RATES OF CHILDREN entering the US foster care system have been on the rise in the last 5 years. On any given day, nearly 443,000 children are in foster care in the US.1 Neglect, child abuse, and parental drug use are major reasons for foster care placement. Other factors may include parental behavioral health issues, poverty, and domestic violence.1
Children in foster care have disproportionately higher rates of physical and behavioral health problems, largely due to having experienced complex childhood trauma and poor access to healthcare.2 (See Foster care demographics at a glance.) Children in foster care are classified as having special healthcare needs because health problems are so highly prevalent among them.2 Therefore, all nurses and providers who care for children in foster care must be able to recognize the physical and behavioral health problems commonly seen in this population and know how to address these needs. This article takes a look at physical and behavioral health problems in children and teens in foster care and offers information and tips for providing care to this vulnerable population.
A significant percentage of children in foster care have severe emotional, behavioral, or developmental problems, and approximately 35% to 45% of children entering foster care have a chronic physical health problem such as asthma.3 Many children enter foster care with conditions that have not been diagnosed or treated.2 Children in foster care are more likely to have fair or poor health compared with children not in foster care and were recently found to have twice the rate of learning disabilities, developmental delays, asthma, speech problems, and obesity than their counterparts not in foster care.3 In fact, 60% of children entering foster care at age 5 years or younger were found to have a developmental delay, and 45% qualified for special education placement.3 Additionally, approximately 40% of children entered foster care with a significant dental or oral health problem.4
Many children in foster care have experienced significant trauma and exposure to toxic stress, which result in neurobiological, neuroendocrine, and structural changes in the brain.4 These alterations lead to an increased risk of behavioral health problems, which are seen in up to 80% of children and adolescents entering foster care.4-6 These problems cover a wide spectrum of diagnoses and behaviors, including conduct disorders, attention disorders, attachment difficulties, depression, delinquency, bipolar disorder, externalizing behaviors, sexualized behavior, aggressive behaviors, low self-esteem, and a greater risk for complex psychopathology.3,7,8 Compared with youth not in foster care, children and teens in foster care have three times the rate of major depression, twice the rate of posttraumatic stress disorder, four times more suicide attempts, and five times the likelihood of being diagnosed with drug dependence.7,9 It is therefore not surprising that children in foster care utilize more behavioral health services than children not in foster care.10
Along with increased utilization of behavioral health services, data have shown that children in foster care are prescribed psychotropic medications at approximately three times the rate of those not in foster care. Contributing factors may include lack of knowledge regarding the impact of childhood trauma by prescribers, lack of available pediatric behavioral health professionals, pressure from foster parents, and misdiagnosis of trauma-related symptoms.
In response to these disproportionately higher rates, Congress passed legislation requiring monitoring and oversight of the prescribing of psychotropic medication to children in foster care.2 This again highlights the need for providers and nurses to be well informed about the guidelines for caring for children in foster care.
Children and teens in foster care need specialized care for their complex physical and behavioral health issues. To address this, the American Academy of Pediatrics (AAP) published guidelines in 2015 for caring for children and teens in foster care.4 The guidelines state that a medical provider should see a child within 72 hours of being placed in foster care (within 24 hours for infants and children with complex medical needs). This visit should include assessment for problems requiring immediate attention, screening for abuse, developmental screening, educating foster parents (if necessary) if the child has a chronic medical condition or takes any medications, and ensuring that the child has any medications necessary. Ideally, the child should be seen at a medical home (either of origin or a medical home with professionals well-versed on trauma-informed care). (See What is a medical home?)
