Foster Care

Overview

More than half a million children and adolescents are served each year by the foster care system in the US. They are a vulnerable population with higher rates of physical, developmental, educational, and dental problems than their peers. [Chernoff: 1994] [Simms: 2000] [Stein: 2013] [Beal: 2016]

Factors contributing to these health and developmental problems include exposure to traumatic experiences and family dysfunction, inadequate care in the family of origin, lack of prior health care, and previously undiagnosed health disorders. Traumatic experiences may include neglect, physical and sexual abuse, domestic and community violence, witnessing parents or loved ones in life-threatening situations or abusing substances, and/or family separation.

Foster care includes children and adolescents from birth to 21 years of age in court-ordered, out-of-home placement. This may involve living in a non-relative foster home, with extended family (“kinship” care), or in certain circumstances, a group home or therapeutic residential placement. [Administration: 2019]

Recognizing the unique needs of children and adolescents in foster care, the child welfare and foster care systems have expanded their roles to include responsibility for the child's overall well-being, including health, safety, stability, and permanency. Primary care clinicians can collaborate with child welfare agencies to improve the physical and mental health of children in foster care. They can leverage their unique position and relationships to engage with families of origin and foster families to minimize the trauma of separation, identify health care needs, initiate treatment, and provide health-related education. [Jones: 2020] Close surveillance and continuity of care should continue as children transition among placements.

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care (AAP) assists primary care clinicians in providing trauma-informed care and meeting the health needs of children in foster care. The article emphasizes the need to seek health care early and often. [Council: 2015]

Other Names & Coding

Children in the child welfare system

Helpful Screening Codes
Z13.40, Visit for screening for certain developmental disorders in childhood (standardized screening code)

Common Behavioral and Mental Health Diagnoses
F94.1, Reactive attachment disorder of childhood
F94.2, Disinhibited social engagement disorder of childhood
F43.0, Acute stress reaction
F43.8, Other reactions to severe stress
F39, Mood disorder
F34.81 Disruptive mood dysregulation disorder (DMDD)
Z79.899, Long-term use of high-risk medication

ICD-10 coding

Z02.89, Medical exam for child entering foster care

Z62.21, Child in foster care

Z63.32, Family disruption due to child in foster care or non-parental family member care

Z62.822, Parent-foster child conflict

Z62.819, History of victim of child abuse

Further coding details can be found by using the search feature at ICD10Data.com.

DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2013] generally designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits our including their codes or descriptions.

Prevalence

Every primary care clinician should be prepared to care for children who have experienced maltreatment and its sequelae, including foster care placement.

In 2017, at least 9 out of every 1,000 children in the US suffered abuse. Of these children, 28.1% were under 3 years of age, 74.9% suffered neglect, 17.5% physical abuse, and 9.3% sexual abuse. [Child: 2019] In 2019, there were 423,997 children in foster care, roughly 1 in 202 children/adolescents. Of these children, the median age at the time of entering foster care was 7.7 years, 44% were white, 23% Black or African American, and 21% Hispanic. [Sepulveda: 2020]

Studies have shown that 35-50% of children entering foster care have significant emotional and behavioral problems; 46% of those under age 6 have developmental problems; 80% of those under age 3 years were exposed to maternal substance abuse in utero. [Stahmer: 2005] [Ringeisen: 2008] Children and youth in foster care are more likely to have an identified special health care need and need more resources than their peers. Reported numbers of children and youth with special health care needs (CYSHCN) in foster care vary by state, comprising at least 24% of the foster care population. Some states report up to 83% as having an identified special health care need. [Sepulveda: 2020]

Genetics

Although genetics does not play a direct role in causing children to be neglected, abused, or placed in foster care, heritable characteristics or conditions can lead to parental behaviors and limitations that then lead to their children needing such placement.

Prognosis

In 2019, more than 248,669 children exited foster care: [Sepulveda: 2020]
  • 47% were reunited with parent(s) or primary caretaker(s)
  • 26% were adopted
  • 11% went to live with a guardian
  • 8% were emancipated or “aged out” of the foster care system when they became too old (usually at age 18) to receive further services
  • 6% went to live with another relative
  • 1% had other outcomes (includes transferal to another agency, running away, or death)
CYSHCN who enter foster care are more likely to face placement instability and challenges with permanency. [Sepulveda: 2020]

Though little data exist on long-term outcomes for children who exit foster care before 18, the effects of child abuse and neglect often have long-lasting adverse consequences for survivors. Untreated conditions, particularly emotional and behavioral ones related to traumatic experiences, are the most common reasons for foster placements to fail, which leads to further disruptions in care, school, and community for the child. [Jones: 2020] The Adverse Childhood Experiences (ACE) Study demonstrated that child abuse, neglect, and other circumstances that disrupt the child-parent relationship are significantly associated with many leading causes of adult death, such as strokes, cancer, and heart disease, and with heavy health service utilization. Stressful childhood experiences lead to higher rates of depression, suicide, cigarette smoking, diabetes, obesity, hypertension, and alcohol and substance abuse. [Felitti: 1998]

One study found that adolescents who “age out” of the foster care system suffer serious lasting consequences: 1 in 4 will be incarcerated within 2 years of leaving foster care; 1 in 5 will become homeless sometime after age 18 years; only 58% will graduate from high school (compared to the 87% national average). [Jim: 2007] Recent studies have found that adult outcomes are better when policies support that youth remain in foster care after the age of 18. [Rosenberg: 2019]

Practice Guidelines

Szilagyi MA, Rosen DS, Rubin D, Zlotnik S.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1142-66. PubMed abstract / Full Text

Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics. 2020. PubMed abstract

Jones VF, Schulte EE, Waite D.
Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.
Pediatrics. 2020;146(6). PubMed abstract

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text

Keeshin BR, Bryant BJ, Gargaro ER.
Emotional Dysregulation: A Trauma-Informed Approach.
Child Adolesc Psychiatr Clin N Am. 2021;30(2):375-387. PubMed abstract

Kerker BD, Zhang J, Nadeem E, Stein RE, Hurlburt MS, Heneghan A, Landsverk J, McCue Horwitz S.
Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.
Acad Pediatr. 2015;15(5):510-7. PubMed abstract / Full Text

Roles of the Medical Home

The primary care clinician and medical home may provide one of the most stable adult influences in the life of a child in foster care. According to the American Academy of Pediatrics (AAP), the medical home serves as the focal point for reducing toxic stress and supporting child and family resiliency. The medical home offers safety, care coordination, access to resources, and continuous care for a child who has experienced trauma. See Health Care Issues for Children and Adolescents in Foster Care and Kinship Care (AAP). [Council: 2015]

Recommendations for adapting the medical home model for the health care needs of youth in foster care include: [Espeleta: 2020]
  • Knowledge about the child welfare system and consent process in your state
  • Supporting access to care and caregiver support through phone consultation
  • Obtaining and maintaining updated medical records
  • Implementing trauma-informed care and best practice guidelines
Routine follow-up visits should be frequent, as should opportunities for the child or adolescent to talk about their needs, fears, and desires. Acknowledging the anger, fear, sadness, loss, grief, and confusion associated with foster placement validates the child’s experience and can support their developing coping skills. Identifying and addressing cognitive distortions (e.g., “it’s my fault,” “no one will ever want me,” or “I should have kept my dad from hurting my mom”) can make a huge difference for a child. Instilling hope and identifying strengths that will help them survive, and perhaps thrive, during the foster care experience is important.
The primary care clinician can provide families with guidance about the effects of traumatic stress on development, behaviors, emotions, and learning, especially during times of transition. The clinician can provide families emotional support, validation, and tools to optimize their responses for challenging symptoms often seen in children and youth in foster care. Identifying toxic stress and related symptoms enables the clinician to advocate for the child within the child welfare system. Interventions that promote a stable foster placement and a timely, well-coordinated transition to a permanent home, including coordination of medical care, will mitigate deleterious effects on the child’s long-term development.

