Achieving better health care outcomes for children in foster care

Management of Vertebral Defects, Anal Atresia, Cardiac Defects, Tracheoesophageal Fistula or Atresia, Renal Anomalies, and Limb Abnormalities (VACTERL) in a Child With Complex Medical Needs in the Foster Care System: A Pediatric Case Study

Vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula or atresia, renal anomalies, and limb abnormalities (VACTERL) association is a complex congenital condition characterized by the presence of malformations that affect various organ systems. Most children born with VACTERL association require surgery shortly after birth, often undergoing multiple procedures during infancy, which can lead to a wide range of physical challenges. The unique combination of malformations in these children in addition to having complex care needs that need to be met can result in physical and social difficulties in their daily lives, affecting both their own and their caregivers' quality of life. In some cases, children with complex medical needs are placed in foster care. When children with complex health needs enter the foster care system, there is a risk of overwhelming the caretaker, leading to their needs continuing to be unmet. Pediatricians have a role not only in helping support families but also in knowing what resources are available to meet these needs, which can be dependent on what their communities offer. Pediatricians require current training to navigate their state's foster care system. This training allows pediatricians to effectively collaborate with foster families while also assisting and coordinating complex care to support these families. We present a case of a child with complex health needs placed in the foster care system, facing multiple healthcare challenges, with care delayed due to difficulty attending appointments. Highlighted is the importance of delivering supportive, personalized, and multidisciplinary care to families with children who have complex health needs, including when caretakers are within the foster care system.

Access to Dental Care for Children and Young People in Care and Care Leavers: A Global Scoping Review

AIMS

This scoping review aimed to explore three research questions: 1. What is the dental care access for children and young people (CYP) in care and care leavers? 2. What factors influence CYP in care and care leavers' access to dental care? 3. What pathways have been developed to improve access to oral health care for CYP in care and care leavers?

METHODS

Five databases (Ovid MEDLINE, Ovid Embase, CINAHL, SocINDEX and Dentistry and Oral Sciences Source) and grey literature sources were systematically searched. Articles relating to CYP in care or care leavers aged 0-25 years old, published up to January 2023 were included. Abstracts, posters and publications not in the English language were excluded. The data relating to dental care access were analysed using thematic analysis.

RESULTS

The search identified 942 articles, of which 247 were excluded as duplicates. A review of the titles and abstracts yielded 149 studies. Thirty-eight were eligible for inclusion in the review: thirty-three peer-reviewed articles, one PhD thesis and four grey literature sources. All papers were published from very high or medium Human Development Index countries. The studies indicate that despite having higher treatment needs, CYP in care and care leavers experience greater difficulty in accessing dental services than those not care-experienced. Organisational, psycho-social and logistical factors influence their access to dental care. Their experience of dental care may be impacted by adverse childhood events. Pathways to dental care have been developed, but little is known of their impact on access. There are very few studies that include care leavers. The voices of care-experienced CYP are missing from dental access research.

CONCLUSIONS

care-experienced CYP are disadvantaged in their access to dental care, and there are significant barriers to their treatment needs being met.

Specialized programs employing different models of care delivery work collaboratively to address the health care needs of children in foster care

Specialized knowledge and skills applicable to caring for children in foster care include guidelines developed to address this population's special health care needs, cross-system collaboration, and helping families cope with the health impacts of trauma. This paper begins with a review of the special health care needs of children in foster care and relevant guidelines. We discuss different models of health care delivery that can be employed to meet the special health care needs of children in foster care. We then provide examples of two programs employing different models of care that work collaboratively to deliver care to children in foster care in our community.

Caring for Hospitalized Children in Foster Care: Provider Training, Preparedness, and Practice

BACKGROUND AND OBJECTIVES

Children and youth in foster care (CYFC) have high rates of health care utilization, including inpatient care. The objective of this study was to explore the inpatient provider experience caring for CYFC.

METHODS

Semistructured interviews were conducted with inpatient pediatric providers from Mid-Atlantic hospitals. Interview questions focused on 3 domains: provider training and preparedness, practice challenges, and strategies to improve care for CYFC. Conventional content analysis was applied to interview transcripts.

