Assessing the Special Health Care Needs of Children in Foster Care

1
Assessing the Special Health Care Needs of
Children in Foster Care

• Wake County Human Services
• Raleigh, North Carolina
• Jean C. Smith, MD
• Susan Schiewe, MSW, LCSW

2

• When I was little I would think of ways to kill
  my daddy. But I did not kill my daddy. He
  drank his own self to death the year after the
  County moved me out.
• Ellen Foster

3
Health Needs of Children in Foster Care

• Children and adolescents in foster care have
  higher prevalence of -
• Physical
• Developmental
• Dental
• Behavioral
• health conditions

4

• my teacher noticed a bruise he put on my arm
  and they all had a field day over it in the
  school nurses office. Calling in everybody but
  the janitor to look at it. I had rather nobody
  saw my business.

5
Health Status of Children Adolescents Entering
Foster Care

• More than 90 have abnormality in at least 1 body
  system
• Vision hearing problems common
• Suboptimal growth 5 times expected
• (Large cohort study of children entering foster
  care - Baltimore, MD)

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Health Status of Children Adolescents Entering
Foster Care

• lt 20 had NO medical conditions
• gt20 had growth abnormalities
• 30 had neurological disorders
• 16 had asthma (3 times national ave.)
• (Large cohort study of children in foster care
  in Oakland, CA)

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Health Status of Children Adolescents Entering
Foster Care

• High incidence of anemia
• High incidence of infectious diseases
• Increased risk for vertically transmitted
  infections (HIV, hepatitis B C, syphilis,
  herpes simplex)

8

• I try not to leave her by herself with him.

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Other problems

• gt80 exposed to domestic and/or community
  violence
• High risk behaviors in adolescents in foster care
  with risk for STDs, etc.
• No cohesive system of care for this vulnerable
  population
• Little tracking or monitoring of care that does
  exist.

10

• When they came back in they said they had
  decided what to do with me. Its about time I
  thought. Yes Lord its about time.

11
Fostering Health Health Care for Children
Adolescents in Foster Care

• Task Force on Health Care for Children in Foster
  Care
• American Academy of Pediatrics, 2005

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Child Welfare League of America

• Standards for Health Care Services for Children
  in Out-of-Home Care
• Washington, DC Child Welfare League of America
  1988

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Evaluating Quality of Care for Children in Foster
Care -CWLA

• Seven criteria
• Access to care
• Appropriateness of services
• Comprehensiveness of care
• Coordination

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Quality of Care Criteria Continued

• Continuity
• Relation to the community
• Family-centered service

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Health Care Delivery Models for Children in
Foster Care

• Agency-based care
• Specialized foster care clinics
• Community-based care

16

• Since my first day here all I felt is luck
  coming my way. I never thought I could have it
  this good.

17
Components of Health Care Services

• Initial health screening
• Comprehensive health assessment
• Developmental mental health evaluation

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Components of Health Care Services

• Primary health care and monitoring health
  developmental status
• Transfer of medical information

19

• All I did was wish him dead real hard every now
  and then. And I can say for a fact that I am
  better off now than when he was alive.

20
Children's Health and Development Program A
collaboration of John Rex Endowment and Wake
County Human Services

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• Wake County Human Services (WCHS) is a
  consolidated agency including health, mental
  health and social services.

22

• ..there have been more than a plenty days when
  she has put both my hands in hers and said if we
  relax and breathe slow together I can slow down
  shaking. And it always works.

23
Services

• A comprehensive health assessment within a month
  which will include gathering and reviewing all
  past medical records, school/child care
  information, immunization status, etc.
• A developmental and mental health evaluation
  (which may occur in the home)
• A review of all medical, school, and mental
  health records are done for children not
  receiving direct assessment by the CHDP.
• A plan of care to include identification of a
  medical home, special health needs, specific
  behavioral/developmental concerns, and assistance
  for families in securing needed referrals.

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Medical Exam

• Review all medical history and request records
  for review
• Full comprehensive PE
• Required state DSS PE form sent
• Assess if HIV testing or other lab work needed
• Skeletal survey done per protocol for children lt
  2 years of age

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Child Health Clinic routine screens

• Labs
• Hgb 1 year
• Lead 1 and 2 years
• Cholesterol Kindg visit
• Vision
• Lang Stereotest 3 years and up
• HOTV/Snellen/Letter Chart 4 years and up
• Hearing
• Beltone Audiometric - 4 years and up
• OAE if fails or does not understand Beltone
• This is possibly being changed

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Developmental Assessment

• Review developmental history, school history, and
  any interventions including IFSP/IEP
• Developmental screening for all children less
  than 5 years of age
• Neurodevelopmental screening for school age
  children who have not had psychoeducational
  testing at school.
• Review school records for those children with
  IEPs to determine the need for changes and/or
  updating.