Behavioral health screening should also be conducted within 24 hours of placement into foster care, with a full behavioral assessment for trauma and comorbidities within 60 days. Children should be evaluated and treated by behavioral health professionals trained in treating childhood trauma using trauma-informed methods that are empirically supported, such as trauma-focused cognitive behavioral therapy.11
Children entering foster care should receive a routine physical within 30 days of entering care. Thereafter, they should be seen at their medical home at frequent intervals for ongoing assessment to manage any physical, developmental, and behavioral health needs and/or changes in home placement.12
Data show that approximately 31% of children entering foster care receive the necessary care as outlined by the AAP's guidelines.10 Very young children are unlikely to receive them at all.13 Access to behavioral health services is affected by placement instability, waiting lists, lack of pediatric behavioral health providers, lack of parental advocates, lack of providers willing to accept Medicaid, and consent barriers.14
Providing high-quality healthcare for children in foster care can be challenging as children enter and exit foster care or move from home to home within the system. Care is often fragmented when children are not seen at a medical home by experts versed in trauma-informed care. Providers and nurses may not be familiar with the guidelines, regulations, and complexities of the child welfare system. Information on a foster child's immunizations, newborn screening results, medications, allergies, chronic illnesses, hospitalizations, and surgeries is often incomplete, and appropriate written consents are often lacking.2 Some of these barriers can be addressed by contacting schools, previous healthcare providers, and shared or partnered electronic health records.
Caring for children in foster care requires time and a significant amount of care coordination and communication between child welfare professionals, parents, foster parents, behavioral health professionals, school personnel, and, at times, legal professionals.2 Nurses are often the first point of contact between the child and the medical home office, and they therefore play an essential role in caring for these children. Nurses who care for children in foster care must be trauma-informed and skilled in effective methods of communication as to avoid triggering or retraumatization. Furthermore, all members of the healthcare team can play an important role in advocating and supporting children in foster care to help ensure that they receive the services they require and to help them heal from the trauma they have experienced, potentially avoid and ameliorate complications from adverse childhood events, and ultimately improve outcomes.
Foster care demographics at a glance2
The average age of children in foster care is 8 years and they remain in care for an average of 20 months. However, 13% to 15% of children remain in foster care for 3 or more years. There are slightly more boys (55%) than girls (48%) in foster care, the majority of whom are White (44%), followed by Black (23%) and Hispanic (21%). Nine percent are other races or multiracial. A small subset of children in foster care are unaccompanied refugee minors, medically fragile children, and adolescents who have engaged in minor criminal activity.
What is a medical home?15
The medical home is a model of care centered on sharing responsibility for the care of a child between the family and the community. The medical home provides medical care that is:
- accessible, using a community-based team if possible
- continuously available
- patient- and family-centered
- culturally sensitive
- comprehensive (for example, it includes primary, preventive, and specialty care)
- coordinated across time and the continuum of care.
1. US Department of Health and Human Services. The AFCARS report #25. 2018. www.acf.hhs.gov/cb/resource/afcars-report-25
2. Szilagyi MA, Rosen DS, Rubin D, et al. Health care issues for children and adolescents in foster care and kinship care. Pediatrics
3. Turney K, Wildeman C. Mental and physical health of children in foster care. Pediatrics
5. Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron
6. Pritchett R, Hockaday H, Anderson B, Davidson C, Gillberg C, Minnis H. Challenges of assessing maltreated children coming into foster care. ScientificWorldJournal
7. Pilowsky DJ, Wu LT. Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. J Adolesc Health
8. Tarren-Sweeney M, Hazell P. Mental health of children in foster and kinship care in New South Wales, Australia. J Paediatr Child Health
9. Kerker BD, Dore MM. Mental health needs and treatment of foster youth: barriers and opportunities. Am J Orthopsychiatry
10. Knight EK, McDuffie MJ, Gifford K, Zorc C. Health service utilization of children in Delaware foster care, 2013-2014. Del Med J
11. Fratto CM. Trauma-informed care for youth in foster care. Arch Psychiatr Nurs
12. Schilling S, Fortin K, Forkey H. Medical management and trauma-informed care for children in foster care. Curr Probl Pediatr Adolesc Health Care
13. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry
14. Milburn NL, Lynch M, Jackson J. Early identification of mental health needs for children in care: a therapeutic assessment programme for statutory clients of child protection. Clin Child Psychol Psychiatry
15. Kuo DZ, Turchi RM. Children and youth with special health care needs. UpToDate. 2019. www.uptodate.com