RESULTS

Thirty-eight interviews were completed with providers from 6 hospitals, including 14 hospitalists, 1 advanced practice provider, 11 registered nurses, 10 social workers (SWs), and 2 case managers. Nearly all (90%) reported at least monthly interactions with CYFC. Themes related to training and preparedness to care for CYFC included: medical providers' lack of formal training, limited foster care knowledge, and feeling of preparedness contingent on access to SWs. Themes related to unique practice challenges included: identifying CYFC, obtaining consent, documenting foster care status, complex team communication, and navigating interpersonal stress. Participants' suggestions for improving their ability to care for CYFC included increasing SW capacity, expanding provider training, standardizing electronic medical record documentation and order sets, and improving team communication and information sharing.

CONCLUSIONS

There are unique medical, social, and legal aspects of caring for hospitalized CYFC; pediatric medical providers receive limited training on these topics and rely heavily on SWs to navigate associated practice challenges. Targeted educational and health information technology interventions are needed to help inpatient providers feel better prepared to effectively meet the needs of CYFC.

Patterns of healthcare utilization with placement changes for youth in foster care

BACKGROUND

Children in foster care experience poor health and high healthcare use. Child welfare agencies frequently require healthcare visits when children enter foster care; subsequent placement changes also disrupt healthcare. Studies of healthcare use have not accounted for placement changes.

OBJECTIVE

To understand patterns of healthcare use throughout the time a child enters foster care and with placement changes, accounting for mandated visits when children enter foster care or experience a placement change.

PARTICIPANTS AND SETTING

Children 4 and older in foster care between 2012 and 2017 (N = 2787) with linked child welfare administrative data from one county child welfare agency and one Midwest pediatric healthcare system.

METHODS

Negative binomial models predicted healthcare days per month that were planned (e.g., scheduled primary/specialty care), unplanned (e.g., emergency care), or missed.

RESULTS

Planned healthcare days increased as a function of placement changes (Incident Rate Ratio [IRR] =1.69, p < .05) and decreased with placement stability (IRR = 0.92, p < .01). Mandated visits that occurred later in a placement were associated with fewer planned (IRR = 0.81, p < .01) and unplanned (IRR = 0.82, p < .01) healthcare days during that placement.

CONCLUSIONS

Patterns of planned healthcare over the time children are in one placement and move between placements suggest more can be done to ensure youth remain connected to primary and specialty care throughout placements and placement transitions, s that children are seen as clinically appropriate rather than a function of placement disruption. Findings regarding the timing of mandated visits suggest that delays in mandated care may also reflect lower healthcare use overall.

Child Welfare System Involvement Among Children With Medical Complexity

Children with medical complexity may be at elevated risk of experiencing child maltreatment and child welfare system involvement, though empirical data are limited. This study examined the extent of child welfare system involvement among children with medical complexity and investigated associated health and social factors. A retrospective chart review of children with medical complexity (N = 208) followed at a pediatric hospital-based complex care program in Canada was conducted. Descriptive statistics and odds ratios using logistic regression were computed. Results showed that nearly one-quarter (23.6%) had documented contact with the child welfare system, most commonly for neglect; of those, more than one-third (38.8%) were placed in care. Caregiver reported history of mental health problems (aOR = 3.19, 95%CI = 1.55-6.56), chronic medical conditions (aOR = 2.86, 95%CI = 1.09-7.47), and interpersonal violence or trauma (aOR = 17.58, 95%CI = 5.43-56.98) were associated with increased likelihood of child welfare system involvement, while caregiver married/common-law relationship status (aOR = 0.35, 95%CI = 0.16-0.74) and higher number of medical technology supports (aOR = 0.75, 95%CI = 0.57-0.99) were associated with decreased likelihood. Implications for intervention and prevention of maltreatment in children with high healthcare needs are discussed.