Toxic Stress Toolkit (AAP) (PDF Document 11.4 MB) and Parenting after Trauma: Understanding Your Child’s Needs (healthychildren.org) provide the tools clinicians will need to care for youth in foster care, identify traumatized children, educate families about traumatic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote more adaptive reactions to stress.

Clinical Assessment

Overview

The reason for placement in foster care may or may not be provided to the clinician at the time of assessment. Prenatal substance exposure and/or living with a parent using substances is common and may impact health.

Every child entering foster care should have a health screening evaluation before or shortly after placement. The examination should identify any safety concerns, as well as medical, mental, or dental needs that require prompt attention or that should be considered in making placement decisions. Within 1 month of the initial screen (or simultaneously with the screen), the child or adolescent should receive a comprehensive health and developmental assessment. The child’s caseworker, foster parents, and/or birth parents (if appropriate) should be present at visits and can help with acquiring medical records and history.

Consent for routine and emergency medical care, as well as the release of past medical records, should be obtained from the family or legal guardian per state regulations. Provide trauma-informed continuity of care, education and support to caregivers, follow-up care, care coordination, and child welfare system communication. [Duffee: 2021]

Comprehensive and well-child health assessments should follow 2021 Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB) screening recommendations by age and risk. Follow screening guidelines for high-risk social determinates of health from Bright Futures Guidelines for Health Supervision - Pocket Guide, 4th Edition (AAP) (PDF Document 5.1 MB).

The American Academy of Pediatrics has published practice guidelines for the care of children and youth in foster care based on consensus among experts due to the lack of research in this area. The guidelines provide recommendations for comprehensive medical, mental health, and dental assessments at the time of entry into foster care and ongoing coordinated care. [Szilagyi: 2015] [Council: 2015] [Duffee: 2021]

Summary of AAP Guidelines
1. Initial assessment
  • Collect and update demographic information, identify the type of placement, past medical, family, and social history, and reason for out-of-home placement.
  • Conduct a complete physical examination, including detailed descriptions of dermatological and other pertinent exam findings.
  • Identify needs that require prompt attention, including assessment for acute injuries, suicide risk, and acute mental health conditions.
  • Schedule follow-up and obtain medical records.
  • Identify the system of communication and care coordination with Child Welfare in your state.
2. Comprehensive assessment and well-child care (within 30 days of entering foster care)
  • Collect comprehensive history and conduct a complete physical exam.
  • Conduct age-appropriate, standardized, developmental and trauma screening; reassess for acute injuries, risk of harm to self or others, and substance use. For all adolescents, include a HEADSS Assessment (PDF Document 72 KB) without the caregiver in the room.
  • Identify gaps in care. Update medication list, provide medication refills as needed, update problem list and prioritize needs. Develop a plan of care with dental, mental health, and specialty care referrals as indicated.
  • Provide trauma-informed anticipatory guidance. Provide support and psychoeducation around the impact of adverse childhood experiences and trauma on child behavior and self-regulation. Help foster parents identify trauma triggers, set appropriate expectations, and promote trauma-informed treatment and resiliency.
3. Continuity of care
  • Coordinate care including referrals, follow-up, and communication with the Child Welfare System.
  • Identify team members including social workers, mental health clinicians, school personnel, subspecialists, others as indicated.
4. Placement stability
  • Ask about interval changes in social history. Youth in foster care may experience disruption in placement for different reasons. Ask about the current placement, how long has the child has been living in this placement. Does the child have other siblings? If so, where are their siblings living?
  • Visitations: Do they have visitations with parents and/or siblings.
  • Demographic information: Maintain updated demographic data. Include information related to name and contact information for child welfare social worker (usually they are the emergency contact); maintain the confidentiality of foster parent(s) by entering their name and contact information in the designated confidential demographic section of the health record.

Pearls & Alerts for Assessment

All children in foster care have unique health care needs

Look for physical, developmental, and emotional health conditions common in children who have experienced trauma. Consider the impact of adverse childhood experiences and traumatic stress on brain development. See youth in foster care frequently, assess safety, look for gaps in care, know who can make decisions, and be aware that trauma can mimic many physical and psychiatric diagnoses. Include trauma screening, physical, dental, and developmental assessments and monitoring. Refer as needed to mental health specialists for evaluation and trauma-based treatment.

Altered responses

Biological and environmental risk factors, as well as adverse childhood experiences and traumatic stress, increase risk for physical, developmental, behavioral, and mental health concerns. [Shonkoff: 2012] Exposed children may have problems with self-regulation (sleep disturbances, eating problems, or toileting problems) and symptoms of depression, anxiety, ADHD, aggression, self-injury, and anger that persist long after the child has been removed from the abusive or neglectful environment. Children may develop symptoms related to separation from their home and other familiar environments, which may be the most traumatic aspect of entering foster care. Physicians can help caregivers identify altered responses, formulate effective coping strategies, and mobilize available community resources. [Stirling: 2008]

Role as confidant

Most children in foster care have been exposed to traumatic events beyond what is known or reported. During the initial visit, children may not be ready to discuss past trauma. Use positive and supportive language to build trust and support the child’s sense of self. The child may be willing to talk to their health care provider about past events, such as other physical or sexual abuse, that they have not previously disclosed. Discuss limits of confidentiality using developmentally appropriate language.

High percentage of children in foster care have ADHD symptoms

While set routines in a predictable home can help some symptoms, many children struggle to engage in trauma-focused mental health treatment because of inattention, impulsivity, and hyperactivity. Start with mental health screenings, including measures assessing traumatic events and trauma symptoms, refer for evidence-based, trauma-focused treatment and additional evaluation as needed in consultation with the child’s mental health therapist. [Fraser: 2019]

Monitor for suboptimal care

Disruptions in care, continuity of care, and schooling can occur at the entry in foster care, during placement changes, or visits with the family of origin and can lead to increased emergency room use. [Rubin: 2004]

Reconstruct medical, medication, and immunization history

Direct contact with previous health care providers or review of previous medical records (e.g., from schools or immunization registries) may enable reconstruction of the child’s health, medication, and immunization history. The child may have been known by other names, and birthdates may be inaccurate. Verify current medications and reconcile medication lists that may be present in the electronic medical record. If immunization information is unavailable, children should be considered susceptible and immunized according to guidelines. [Szilagyi: 2015]

Screening

For Complications

Consider screening for developmental delays, vision, hearing, autism, effects of traumatic stress, alcohol and substance abuse, depression (e.g., PHQ-A and GAD), ADHD, other mental health disorders, risky sexual behavior, and learning disabilities. Because many young children entering foster care have been exposed to substance abuse and/or sexual abuse, they should be considered high risk for HIV infection, hepatitis, and other sexually transmitted infections. Laboratory tests for these conditions should be performed when appropriate. [Szilagyi: 2015] See Medical Screening Reference Table (Bright Futures) (PDF Document 1.0 MB) for high-risk screening guidelines.

