. MeKonnen et al. (2009) have reported that children in foster care are often given medications to control behaviors without getting at the root cause of the behaviors, such as attachment issues or trauma-related symptoms. In addition, placement disruptions increase the difficulty of linking children with appropriate mental health diagnostic and ongoing treatment. Frequent moves between homes also increase the potential for discontinuity of treatment, which can result in the use of more psychotropic medication in varying combinations, inappropriate administration, and abrupt discontinuation.
Practice Recommendations
The unique physical, developmental, and mental health needs of children in foster care present the pediatric healthcare system, including the pediatric forensic nurse, with the challenging task of meeting their needs. First of all, these children need a true healthcare home, one that is accessible and remains continuous even through changes in foster home placements (Szilagyi, 2012). Healthcare coordination is an essential role of the healthcare home for children in foster care reflecting an understanding of the child's special needs and the potential impact of trauma exposure and loss upon the child. Healthcare providers must collaborate with the child welfare system as well as foster parents and, when appropriate, biological parents (especially as reunification becomes more imminent) regarding the child's healthcare plan and needs.
The AAP (2013) has established guidelines for the care of children in foster care (see Table 2 for recommended foster care health visits). All children entering foster care need to have a health screening completed within 72 hours of placement to identify signs of child abuse and neglect, acute or chronic health problems, and developmental concerns (all children less than the age of 6 years). Some children may be identified as requiring immediate referral to a subspecialist or pediatric emergency department for care. It is important to determine if the child has all necessary medications or medical equipment. A plan for the treatment of any acute or chronic illnesses must be identified. All information should be clearly communicated with the CPS caseworker and foster parent. Immunization records and full medical records should be requested for all children and the newborn screen for all children less than 3 years old. Growth parameters for all children including head circumference for all children less than 3 years old should be obtained (AAP, 2013).
Mental health evaluation of children entering into foster care is essential to identify preexisting mental health concerns as well as mental health conditions that have developed because of the trauma of entering into foster care. Recent legislation, Fostering Connections to Success and Increasing Adoptions Act of 2008, has required state child protective agencies, Medicaid departments, and pediatric experts to work together to develop a plan for mental health evaluations and treatment of children in foster care, including an initial assessment upon entry into care and periodic follow-up evaluations (Hayek et al., 2013). The AAP (2013) standards state that, within 24 hours of entering into foster care, every child over the age of 5 years should receive a mental health screen administered by the child's primary care provider or CPS staff. Most importantly, the purpose of the initial mental health screen is to identify urgent needs such as suicidality, harm to others, substance abuse, and medication monitoring (see Table 3 for a list of mental health screening instruments, which received an A rating demonstrating reliability and validity) when evaluated by the California Evidence-Based Clearinghouse for Child Welfare.
A comprehensive health assessment should be completed within 30 days of foster care placement. At this time, a comprehensive physical examination should be completed along with a mental health and developmental assessment focusing on the child's adjustment to foster care. At all visits, it is vital to assess for and document any signs of abuse and neglect and notify CPS immediately if any are observed. A written plan including all identified problems (physical, developmental, or mental health related) along with the treatment plan should be given to the foster parent and sent to the caseworker with each healthcare visit. Foster children need to be monitored more closely, even when healthcare concerns have not been identified. As a high-risk group, healthcare visits should be more frequent.