Multi-center nationwide study on pediatric psychiatric inpatients 2000-2018: length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnostic profiles

Inpatient treatment is an important part of child and adolescent psychiatric (CAP) care. This nationwide study explores the changes in length of stay, recurrent hospitalization, functioning level, suicidality, violence and diagnoses of CAP inpatients in Finland in 2000, 2011 and 2018. We obtained comprehensive questionnaire data on each study year from 93 to 95% of all CAP wards in Finland. We split the 1276 inpatients into two age groups in each study year: under 13 and 13-18. The median length of stay in inpatient treatment decreased from 82.0 days in 2000 to 20.5 days in 2018 (p < 0.001) and recurrent hospitalization increased from 38 to 46%. General functioning, which was evaluated by the Children's Global Assessment Scale, deteriorated by an average of six points between 2000 and 2018. Violent threats decreased from 21.5 to 16.6% and violent acts decreased from 26.9 to 20.3%. Suicidal threats decreased from 42.6 to 23.3% in those aged under 13 and remained stable among those aged 13-18. In the 13-18 group, there was an increase in the diagnoses of ADHD, from 5.0 to 16.9% and depression, from 25.1 to 41.7%. However, psychosis decreased from 23.2 to 12.6% in the older age group. In the whole cohort, anxiety disorders increased from 7.6 to 15.6%. The overall picture does not show that CAP inpatients have become more disturbed. While the general functioning of CAP inpatients deteriorated somewhat over the 2000-2018 study period, symptoms of suicidality and violence remained stable or decreased. There was also a continuous increase in short-term treatment.

Children at the Intersection of Pediatric Palliative Care and Child Maltreatment: A Vulnerable and Understudied Population

CONTEXT

Concerns for child maltreatment can complicate the provision of pediatric palliative care (PPC). Little is known about the vulnerable population of children with life-threatening conditions involved with PPC and state Child Protective Services (CPS) or hospital Child Protection Teams (CPTs). More information is needed to inform and optimize collaborative care.

OBJECTIVES

Define and describe the population of children with PPC involvement for whom there was concern for maltreatment.

METHODS

Single-center retrospective chart review of children with PPC involvement for whom there was concern for maltreatment, defined as involvement of CPS/CPT between 2005 and 2017. Medical and demographic variables were abstracted and analyzed. Analyses include descriptive tabulation and measurements of association between PPC and CPS/CPT variables.

RESULTS

Among 1804 children followed by PPC, 189 (10.4%) had documented CPS/CPT involvement. Among those, 113 (60%) had CPT involvement, 88 (47%) had concerns of medical neglect, and 100 (53%) had simultaneous CPS/CPT and PPC involvement. Goals of PPC consultation varied by clinical characteristics and concerns for medical neglect. Frequency of CPT involvement and physical abuse concerns also varied by child clinical characteristics.

CONCLUSION

PPC practitioners regularly encounter children with CPS/CPT involvement. PPC practitioners should be aware of the risk of maltreatment in their patients. Although rare in the general pediatric population, medical neglect is a relatively frequent maltreatment concern in children cared for by PPC. PPC practitioners have an opportunity to aid in proper evaluation of medical neglect in children they care for. Closer PPC collaboration with CPS/CPT may further optimize care.

Foster Care: How We Can, and Should, Do More for Maltreated Children

Foster care provides round-the-clock substitute care for nearly 700,000 U.S. children who are temporarily or permanently separated from their family of origin each year. Each state manages its own foster care system according to federal regulations. Despite numerous large-scale federal policy reforms over the past several decades, substantial concerns remain about the experiences and outcomes of children in the foster care system. The most recent effort to reform foster care, the Family First Prevention Services Act of 2018, attempts to both reduce the use of foster care and increase the quality of care. In this report, we review how policy has shaped the experiences and outcomes of children in foster care, where policy has succeeded, and where it falls short of achieving its goals. We then identify opportunities for federal and state policy to better support the safety, health, and well-being of children in foster care.

Health Care Utilization for Children in Foster Care

OBJECTIVE

To utilize hospital EMR data for children placed in foster care (FC) and a matched control group to compare: 1) health care utilization rates for primary care, subspecialty care, emergency department (ED) visits, and hospitalizations; 2) overall charges per patient-year; and 3) prevalence of complex chronic conditions (CCC) and their effect on utilization.

METHODS

Children ≤18 years old with a designation of FC placement and controls matched on age, race/ethnicity, gender, and zip code who had an encounter at an urban pediatric health system between 7/1/11 and 6/30/12 were identified in the EMR. Data on outpatient, ED, and inpatient encounters and charges for 7/1/12 to 6/30/13 were obtained. A general linear mixed-effects model was applied to estimate means and rates for each group. Analyses were repeated among the subpopulations of children with and without CCCs.