Presentations

Unless the family volunteers the information, the primary care clinician may not know that a child has had an episode in foster care between office visits. If aware of a pending or completed placement, the primary care clinician can advocate for maintaining continuity of care or collaborating with a new clinician if necessary.

Comorbid & Secondary Conditions

Children in foster care may manifest many disorders that reflect the impact of social determinants of health, prenatal risk factors including in-utero alcohol and substance exposure, early childhood traumatic experiences, toxic stress, and lack of preventive health care. Lack of medical and developmental history may create diagnostic challenges. For example, rates of missed or misdiagnoses of fetal alcohol spectrum disorders are higher in youth in foster care due to unknown history of maternal alcohol use during pregnancy, variability of presentation of physical features, and high rate of co-occurring mental health disorders. [Chasnoff: 2015]

Common health problems of children and youth in foster care include: [Turney: 2016]
  • Asthma
  • Growth concerns
  • Metabolic syndrome
  • Dental caries and other dental conditions
  • Infectious disease
  • Inadequate immunizations
  • Vision and hearing issues
  • Developmental delay, speech and language problems, learning disability other neurodevelopmental disabilities (e.g., fetal alcohol syndrome, autism, other)
  • Emotional dysregulation
  • Sleep disturbances
  • Mental health problems
    • Attachment disorder
    • Post-traumatic stress disorder (PTSD)
    • Depression, anxiety, and other mood disorders
    • Behavioral disorders, such as attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), and conduct disorder (CD)

History & Examination

At the initial visit, little, if any, medical and other histories may be available. Suspicion of previously undiagnosed or untreated special health care needs should be high. The child might have corrective lenses, hearing aids, dental retainers, inhalers, or medicines that did not accompany them into the foster care system or in transition between placements. The history should include foster parent needs, normalizing activities for the child, other services the child may be receiving, school adaptation and function, and any behavioral or emotional issues.

Current & Past Medical History

If information is insufficient, the child welfare worker and parents (if possible) should be contacted to gather relevant history. Exercise, nutrition, elimination, and sleep hygiene should be reviewed. If possible, obtain information regarding seizures or previous head injuries or concussions. Concussions may result from physical abuse, accidental or sports-related injury. Immunization status should be confirmed.

Family History

Children in foster care likely have complicated family and social histories. Collect a detailed family and social history to understand health risks and experiences prior to living with the current caregiver. [Winokur: 2018] If possible, obtain a history of mental illness from the family of origin.

The foster parent or caregiver may have little or no information about the child’s family history or past social history. A young child may not use words that distinguish caregiver and family of origin relationships. Work with child welfare to obtain this information.

The foster family’s history and experience with special needs children are important in understanding how comfortable they are likely to be with managing any medical or mental health problems.

Pregnancy/Perinatal History

Consider likelihood of maternal alcohol use, substance abuse, or smoking during pregnancy prematurity related to poor prenatal care, poor nutrition, or stress related to domestic violence; postnatal exposure to neglect or substance abuse in the environment; and shaken baby syndrome. Document gestational age, significant information from newborn records, known prenatal exposure to alcohol, marijuana, opioids, methamphetamine, other substances of abuse, and/or history of neonatal opioid withdrawal syndrome.

Developmental & Educational Progress

Developmental screening is recommended for children under 6 years. Review any changes in school placement. If the child has an individualized education plan or a 504 plan for health accommodations at school, check if the plan has transitioned to the present school.

Maturational Progress

With adolescents, discuss gender identity, sexual orientation, sexual activity, alcohol or drug use, tobacco use, prevention of sexually transmitted disease, and contraception (see Contraception & Menstrual Management). For children entering puberty, identify who is providing education and guidance.

Youth that identify as lesbian, gay, bisexual, transgender, and questioning (LGBTQ) are at increased risk for family relationship disruptions, discrimination, and harm. A 2019 study found that LGBTQ youth are over-represented in foster care compared to LGBTQ youth not in foster care (30.4% vs. 11.2%). These youth need protection and care that is affirming of their sexual orientation and gender identity. [Baams: 2019] [Sepulveda: 2020]

Ask about family relationships (both foster and family of origin), adjustment to foster care, peer relationships, adjustment to school, hobbies, education, or career plans. Asking caregivers about discipline techniques and assessing developmentally appropriate expectations for these very emotionally and behaviorally challenging children may help identify caregivers at risk for punishing harshly. Goals for the child’s permanent placement (e.g., reunification with parents, adoption, guardianship, or kinship placement) will guide who should be involved in health care planning and consent for treatment.

Physical Exam

General

An initial complete physical examination, including genital exam, is indicated. Inspect closely for signs of abuse, neglect, or maltreatment and report with photographic documentation when indicated. Approach the exam with sensitivity and awareness of the impact of traumatic experiences and developmental stage of the child. It may be appropriate to defer a genital exam at the initial exam based on the child’s preference and history.

Vital Signs

Baseline vital signs are important since children and adolescents exposed to toxic stress are at risk for developing hypertension or cardiac disease.

Growth Parameters

Plot growth, including BMI. Children on psychiatric medicines may experience weight loss or weight gain. Children on antipsychotic medicines are at risk for metabolic syndrome; BMI > 95th percentile or waist circumference > 90th percentile and Blood Pressure > 90th %.

Skin

A full exam is important to look for bruising or injury that may reflect abuse or self-harm. Common areas of self-harm include forearms, abdomen, and thighs. Document presence and location of tattoos and piercings.

HEENT/Oral

Children in foster care are at increased risk for caries and poor dental hygiene.

Genitalia

Identify yourself to the child or adolescent as a clinician. Conduct the exam in a matter-of-fact way that normalizes the experience as a standard part of every full exam. Avoid using endearments such as “honey” or “sweetie.” Instead of interrogating, use statements such as “I don’t understand” or “can you help me understand?” and “I wasn’t there, so I don’t know.” During the exam, let the child use their own language and do not correct or interrupt when first describing an incident.

Extremities/Musculoskeletal

Examine for fractures or injury, present and past.

Neurologic Exam

Without adequate history, it may be unknown if the child or adolescent has had previous head injuries.

Testing

Sensory Testing

Screen hearing and vision. Traumatized children may dissociate and seem “not to hear.” They may be over- or under-reactive to sensory input. Consider a referral to Occupational Therapy to evaluate for sensory modulation disorder and provide ongoing therapy and support.