Practice Realities
Children in foster care utilize more mental health services than the general population, especially older adolescents. It is estimated that, over time, 80% of children in foster care receive some mental health services (Pecora et al., 2009). However, three of four foster children who meet the criteria for mental health services are not receiving these services within 12 months of entering into care. The most prevalent mental health diagnoses for children in foster care include PTSD and abuse-related trauma, disruptive behavior disorders such as attention deficit-hyperactivity disorder, depression, and substance abuse (Bertram et al., 2013; Landsverk, Burns, Stambaugh, & Rolls-Reutz, 2009). Evidence strongly supports the use of behavioral or cognitive-behavioral interventions that address symptoms and behavior as well as overall functioning. Treatment models such as trauma-focused cognitive behavioral therapy, parent-child interaction therapy, and cognitive behavioral therapy for depression have proven effectiveness. Caregiver involvement is crucial to these treatment models. Children and adolescents with complex mental health needs may benefit from intensive home- and community-based services. Providing intensive services in the home and community may allow for avoiding institutionalization for the provision of care, which has the potential of resulting in negative consequences such as loss of contact with family and friends, educational interruption, and potential exposure to deviant peers (Dishion, McCord, & Poulin, 1999).
Up to 65% of preschool children entering into foster care meet criteria for a mental health diagnosis (Hillen & Gafson, 2013; Milburn, Lynch, & Jackson, 2008). Early detection of mental health concerns coupled with effective intervention can lead to improved outcomes; therefore, effective screening of preschool children entering into foster care is crucial. Hillen and Gafson examined the diagnostic accuracy of mandatory health assessments, which are required upon entry into foster care, in identifying mental health disorders in preschool children. Multiple instruments were administered to insure a comprehensive multidimensional assessment: Pre-school Age Psychiatric Assessment, which covers the full range of mental health problems; Parent-Infant Relationship Global Assessment Scale to assess the quality of the infant-child relationship; Mullen Scales of Early Learning, a measure of cognitive functioning for infants and preschool children; Placement Stability Rating Scale identifies foster care placements at risk for disruption; and The Ages and Stages Questionnaire: Social Emotional (ASQ:SE) to screen for mental health difficulties but not developmental delays. The ASQ:SE is a quick caregiver-completed and provider-scored screen frequently used in the primary care setting. However, the ASQ:SE failed to identify 65% of preschool children who were diagnosed with a mental health disorder (Hillen & Gafson, 2013), even though it received an A rating (demonstrated reliability and validity) when evaluated by the California Evidence-Based Clearinghouse for Child Welfare (2013). Primary care providers in the study were much better at identifying developmental delay versus mental health concerns in preschool children.
Conclusions and Implications for Forensic Nursing
Children in foster care have experienced significant trauma and are at high risk for physical, emotional/behavioral, and developmental consequences. Yet, children in foster care can also demonstrate resilience. Not surprisingly, the positive functioning of the foster family and the stability of the foster placement can support resilience in children (Bell, Romano, & Flynn, 2013). Continued contact with the biological family, particularly biological parents, is important to resilience in children because this contact helps to reduce feelings of abandonment, grief, and depression. Children at higher developmental levels show higher resilience.
All forensic nurses, especially those working in pediatric settings, need to be advocates for children in foster care. A thorough understanding of their unique healthcare needs is essential for the forensic nurse. Advocacy at the local, state, and national levels for legislation, programs, and policies that show recognition of the healthcare needs of children in foster care allow for the development of interventions that support meeting these needs.
The individual practice of the forensic nurse must reflect an understanding and incorporation of the latest AAP recommendations for the care of children in foster care. Pediatric forensic nurses are truly in a unique position to encourage, plan, and implement programs that support children in foster care and allow for care provision that meets their needs. A critical role for forensic nurses working in a pediatric setting is to both educate and support foster parents providing the day-to-day care of children in foster care (Blythe, Halcomb, Wilkes, & Jackson, 2013). Forensic nurses should consider incorporating the care of children in foster care into their forensic practice by advocating for the formation of a specialized program/clinic to provide care for these children. Pediatric forensic nurses in advanced practice positions are uniquely prepared to meet not only the physical and mental health needs, but also the forensic needs of children in foster care. Forensic nurses are innovative care providers; they have revolutionized the care of the sexual assault/abuse victim. This spirit of innovation can assist the pediatric forensic nurse in changing the healthcare system to better meet the needs of children in foster care.
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