RESULTS

A total of 1156 FC cases were matched to 4062 controls (mean = 3.5 controls/case). FC cases had significantly higher rates (per 100 patient-years) of hospitalizations (18.5 vs 12.7, P = .005), and subspecialty visits (173.3 vs 113.6; P < .001) but not ED (50.4 vs 45.2, P = .056) or primary care visits (154.6 vs 149.8; P = .50). FC cases had higher charges ($14,372 vs $7082; P < .001). Among children with CCCs, health care utilization rates and charges were higher among FC cases (all P < .001). Among children without CCC, rates and charges were similar for FC cases and controls (all P > .20).

CONCLUSIONS

FC children utilized more hospitalizations and subspecialty office visits. The increased utilization rates and charges among children in FC were driven by the subset of children with CCCs.

Safely surrendered infants in Los Angeles County: A medically vulnerable population

BACKGROUND

As a means to provide safety for a population at great risk of harm through abandonment, every state in the United States now has laws and practices for the safe relinquishment of newborns and infants. However, there is no national database tracking the population of infants surrendered through such programmes, and few states monitor these numbers. The primary aim of this study was therefore to examine the descriptive characteristics of infants who have been safely surrendered in a large, socio-economically diverse urban area. The secondary aim was to compare them with local population norms to determine whether differences exist and to begin exploring what implications such differences may have for the treatment provided to these infants.

METHODS

A retrospective cross-sectional study was conducted among safely surrendered infants.

RESULTS

Over half of the infants had medical issues, and the majority of the infants were surrendered in communities characterized by low median income.

CONCLUSIONS

Preliminary information highlights potential economic, social, and medical risk factors, suggesting that these infants may require increased monitoring and/or specialized care.

Exploring Medical Foster Care as a Placement Option for Children With Medical Complexity

BACKGROUND

Medical foster care (MFC) offers a family-home setting for children with medical complexity (CMC) who cannot be cared for by their parents. We explored MFC as a placement option for CMC via in-depth interviews with the individuals providing and monitoring care.

METHODS

In collaboration with an MFC agency, we recruited care team members for 15 CMC. Semistructured interviews were audiotaped and transcribed. Descriptive analyses were performed on care team composition and roles, the placement process, and child medical, placement, and quality of life (QoL) characteristics. Foster parents completed child QoL questionnaires. Conventional content analysis was applied to participant suggestions for MFC improvements.

RESULTS

Fifty-eight interviews were conducted; a median of 4 care team members interviewed per child. An extensive network of individuals and systems are involved in providing care. Each child received care from multiple subspecialists (median = 5). Most children were technology dependent (87%), developmentally delayed (87%), and entered MFC from the hospital (73%) because of medical neglect (86%). Nearly half were in care for >2 years. Changes in placement and/or care team were common. QoL scoring showed impairments in multiple domains, whereas respondent interviews described positive aspects of QoL. Participants provided suggestions to improve care within MFC.

CONCLUSIONS

MFC is a promising placement option for CMC. Because many CMC are entering MFC directly from the hospital and require ongoing care from pediatric subspecialists, pediatricians should be familiar with MFC, the placement process, and the various systems and individuals involved. Pediatricians can play important roles in ensuring that children in MFC receive coordinated and high-quality care.

Foster Care Involvement Among Medicaid-Enrolled Children with Autism

The prevalence and risk of foster care involvement among children with autism spectrum disorder (ASD) relative to children with intellectual disability (ID), children with ASD and ID, and typically developing children were examined using 2001-2007 Medicaid data. Children were followed up to the first foster care placement or until the end of 2007; a discrete time logistic regression analysis was conducted. Both the prevalence and risk of foster care involvement were greatest for children with ASD, and the prevalence increased substantially over the study period among children with ASD. Continued examination of the factors contributing to the higher risk of foster placement is warranted to unravel the complex circumstances facing these vulnerable children and their families.

End-of-life trends and patterns among children in the US foster care system: 2005-2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005-2015), demographic, health, foster care, and geographic characteristics of decedents (N = 3653) aged 1-17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.

Serious Illness and End-of-Life Quality for US Foster Children: A National Study

BACKGROUND:

Of the nearly 500 000 children in foster care, several hundred children die each year. Their quality of life at end of life is a matter of their foster care experience.