Laboratory Testing

Depending on the clinical scenario and access to and reliability of medical history, consider screening for:
  • Anemia
  • Lead level
  • Tuberculosis (purified protein derivative tuberculin (PDD) if 3 months or older; or quantiferon -TB gold test)
  • HIV
  • Hepatitis B
  • Hepatitis C
  • Sexually transmitted infection
    • Chlamydia, gonorrhea, syphilis, and HIV testing if risk assessment is positive. Follow universal screening guidelines, including HIV screening once between 15 -18 years of age. (Check state policy regarding who can give consent for testing and confidentiality of test results.) 2021 Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB)
  • Pregnancy testing (Check state policy regarding who can give consent for testing.)
  • Evaluation for metabolic syndrome
    • Fasting serum triglyceride levels (>110mg/dL)
    • Fasting HDL-cholesterol (<40mg/dL)
    • Fasting glucose (>110mg/dL)
    • HbA1C (5.7 - 6.4 pre-diabetes; >6.5 diabetes)
  • Consider maternal labs for evaluation of newborn

Imaging

Perform appropriate studies if suspicion of previously undiagnosed new or past fractures, including skull fractures or head injury.

Other Testing

EEG if suspicion of seizure disorder. Children may present with episodic “blank staring” that may be secondary to dissociation that must be differentiated from seizures; the Portal’s Seizures/Epilepsy, Initial Diagnosis.

Specialty Collaborations & Other Services

Consider/participate in interprofessional team-based care if possible. Identify medical specialists previously involved with the child and determine if follow-up visits are indicated.

For children under age 5, identify prior developmental assessments, early intervention, or other services involved. Children 3-5 years may need special education services.

Children in foster care have a high incidence of psychiatric disorders, including PTSD. Determine if the child/adolescent was receiving mental health services prior to placement and then, if possible, coordinate ongoing care. The child welfare worker should be able to provide access to mental health assessments and treatment. Often there will be a forensic evaluation if the child or adolescent has experienced abuse. This may include a physical exam and a video-recorded interview that meets legally defined standards of care.

Early Intervention for Children with Disabilities/Delays (see RI providers [14])

For children birth to age 5 who qualify for early intervention and/or special education preschool.

Early Childhood Education/Preschool (see RI providers [7])

For children with developmental concerns.

Occupational Therapy (see RI providers [14])

Consider referral or children with high levels of sensory sensitivities or hypo-responsiveness.

Speech - Language Pathologists (see RI providers [27])

For children with delayed language or speech development.

Psychiatry/Medication Management (see RI providers [78])

For children with evidence of mental health disorders, such as post-traumatic stress disorder (PTSD).

Neuropsychological Assessment (see RI providers [19])

Psychological/neuropsychological evaluations for children with neurodevelopmental disorders

Head Start/Early Head Start (see RI providers [16])

For infants and toddlers with disabilities or delays to learn many key skills and catch up in their development.

Treatment & Management

Overview

Management strategy
Because of multiple risk factors, children in foster care often benefit from the following management strategies:
  • Assess safety (just because they are in custody does not mean they are safe)
  • Be aware of placement disruptions, look for gaps in care and services, may need prescription refills
  • Know who can make medical decisions
  • Provide education and support to caregivers, continuity, tracking, and care coordination
  • Symptoms of trauma can mimic many physical and psychiatric diagnoses
  • Be an advocate and liaison with child welfare

Pearls & Alerts for Treatment & Management

Motivational interviewing for adolescents

Motivational interviewing can be a valuable technique for approaching risk-reduction counseling and contraception with adolescents. Motivational Interviewing (MINT) provides details of this technique.

Share the treatment plan

Consider the health literacy of the child and foster parents when formulating and discussing the treatment plan. Also, share the treatment plan with the child’s caseworker and birth parents if appropriate.

Balancing short- and long-term goals of care

Providing primary care for children in foster care presents several dilemmas for the clinician. First, the caregiver who accompanies the foster child may be the foster parent, the child welfare worker, or simply a transport provider. They may be most interested in resolving an immediate problem (e.g., the child needs to be calmer or go to sleep) and may not address long-term concerns or issues as most parents would. This places greater responsibility on the primary care clinician to consider and advocate for the child’s long-term needs and interests. Discontinuity of care and lack of access to medical records are often a challenge since the foster parents may prefer not to (or are unable to) continue care with the child’s previous primary care clinician.

Multiple psychotropic medications are often prescribed to manage behavioral symptoms. This may be driven in part by relatively short-term goals that may not be in the child's long-term best interest. Addressing the latter and collaborating with foster care programs to access services that help foster families manage symptoms non-pharmacologically may be useful.

How should common problems be managed differently in children with Foster Care?

Development (Cognitive, Motor, Language, Social-Emotional)

Beware of the impact of trauma on brain development, which may result in responses that can be misidentified and/or comorbid with behavioral and mental health diagnoses. For more information, see below.

Prescription Medications

See UPOP Resources Medical Professionals for detailed information about Monitoring Physical Health and Side Effects of Psychotherapeutics and a Guide to Psychotropic Medication Prescribing in Children and Adolescents.

Systems

Other

Overcoming Barriers to Caring for Children and Adolescents in Foster Care

Access to medical records
Access of individuals to protected health information is regulated under 45 CFR § 164.524. Be aware of who can have access to the medical record. Update guardian, emergency contact, and electronic access to the medical record. At the time of entry into foster care, identify the legal guardian and update electronic health record access and demographic information. Changes may need to include removing the parent’s or prior guardian’s access to the medical record. Determine if it is appropriate for the youth to have electronic access to their health record.

Confidentiality
Adolescents may be able to retain their right to confidentiality and consent for treatment for pregnancy and STI. However, the current legal guardian may still have access to the medical record, including visit notes (i.e., HEADDS assessment), unless there is documentation stating that doing so may result in substantial harm. For this reason, know the related privacy rule policies for your organization.

It is appropriate to talk with the youth without the caregiver in the room to assess safety. Age-appropriate opportunities for youth to talk privately with the health care provider should be provided. Obtain consent from the caregiver, and discuss the limits of confidentiality with the youth and caregiver. For example, the discussion between youth and health care provider may remain confidential unless there is a risk of harming oneself or others.

Consent
Another challenge is understanding who has legal authority to consent for care—the rules vary by state. When the state takes custody, the parents maintain legal guardianship unless the courts legally terminated parental rights. If birth parents are unavailable or uncooperative, an authorized committee or person within social services usually can provide medical consent for care. Depending on state regulations, foster parents may or may not be able to provide consent for certain medical interventions. Primary care physicians should receive (or seek) a copy of general medical consents from foster care agencies. [American: 2005]

Family

Foster, Kinship, Adoptive Families
Clinicians need to understand the complexities of the child’s current living situation to support the child and the family. Become familiar with the child welfare system in your state. One-quarter of placements are likely to be in kinship care. Fifty-nine percent of children exiting foster care in 2018 returned to a parent or primary caregiver, 25% were adopted, 7% lived with other relatives (kinship care). [Children's: 2019]

Multiple studies support the benefit of kinship placements. To help these placements succeed, clinicians can help families understand the effects of adverse childhood experiences and encourage developmentally appropriate expectations and responses to the child. Lay a foundation for a child’s later understanding of foster care and self-identity by encouraging conversation using developmentally natural discussions about foster care, adoption, and birth family. Help families acknowledge racial and cultural differences. Be aware of the complexity of losses experienced by foster, adoptive, and birth parents; provide support and facilitate mental health referrals as needed. [Jones: 2020]

Caregiver Support
When parents or foster parents report significant behavioral or emotional problems with a child, consider their capacity to manage the child’s behaviors without emotional or physical abuse. Referral for respite care may be useful or, if punishment appears to be abusive, child protective services should be contacted.