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Developmental Screening Protocol for Child Health
Clinic

• 2 and 4 mo Edinburgh Depression Screen
• 6 months PEDS Response
• 12 months PEDS Response
• 18 months PEDS Response and M-CHAT
• 24 months ASQ and M-CHAT
• 3, 4, 5 years PEDS Response
• gt6 years Pediatric Symptom Checklist (PSC)
• Adolescent CES-DC Depression Scale

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Developmental Assessment

• For children in foster care, a developmental
  screening for all children less than 5 years of
  age is done that is not dependent on caregiver
  report.

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Brigance Screens

• Birth through First grade
• Direct elicitation
• 15-20 minutes to complete
• Standardized and validated

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Domains
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Brigance Domains

• Screens across 6 Developmental Domains
• - Fine Motor
• - Gross Motor
• - Receptive Language
• - Expressive Language
• - Self Help
• - Social Emotional

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Developmental Screening Tools -ordering
information

• www.dbpeds.org tools, screening information,
  tips
• www.curriculumassociates.com -
• The Brigance System
• www.epsbooks.com (PEEX 2, PEER, PEERAMID 2)
• www.brightfutures.aap.org

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Developmental Assessment

• Neurodevelopmental screening for school age
  children who have not had psychoeducational
  testing at school.

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Neurodevelopmental ScreeningPEEX 2 PEERAMID 2

• School age children
• 45-60 minutes to administer
• Positive experience for children
• When are we going to play more games?

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Domains

• Fine Motor
• Graphomotor
• Gross Motor
• Language
• Memory
• Visual Processing

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Referrals

• Birth to age 3 years CDSA
• (Childrens Developmental Service Agency)
• ( Eligibility for Early Intervention)
• Age 3-5 years School System
• (Eligibility for Special Education process)
• School age - Base school and request testing
• (IEP process)

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School referrals/IEP reviews

• Review school records for those children with
  IEPs to determine the need for changes and/or
  updating.
• How to refer to SST

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McKinney Vento Part C

• Part of Homeless Assistance Act 1980s
• Allows students to remain in their base school
• Schools responsible for transportation to the
  base school

39

• Every Tuesday a man comes and gets me out of
  social studies and we go to a room and talk about
  it all. ..He spread out pictures of flat bats for
  me to comment on. I mostly saw flat bats. Then
  I saw big holes a body could fall right into.

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Mental Health Assessment

• Review mental health history and prior MH
  services/assessments.
• MH evaluations for all children ages 4 18 years
  if not currently in treatment
• MH evaluation may include observation of child in
  the home, daycare, or office setting along with
  collateral contacts with those working with child
• Complete a Doctors order for services and
  provide level of care information for indicated
  therapeutic services

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• ..he tells me Im scared. I used to be but I am
  not now.I might be a little nervous but I am
  never scared.

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Plan of Care

• Summary of each of the assessments findings
• List of referrals made
• Recommendations including primary care provider
  and other follow up recommendations
• Program coordinator reviews the POC with the
  caseworker.
• Copies of POC sent to PCP and foster parent.

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Lessons Learned

• Health care and child welfare agencies have a
  significant responsibility to assure
  comprehensive care for children in foster homes.
• Families and DSS staff prefer regionalization of
  services.
• Protocols (skeletal surveys, developmental
  screening, etc.) need to be followed.

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Lessons Learned

• More children were found in need of developmental
  and/or mental health services than DSS had
  previously anticipated. (DS-17 MH-50)
• Children are receiving services in a timelier
  manner than previously.

45

• Sometimes I count up what I like about the way
  Im living now. .And the best one number four
  is my new mama saying good morning to me like she
  means it.

46

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• The CHDP has offered comprehensive health
  services to all children entering foster care
  each year. The program has offered a resource
  that was not available previously and assures an
  individual plan of care addressing health,
  development, behavioral, and mental health needs.
  Foster children generally come from a background
  of poor or inconsistent health care records are
  frequently scarce. The CHDP is invaluable in
  providing a complete and thorough health view of
  these children who may be vulnerable to delays,
  emotional problems or other medical concerns.
• Elaine Rakouskas, WCHS Program Manager for
  Foster Care Services