OBJECTIVES:

The purpose of this study was to investigate whether serious illness was associated with foster care placement outcomes.

METHODS:

US foster care data from 2005 to 2015 were used. Children who were younger than 18 years with residence in the United States were included. Serious illness (ie, physical health, mental/behavioral health, developmental disabilities) was measured via the foster care files. Two foster care placement outcomes were created (ie, type of placement, placement instability). Using multinomial and logistic regressions, the influence of serious illness on placement outcomes was evaluated while controlling for demographic, geographic, prior trauma, and foster care support characteristics.

RESULTS:

Fifty-seven percent of the children were placed with nonrelatives, 27% in group homes/institutions, and 17% with relatives. Twenty-eight percent experienced placement instability. Serious illness was significantly associated with nonrelative (relative risk ratio [RRR] = 1.97; 95% confidence interval [CI] = 1.58-2.45) and group home/institution placement (RRR = 2.67; 95% CI = 2.09-3.40). Serious illness was not significantly related to placement instability. Children with serious illness were no more likely than their peers to experience multiple foster care placements.

CONCLUSIONS:

Foster care youth at end of life were more likely to be placed with nonrelatives or in group homes/institutions. They also did not experience the disruption and stress of being moved to multiple foster homes while seriously ill.

Changes in the clinical features of child and adolescent psychiatric inpatients: a nationwide time-trend study from Finland

BACKGROUND

Few studies have focused on the recent trends in clinical features child and adolescent inpatient.

AIMS

This study focuses on the change in the characteristics of child and adolescent psychiatric inpatients in Finland.

METHODS

The data collection was carried out on selected study days in 2000 and 2011. Questionnaires were sent to the psychiatrists of all child and adolescent wards in Finland.

RESULTS

By comparing the data obtained in 2000 (n = 504) and 2011 (n = 412), several changes were found: the percentage of girls in adolescent wards grew and the diagnoses of depression, anxiety disorders, attention deficit hyperactivity disorder and eating disorders increased. In contrast, the diagnoses of psychosis and conduct or oppositional disorders decreased. General functioning was evaluated with the Childreńs Global Assessment Scale (CGAS). There were no changes in the distribution of CGAS scores among child inpatients, whereas among adolescents the share of inpatients with lowest CGAS scores (1-30) increased significantly. The mean length of stay dropped.

CONCLUSIONS

The growing percentage of girls in adolescent wards is associated with an increase in diagnoses that are more prevalent among girls than boys, namely depression, anxiety, and eating disorders. The changes in the distribution of diagnoses may be due to changes in diagnostic or referral practices, or reflect true changes in the prevalence of disorders among children and adolescents in need of inpatient treatment. The share of adolescent inpatients with the poorest general functioning has increased. The observed shortening in inpatient treatment time seems to be a result of changes in treatment practices.

Medical foster care: what happens when children with medical complexity cannot be cared for by their families?

Medical interventions for life-threatening pediatric conditions often oblige ongoing and complex medical care for survivors. For some children with medical complexity, their caretaking needs outstrip their parents' resources and abilities. When this occurs, the medical foster care system can provide the necessary health care and supervision to permit these children to live outside of hospitals. However, foster children with medical complexity experience extremes of social and medical risk, confounding their prognosis and quality of life beyond that of similar children living with biologic parents. Medical foster parents report inadequate training and preparation, perpetuating these health risks. Further, critical decisions that weigh the benefits and burdens of medical interventions for these children must accommodate complicated relationships involving foster families, caseworkers, biologic families, legal consultants, and clinicians. These variables can delay and undermine coordinated and comprehensive care. To rectify these issues, medical homes and written care plans can promote collaboration between providers, families, and agencies. Pediatricians should receive specialized training to meet the unique needs of this population. National policy and research agendas could target medical and social interventions to reduce the need for medical foster care for children with medical complexity, and to improve its quality for those children who do.

Timely Health Service Utilization of Older Foster Youth by Insurance Type

PURPOSE

To evaluate the impact of a policy change for older foster care youth from a fee-for-service (FFS) Medicaid program to health maintenance organization (HMO) providers on the timeliness of first well-child visits (health care physicals).