Help families understand the potential for trauma-induced aberrations in bodily functions and behaviors and help determine the need for intervention. Understanding responses to trauma can help families set appropriate expectations. Toxic Stress Toolkit (AAP) (PDF Document 11.4 MB) provide useful information to begin this educational process.

Mental Health/Behavior

Impacts of Toxic Stress
Trauma-related toxic stress may result in neuro-dysregulation and explain behavior problems commonly observed in children that may be misidentified as ADHD, ODD, or conduct disorder. In addition, comorbid behavioral and mental health conditions, such as reactive attachment disorder, are common. Understanding the impact of ACES and traumatic experiences on development provides a framework for caring for children and youth in foster care. See Toxic Stress Toolkit (AAP) (PDF Document 11.4 MB).

In addition, agitation, anxiety, and poor attention are common responses to entering foster care and a new, unfamiliar home. Children and teens are often grieving the separation from their family and feeling confused by what has happened. These symptoms should be evaluated and followed to determine if they are transitory adjustments to foster care, recovery from exposure to past trauma, or a psychiatric disorder, such as ADHD or post-traumatic stress disorder.

Triggers
Family visitations will be part of the child welfare plan. Initially, the child may have no contact with their family of origin. When deemed safe, visitations will start with supervised visits and, depending on progress toward reunification, visits will become more frequent. Although visitation with their parents may be healing when they go well, they may bring back separation, loss, fear, and anger. It is common for children to be emotionally reactive following a visit. [Winokur: 2018] Foster families may seek guidance on managing changes in eating patterns, emotional dysregulation, and sleep following visits. For a helpful handout to guide foster families, go to Parenting after Trauma: Understanding Your Child’s Needs (healthychildren.org).

The primary care clinician may feel pressure to start or continue and monitor use of psychotropic medication(s) when they see 1) a child or adolescent as they transition from a residential setting where medicines were used, 2) a child in jeopardy of losing their foster placement or having school problems due to behavior, or 3) the caregivers and caseworkers are not able to provide an adequate past or present history.

However, use of psychotropic medication may not be in the child’s best interest. Disruptive behaviors, such as aggression, defiance, and temper tantrums/outbursts, may indicate a reaction to traumatic events, which does not respond well to medicine. Poor sleep may contribute to moody behavior or poor attention span. Dissociation may look like oppositional behavior or the child ignoring directions.

Take the time to involve the relevant caregivers, obtain adequate information from the homes and the school, and clarify symptoms and diagnosis. In addition to evaluating for trauma and assessing sleep, use the “BOLDER” approach to assessment: T-MAY (Treatment of Maladaptive Aggression in Youth) Toolkit:
  • Behavior: In what ways does the child exhibit aggression?
  • Onset: When does it happen? What triggers it and why?
  • Location: Where do the symptoms occur - home/school?
  • Duration: How long does it last?
  • Exacerbates: What makes it worse?
  • Relief: What makes it better?
Maladaptive Aggression
Evidence-based treatment recommendations for maladaptive aggression in youth were published in the June 2012 issue of Pediatrics. The T-MAY guidelines are as follows:
  • Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management. [Knapp: 2012]
  • Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management. [Scotto: 2012]
  • See Emotional Dysregulation: A Trauma-Informed Approach [Keeshin: 2021]
Also, see Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder [Zeanah: 2016].

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see RI providers [78])

Assists with diagnosis of mental health disorders, symptom and medication management, particularly in complex cases with children who exhibit both medical and psychiatric disorders, and/or the coordination of mental health care.

General Counseling Services (see RI providers [33])

Evaluates for learning disabilities, autism, or developmental disorders. May provide individual or family therapy. Some psychologists have additional training in trauma-informed or trauma-focused treatment.

Neuropsychiatry/Neuropsychology (see RI providers [6])

Consider referral when a child has complex learning disorders associated with possible autism, intellectual disability, or brain injury.

Family Support Services (see RI providers [41])

Many community mental health centers provide case management or respite care for children in their programs. When a child is in the custody of the state, there are sometimes financial restrictions on whether the local mental health center or the child welfare system should provide these services.

Crisis Mental Health Care (see RI providers [10])

The Child Welfare system often contracts with specific providers for more intensive crisis and residential care and should be contacted when these services are needed.

Address safety and address local resources, crisis numbers, apps on Mobile Devices.

Sexual Assault Counseling (see RI providers [3])

Provides prevention, intervention, and treatment services for children and families.

Respite Care (see RI providers [13])

Services to provide caregivers a break.

Pharmacy & Medications

Managing psychotropic medications for children and adolescents in foster care can present numerous challenges related to complicating emotional/behavioral problems, sleep issues, ongoing instability in the home, school and supervision, and polypharmacy. Guidelines for treatment of ADHD, depression, or other psychiatric problems, which include information about choices and dosages of medications, can be found in the following resources:


Clearly define target symptoms, expected outcomes, and potential side effects. “Start low and go slow” – one medicine at the lowest dose expected to be effective and (increase dose or change/add medication deliberately to allow response both to the medication(s) and the new home environment. Follow up frequently to assess response, make needed adjustments, and provide support.

Medications do not treat oppositional-defiant disorder or conduct disorder. Refer for evidence-based treatment for trauma-related symptoms and PTSD, including Parent-Child Interaction Therapy (PCIT), trauma-informed CBT, and other evidence-based therapeutic modalities. If medication trials do not result in expected response, consider the impact of trauma and what other behavioral and psychosocial supports need to be considered. Assess other contributing factors such as sleep disturbance, psychosocial issues, and school behavior. The use of antipsychotic medications in preschoolers (children under 6 years of age) is generally “off-label,” not recommended, and should only be considered under the most extraordinary circumstances. Disruptive aggression in autism is one such circumstance.
If considering starting a psychotropic medicine:
  1. Know your state’s consent guidelines for initiation of psychotropic medications. Consent guidelines may range from consent by the caregiver accompanying the child to court approval.
  2. Conduct comprehensive multi-informant, multi-modal, and multi-disciplinary assessments for those with a positive screen. Evaluate medical, social, and cognitive causes of behavioral symptoms. Use validated measures to assess and track psychiatric symptoms and impairment in young children, including psychosocial treatment /trauma-focused therapy.
  3. Assess side effects and consider laboratory tests for baseline and ongoing metabolic monitoring.
  4. Psychotropic medication monitoring recommendations for youth in foster care: [Keeshin: 2020]
    • Appointments every 3 months (include BMI assessment). Consider a telehealth visit if stable.
    • Baseline to and periodic assessment/updates to:
  5. Educate families and caregivers on side effects, administering medication, maintaining an accurate medication list, bringing medication lists to each visit, and how to make medication changes when indicated. [Keeshin: 2020]
With school-age children, maintain high suspicion for ADHD. Girls, in particular, may be considered socially disruptive or purposefully disobedient rather than suffering from impulsivity and working below their abilities due to ADHD, inattentive type. Treatment typically begins with stimulants but, if risk of substance abuse or drug diversion, consider non-stimulant drugs such as clonidine, guanfacine, or atomoxetine. These may have the advantage of improving sleep and not interfering with appetite.
For older children and teenagers, evaluation for depression and anxiety disorders is critical. While SSRIs are associated with increased risk of suicidal ideation, there are significant benefits in overall functioning and in decreasing actual suicide with SSRIs. Psychotherapy is the treatment of choice for a child or youth with anxiety or depression. The primary care clinician should monitor response and notify the child’s therapist when there is inadequate progress. Atypical antipsychotics, such as risperidone, aripiprazole, and quetiapine, are approved for mood stabilization in children and adolescents with bipolar disorder and symptoms of agitation and aggression associated with autism. They may decrease aggression, but the long-term side effects can be significant and demand monitoring. These medicines may provide short-term support while other services are being accessed - they should not replace intensive mental health care.

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see RI providers [78])

Assists with diagnosis of mental health disorders, helps with symptom and medication management - particularly with complex cases such as children with both medical and psychiatric disorders, and assists with coordinating mental health care.

Nutrition/Growth/Bone

Previous height and weight records, if available, may suggest neglect and/or ongoing stress. Some children react to the lack of control in their lives through choices about eating or not eating. Cultural or family-specific food preferences and rituals may affect the child’s eating habits. Neglected children may hoard food, search through garbage, or eat until they vomit due to anxiety over past lack of access to food. Psychiatric medicines may decrease or increase appetite and affect weight gain or loss.

Specialty Collaborations & Other Services

Nutrition Assessment Services (see RI providers [2])

May help devise dietary approaches and recommend foods that will optimize nutrition in the face of behavioral challenges.

Development (general)

Children in foster care have a high incidence of developmental delay; prompt referral for evaluation and/or early intervention should be considered whenever there is a concern.

Specialty Collaborations & Other Services

Developmental Assessments (see RI providers [34])

May be very useful in understanding the range of delays present and in formulating an intervention plan.

Developmental - Behavioral Pediatrics (see RI providers [11])

May be very useful in understanding the range of delays present and in formulating an intervention plan, particularly if a Developmental Evaluation program is not available.

Early Intervention for Children with Disabilities/Delays (see RI providers [14])

Often provide developmental evaluation, as well as programs to mitigate the causes and impact of developmental delays.

Sleep

Children and adolescents who have suffered trauma often show signs of stress through their sleep patterns. This is another common response to entering foster care or an unfamiliar, new home. Children and teens are often grieving the separation from their family and confused by what has happened. These symptoms should be evaluated and followed to determine if they are transitory adjustments to foster care and/or recovery from exposure to past trauma, or if they represent a psychiatric disorder such as Attention-Deficit/Hyperactivity Disorder (ADHD), Depression , or post-traumatic stress disorder. Sleep disturbance also may be due to psychiatric medicines, such as stimulants for ADHD or the sedating qualities of the atypical antipsychotics. Assess sleep hygiene and provide appropriate education about sleep hygiene and stress management at each visit.

Specialty Collaborations & Other Services

Pediatric Sleep Medicine (see RI providers [2])

Consider referral if the sleep issues prove recalcitrant to primary care management or may be related to other anatomic or physiologic problems such as Obstructive Sleep Apnea.

Maturation/Sexual/Reproductive

Regulations regarding testing for HIV vary from state to state. If a health care professional feels a minor has the capacity, the minor must consent for medical services related to reproductive health, sexually transmitted disease, HIV testing, and substance abuse. Adolescents in foster care have a greater risk for past and future participation in risky behaviors, including sexual encounters. See Issues Related to Foster Care Limits of Confidentiality and Contraception & Menstrual Management.

Transitions

Quote from young adult formerly in foster care regarding information they did not receive about healthcare
Nearly 24,000 adolescents age out of the foster care system annually, usually when they turn 18. [Child: 2013] As they do so, they face serious challenges, including special health care needs that may not have been well-addressed when they were young and did not get better in adulthood. For most, lack of health care poses a substantial barrier. Even with health care, it can be difficult for aged-out foster youths to navigate the health care system or find medical practices that will accept their insurance.

Primary caregivers can help transition patients by working collaboratively with child welfare workers and assisting youth in: [American: 2005]
  • Gathering medical records that list past health provider names, major illnesses and conditions, medications taken, immunizations, and family medical history.
  • Understanding their health issues, including safe use of medication and knowing when to seek treatment. Making Healthy Choices: Guide for Youth in Foster Care on Psychotropic Medications (PDF Document 9.7 MB) may help youth to understand the use, limits of, and alternatives to psychotropic medication.
  • Understanding why their ongoing health care should be a priority.
  • Finding a new adult primary care clinician as well as needed mental health, reproductive health, and dental services. See Finding Adult Health Care.
  • Understanding the importance of health insurance and working with the caseworker to identify post-foster care insurance options.
  • Identify emergency contacts and other individuals who support and encourage youth to be involved in making health care decisions.
As of 2014, the Patient Protection and Affordable Care Act makes youth aging out of foster care eligible for Medicaid coverage until age 26, regardless of income. This is retroactive for young adults who used to be in foster care. Other state-specific health coverage opportunities may include low-cost health and mental health services through community health centers, student health centers, or other resources. Health Services Locators provides a list of free or low-cost government services and insurance options, and Health Insurance Marketplace (HealthCare.gov) may be helpful to youth who no longer qualify for Medicaid.

During the numerous transitions that children in foster care experience - whether during reunification with parents or primary caregivers, adoption, guardianship, or emancipation from foster care, the primary care clinician can bring a whole-child perspective of health care for these youth and work with other caregivers to ensure comprehensive health services are maintained. [American: 2012] Helping Youth Transition to Adulthood: Guidance for Foster Parents (CWIG) (PDF Document 680 KB) may be helpful for foster parents involved in transitioning youth. Other resources include Got Transition (MCHB/NAAAH) and

Specialty Collaborations & Other Services

Mentoring Programs (see RI providers [7])

Offers access to models of care and support in times of transition.

Vocational Education (see RI providers [10])

Provide career guidance and career coaching.

College Disability Centers (see RI providers [19])

Coordinate academic modifications, adjustments, auxiliary aids, adaptive technologies, and resources for academic and life planning.

Adult Education (see RI providers [18])

Teach academics, English as a Second Language, preparation for post-secondary training or education, and skills for success in employment.

Temporary Financial Assistance (see RI providers [3])

Provide emergency assistance, which helps homeless and low-income individuals and families work toward self-sufficiency.