METHODS

A three-year retrospective study using linked administrative data collected by the Michigan Departments of Human Services and Community Health of 1,657 youth, ages 10-20 years, who were in foster care during the 2009-2012 study period was used to examine the odds of receiving a timely well-child visit within the recommended 30-day time frame controlling for race, age, days from foster care entry to Medicaid enrollment, and number of foster care placements.

RESULTS

Youth entering foster care during the HMO period were more likely to receive a timely well-child visit than those in the FFS period (odds ratio, 2.46; 95% confidence interval, 1.84-3.29; p < .0001) and days to the first visit decreased from a median of 62 days for those who entered foster care during the FFS period to 29 days for the HMO period. Among the other factors examined, more than 14 days to Medicaid enrollment, being non-Hispanic black and having five or more placements were negatively associated with receipt of a timely first well-child visit.

CONCLUSIONS

Those youth who entered foster care during the HMO period had significantly greater odds of receiving a timely first well-child visit; however, disparities in access to preventive health care remain a concern for minority foster care youth, those who experience delayed Medicaid enrollment and those who experienced multiple placements.

Children in nonparental care: health and social risks

Approximately 2.3 million children in the United States live separately from both parents; 70-90% of those children live with a relative. Compared with children living with one or both parents, children in nonparental care are in poorer health, are at heightened risk for experiencing disruptions and instability in caregiving, and are vulnerable to other social antecedents of child health (e.g., neglect, poverty, maltreatment). Given the significant impact of adversity in childhood on health across the lifespan, which is increased among children in nonparental care, it is informative to consider the health risks of children living in nonparental care specifically. Research examining the contributions of poverty, instability, child maltreatment, and living in nonparental care, including meta-analyses of existing studies, are warranted. Longitudinal studies describing pathways into and out of nonparental care and the course of health throughout those experiences are also needed. Despite these identified gaps, there is sufficient evidence to indicate that attention to household structure is not only relevant but also essential for the clinical care of children and may aid in identifying youth at risk for developing poor health across the lifespan.

Foster Care and Child Health

Children in foster care need more from health providers than routine well-child care. The changes in legislation that were designed to prevent children from languishing in foster care also necessitate a plan that works with the child, the biological family, and the foster family in ensuring the best outcome for the child. This approach acknowledges that most foster children will return to the biological family. Recent research on the effect of adverse childhood experiences across all socioeconomic categories points to the need for specifically designed, focused, and coordinated health and mental health services for children in foster care.

Mental Health, Behavioral and Developmental Issues for Youth in Foster Care

Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Physical Health Problems and Barriers to Optimal Health Care Among Children in Foster Care

Children and adolescents in foster care placement represent a unique population with special health care needs, often resulting from pre-placement early adversity and neglected, unaddressed health care needs. High rates of all health problems, including acute and/or chronic physical, mental, and developmental issues prevail. Disparities in health status and access to health care are observed. This article summarizes the physical health problems of children in foster care, who are predisposed to poor health outcomes when complex care needs are unaddressed. Despite recognition of the significant burden of health care need among this unique population, barriers to effective and optimal health care delivery remain. Legislative solutions to overcome obstacles to health care delivery for children in foster care are discussed.

Children in family foster care have greater health risks and less involvement in Child Health Services

AIM

This study investigated the impact of being in family foster care on selected health determinants and participation in Child Health Services (CHS).

METHODS

Two groups of 100 children, born between 1992 and 2008, were studied using data from Swedish Child Health Services for the preschool period up to the age of six. The first group had been in family foster care, and the controls, matched for age, sex and geographic location, had not. Descriptive statistics were used to describe differences in health determinants and participation in Child Health Services between the two groups.

RESULTS

The foster care group had higher health risks, with lower rates of breastfeeding and higher levels of parental smoking. They were less likely to have received immunisations and attended key nurse or physician visits and speech and vision screening. Missing data for the phenylketonuria test were more common in children in family foster care.

CONCLUSION

Children in family foster care were exposed to more health risks than the control children and had lower participation in the universal child health programme during the preschool period. These results call for secure access to high-quality preventive health care for this particularly vulnerable group of children.

Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health

OBJECTIVE

Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures.

METHODS

Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates.

RESULTS

With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics.

CONCLUSIONS

Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.