Financial Education & Counseling (see RI providers [11])

Helps to increase the financial stability of low to moderate income households through obtaining a livable wage and learning basic financial principles.

Homeless Shelters (see RI providers [1])

Offers shelters, programs, and services that help homeless and low-income individuals and families work toward self-sufficiency.

Adolescent Health Transition Programs (see RI providers [2])

Provides support services usually include financial assistance, food stamps, child care, and eligibility to Medicaid, UPP, PCN, and CHIP. If unsure about State resources, collaborate with the child’s caseworker.

Dental Care Expense Assistance (see RI providers [4])

Offers free or low-cost emergency care, preventive (cleanings) and periodontal maintenance, restorative care (fillings, crowns, bridges), root canals, oral surgery, and dentures or partials.

Crisis Mental Health Care (see RI providers [10])

Provides immediate help for an array of mental health issues, including drug and alcohol abuse.

Community Advocacy Organizations (see RI providers [53])

Offers representation for an array of social, legal, and cultural issues.

Educational Advocacy (see RI providers [10])

Provides services designed to increase the numbers of low-income students who graduate from high school and go on to attend college.

Outpatient Mental Health Care (see RI providers [12])

Provides mental health and substance abuse services.

Disability Awareness Programs (see RI providers [55])

Offers education and support through facilitation of resources for specific health conditions.

Ask the Specialist

What can I do to help a patient in foster care with mental health or behavioral problems?

Psychoeducation for parents, foster parents, children, and youth is powerful and reassuring. To know “I am not crazy for feeling/behaving this way” is comforting whether for the child unable to sleep due to nightmares, the youth who is agitated and can’t sit still, or the parent frustrated because the child is hoarding food or waking up in the middle of the night to access food.

Can I provide a meaningful intervention in a 15-minute visit for a patient who is depressed or traumatized?

Helping depressed adolescents: a menu of cognitive-behavioral procedures for primary care offers 7 types of basic cognitive-behavioral interventions that can be provided in a 15-minute office visit. These effective interventions build on the history taking already being done. Examples include clarifying a psychosocial problem, asking the child about their feelings surrounding it, and providing empathy. Another intervention is to coach patients on how to better present themselves so they receive the responses they really desire. This may include teaching about the impact of body posture, eye contact, speech, and tone of voice and encouraging practice techniques. Have them watch Elmo's Teaching Belly Breathing YouTube video and practice breathing exercises.

Resources for Clinicians

On the Web

Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians (AAP) (PDF Document 3.6 MB)
Designed to strengthen clinicians' abilities to identify traumatized children, educate families about toxic stress, and empower families to respond to children’s behavior in ways that acknowledge past traumas but promote the learning of adaptive reactions to stress; American Academy of Pediatrics.

Child Welfare Information Gateway (HHS)
Connects child welfare and related professionals to comprehensive resources; U.S. Department of Health & Human Services.

Child Welfare Guide for Behavioral and Mental Health Professionals (Child Welfare Information Gateway) (PDF Document 288 KB)
Six-pages focusing on cross-system partnerships(2019).

Fostering Health Online Resource Library (NCPeds)
Best Practice documents, videos, streamlined forms for exchanging information, and information about the American Academy of Pediatrics’ Standards of Care for the foster care population; North Carolina Pediatric Society (sign-in required).

California Evidence-Based Clearinghouse for Child Welfare
Easy access to research about screening, assessment tools, and treatment practices for children in foster care.

Council on Foster Care, Adoption, and Kinship Care (AAP)
Dedicated to improving the health and well-being of children and youth in foster care, kinship care, and those who have been adopted.; American Academy of Pediatrics.

Learning Center for Child and Adolescent Trauma (NCTSN)
Online courses and webinars focused on child welfare issues. See particularly the 0 to 6 Child Welfare series on the left menu; National Child Traumatic Stress Network.

National Scientific Council on the Developing Child
Information about toxic stress, the science of neglect, and much more; based at Harvard University.

Complex Trauma: Facts for Caregivers (NCTSN)
Helps parents and caregivers recognize the signs and symptoms of complex trauma and offers recommendations on how to help children heal; National Child Traumatic Stress Network.

Improving Outcomes for Youth Transitioning Out of Foster Care (Hawai'i Kids Count) (PDF Document 2.7 MB)
Strategies to improve outcomes for youth transitioning out of foster care, such as supporting educational success, providing employment and affordable housing opportunities, and ensuring access to health care.

How the Child Welfare System Works (Child Welfare Information Gateway) (PDF Document 789 KB)
Answers questions about the welfare system and what happens if abuse or neglect is reported or substantiated

Tackling Toxic Stress (Harvard University)
A series of articles that re-thinks services for children and families based on the science of early childhood development and an understanding of the consequences of adverse early experiences and toxic stress; Center on Developing Child.

Helpful Articles

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract
Summary of guidelines developed at the 2007 Best Practices for Mental Health Child Welfare Consensus Conference related to parent engagement and youth empowerment.

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care clinician's supporting role.

Clinical Tools

Assessment Tools/Scales

Adversities – Beliefs - Consequences (ABC) Worksheet (PDF Document 115 KB)
Helps identify the impact of thoughts and feelings, as related to adversity, on the future; adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

M-CHAT-R/F Screen (PDF Document 1 KB)
Parent-completed questionnaire designed to identify children at risk of autism. An instrument available for free download in different languages for clinical, research, and educational purposes; © 2009 Diana Robins, Deborah Fein, & Marianne Barton.

Ages and Stages Questionnaire: Developmental (ASQ-3)
Parent-completed, age-specific questionnaires that screen for developmental delays in children between 1 month and 5½ years old; available for purchase.

ASQ:SE-2 (Ages and Stages Questionnaire: Social-Emotional)
A parent-completed series of 19 age-specific questionnaires screening communication, gross motor, fine motor, problem-solving, and personal adaptive skills. Results are in a pass/fail format for domains; available for purchase.

SEEK Parent Screening Questionnaire (PSQ-R)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions. Scroll to bottom of the page for links to free to download in English, Chinese, Spanish, Swedish, and Vietnamese; from the University of Maryland, School of Medicine Department of Pediatrics.

Vanderbilt ADHD Parent Rating Scale (PDF Document 72 KB)
A 40-questions assessment designed to identify behavior problems and performance impairments at home; contains scoring information.

Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.

SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA)
Describes this evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs; Substance Abuse and Mental Health Services Administration.

Children’s Impact of Event Scale-13 (CRIES-13) (PDF Document 527 KB)
15 question assessment for survivors of trauma including avoidance, intrusion, physiologic arousal, ages 8 and above; youth version.

Care Processes & Protocols

Fostering Health: Standards of Care for Children in Foster Care
Developed by an AAP multidisciplinary panel of experts, Fostering Health has been designed for use by medical, mental health, and developmental health care professionals, as well as foster parents, social welfare agencies, members of the legal community, health insurance agencies, and policy makers. Standards of health care for children and adolescents in foster care are detailed in 10 chapters.