Children in foster care: what forensic nurses need to know

Children living in foster care are a unique population with specialized healthcare needs. This article will assist forensic nurses and advanced practice forensic nurses, particularly those working in pediatrics, in understanding the needs of children in foster care and implementing a practice plan to better meet their healthcare needs. To that end, a basic understanding of the foster care system is crucial and involves an appreciation of the interface between the legal system and the child welfare system. Most important to providing care to children in foster care is a true understanding of trauma exposure and its potential effects on the lives of children: physically, developmentally, emotionally, and psychologically. This article will assist forensic nurses working with pediatric populations to more fully understand the needs of children in foster care and to develop innovative interventions to appropriately meet their unique needs.

Psychosocial pathways to sexually transmitted infection risk among youth transitioning out of foster care: evidence from a longitudinal cohort study

PURPOSE

To test the fit of a theoretically driven conceptual model of pathways to sexually transmitted infection (STI) risk among foster youth transitioning to adulthood. The model included (1) historical abuse and foster care experiences; (2) mental health and attachment style in late adolescence; and (3) STI risk in young adulthood.

METHODS

We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Covariates included gender, race, and an inverse probability weight. We also performed moderation analyses comparing models constrained and unconstrained by gender.

RESULTS

Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Square Residual of .026). Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use. There was also a borderline association with having greater than five partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 years decreased STI risk. Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models.

CONCLUSIONS

Interventions/policies that (1) address externalizing trauma sequelae; (2) promote close, stable substitute caregiver relationships; and (3) extend care to age 21 years have the potential to decrease STI risk in this population.

Health profiles of adolescents in foster care

The purpose of this paper is to describe health profiles of adolescents in foster care. The Child Health and Illness Profile-Adolescent Edition clustered adolescents in foster care into 13 mutually exclusive health profiles using dimensions of satisfaction with health, risks, resilience, and discomfort. Health profiles were further characterized into four health status rankings from best to worst health status. Many reported best health status (39%); nearly equal numbers (30.6%) had profiles indicating poor or worst health status, particularly girls and those with high risk behaviors, aggression, sexual abuse, or suicidality. It is valuable to identify health characteristics of the most vulnerable subgroups of foster youth to tailor specific interventions.

The Caregiver as Gatekeeper for Accessing Health Care for Children in Foster Care: A Qualitative Study of Kinship and Unrelated Caregivers

The objective of this qualitative study was to examine issues that unrelated and kinship foster caregivers in Los Angeles, CA, have in seeking help and accessing and using health care for children in foster care. There were four themes identified for all caregivers: (1) "Doing Our Best" (caregivers advocated persistently and creatively for health care); (2) "Support from Others Helped" (caregivers relied on caseworkers, organizations, and their social network); (3) "Child has Complicated, Serious, Chronic Health Problems" (caregivers had difficulty securing specialty services and with Medicaid insurance to meet health care needs); and (4) "Caregiver Competence in Meeting Health Needs" (caregivers noted their ability to attend health appointments and understand instructions). An additional theme of "Differences between Unrelated and Kinship Foster Caregivers" highlighted more difficulties among kinship caregivers in finding and using primary health care services and more financial stress, whereas unrelated caregivers were less satisfied with child welfare caseworker help. Despite wide-ranging stressors and serious frustrations with the child welfare and health care systems, caregivers emerged as powerful drivers of health care for foster children. National adoption of a medical home model would ameliorate some of the access barriers identified by foster caregivers in this study.

Children with Fetal Alcohol Spectrum Disorders in the Dependency Court System: Challenges and Recommendations

Children with Fetal Alcohol Spectrum Disorders (FASD) are at a greatly increased risk for developmental delays, learning disabilities, and behavioral, social, and emotional problems. High rates of secondary disabilities have been reported in this population, including mental health problems, school failure, delinquency, plus alcohol and substance abuse problems. Long-term outcomes for adolescents and adults with FASD include increased risk for unemployment, suicidal ideation and behavior, and confinement in psychiatric facilities and correctional institutions. Many children impacted by prenatal alcohol exposure are raised in out-of-home placements, and thus will likely have extensive involvement with the child welfare and dependency court systems. However, child welfare agencies and dependency courts are often not well-equipped to handle cases involving these children. This article will address the challenges that children with FASD and their families face in those systems, as well as recommendations for improvements in how those systems respond to the needs of these highly vulnerable children.