Traumatic Stress in Pediatric Patients Care Process Model (PDF Document)
Best-practice recommendations (2020) for the prevention of childhood trauma as well as the identification and management of pediatric traumatic stress in primary care and children’s advocacy center settings. Includes screening and assessment tools. Developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.

Medication Guides

Making Healthy Choices: Guide for Youth in Foster Care on Psychotropic Medications (PDF Document 9.7 MB)
Explores signs that indicate you may need help, knowing your rights and who can help, considering options, making decisions, and maintaining treatment; 28 pages. Created by youths who have experienced foster care and the U.S. Dept. of Health and Human Services.

Florida Best Practice Psychotherapeutic Medication Guidelines for Children and Adolescents (2019) (PDF Document 2.7 MB)
Recommendations for psychotherapeutic medication prescribing based on evidence and clinical consensus for a range of severe behavioral health symptoms and diagnoses; Florida Center for Behavioral Health.

Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care (HHS) (PDF Document 534 KB)
General principles, role of primary care providers, medication use criteria, and tables with dosage and schedules; Health and Human Services (2021).

Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care (Ohio Dept of Family Services) (PDF Document 437 KB)
Psychotropic medication practices, guidelines, ongoing monitoring, and evaluation (2014).

Toolkits

Primary Care Tools to Help Care for Children in Foster Care
Tools and resources aim to provide health care professionals with the necessary background, health assessment forms, forms to facilitate communication and collaboration between professionals, and other materials to help care for children and teens in foster care.

Toxic Stress Toolkit (AAP) (PDF Document 11.4 MB)
Information for primary care providers and their multidisciplinary teams serving young children in foster care in Rhode Island but relevant for all. Includes information about the negative health impacts of childhood adversity and toxic stress, screening tools for identifying those at highest risk for toxic stress and poor developmental and health outcomes, and an outline of resources; American Academy of Pediatrics, Rhode Island Chapter.

GLAD-PC: Guidelines for Adolescent Depression - Primary Care (REACH Institute)
Comprehensive set of guidelines addressing issues in screening, diagnosis, and treatment of depression in adolescents age 10-21 - includes an extensive toolkit; a PDF file from Resource for Advancing Children's Health.

Mental Health Practices in Child Welfare Guidelines Toolkit (PDF Document 1020 KB)
Comprehensive, 153-page guide, including ratings of the evidence behind its recommendations. Published by the Annie E. Casey Foundation, based on Mental Health Practice Guidelines for Child Welfare: Context for Reform: A Special Issue of Child Welfare Journal (Vol. 88, No. 1).

Health Care Toolbox
Assessment, intervention, and training tools focused on helping children and families cope with illness and injury; Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia.

Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes a variety of resources, checklists, intake and assessment forms, and patient education materials.

Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit (AAP)
Toolkit for pediatric care providers delivering comprehensive mental health care. Now in a new online format; available for a fee from American Academy of Pediatrics.

Other

Four Steps to Reframing Worksheet (PDF Document 94 KB)
A tool for children that helps break down problems into smaller steps. Adapted from the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) manual; site developed by The Center for Pediatric Traumatic Stress and The Children’s Hospital of Philadelphia.

Traumatic Stress in Pediatric Patients Care Process Model (PDF Document)
Best-practice recommendations (2020) for the prevention of childhood trauma as well as the identification and management of pediatric traumatic stress in primary care and children’s advocacy center settings. Includes screening and assessment tools. Developed through a collaboration of the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.

Resources for Patients & Families

Foster Care of Children with Special Needs
Understanding foster care for children with special needs, basic considerations for foster families, welcoming a child into your home, and saying goodbye to a child.

Information on the Web

HealthyChildren.org
The AAP parenting website priors foster care resources for parents, families, and caregivers.

Safe and Sound: Helping Children Who Have Experienced Trauma and Adversity
This series of resources is designed to help children who have experienced trauma and adversity, by helping their parents, caregivers, and other adults in their lives understand how that early trauma may have affected them. Each guide can be downloaded and shared to provide ideas for how to help children, and links to additional information and resources.

Child Welfare Information Gateway (HHS)
Connects child welfare and related professionals to comprehensive resources; U.S. Department of Health & Human Services.

Time for Reform: Aging Out and On Their Own (PEW Charitable Trusts)
Challenges of adolescents aging out of foster care systems with no permanent home or support.

Time for Reform: Preventing Youth From Aging Out On Their Own (PEW Charitable Trusts)
Recommendations for policy-level changes to enhance the success of those transitioning out of foster care.

Improving Outcomes for Youth Transitioning Out of Foster Care (Hawai'i Kids Count) (PDF Document 2.7 MB)
Strategies to improve outcomes for youth transitioning out of foster care, such as supporting educational success, providing employment and affordable housing opportunities, and ensuring access to health care.

Helping Youth Transition to Adulthood: Guidance for Foster Parents (CWIG) (PDF Document 680 KB)
Discusses the critical role of foster parents, laws, and programs supporting transitioning youth; Child Welfare Information Gateway.

National & Local Support

Foster Care Alumni of America
Connects the alumni community and works to transform policy and practice to help ensure opportunity for people in and from foster care.

Foster Care to Success--Aging Out Institute
Nonprofit organization with resources, programs, and research to help youth age out of foster care and into independence successfully.

Studies/Registries

Foster Care (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: April 2014; last update/revision: September 2021
Current Authors and Reviewers:
Authors: Julie Steele, FNP, DNP
Elizabeth R Gargaro, MD
Funding: Funding support from the Annie E Casey Foundation and from the Substance Abuse and Mental Health Services Administration.
Authoring history
2014: first version: Kristina Hindert, MDA; Julie Steele, FNP, DNPCA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Bibliography

Administration on Children, Youth and Families, Childrens Bureau.
The AFCARS Report #26. Preliminary FY 2018 Estimates as of August 22, 2019 - No. 26.
Washington, DC: US Department of Health and Human Services; (2019) https://www.acf.hhs.gov/cb/report/afcars-report-26. Accessed on 1/28/2020.

American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood.
Health care of youth aging out of foster care.
Pediatrics. 2012;130(6):1170-3. PubMed abstract / Full Text
Identifies challenges and recommendations for youth aging out of foster care.

American Academy of Pediatrics, Task Force on Health Care for Children in Foster Care.
Fostering health: health care for children and adolescents in foster care, 2nd edition.
American Academy of Pediatrics; (2005) https://aapca1.org/resource/book-fostering-health/. Accessed on 9/9/21.
Practice parameters for primary care, developmental and mental health care, and care when child abuse and neglect are involved; downloadable as pdf.

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...

Baams L, Wilson BDM, Russell ST.
LGBTQ Youth in Unstable Housing and Foster Care.
Pediatrics. 2019;143(3). PubMed abstract / Full Text

Beal SJ, Greiner MV.
Children in nonparental care: health and social risks.
Pediatr Res. 2016;79(1-2):184-90. PubMed abstract

Chasnoff IJ, Wells AM, King L.
Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure.
Pediatrics. 2015;135(2):264-70. PubMed abstract

Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A.
Assessing the health status of children entering foster care.
Pediatrics. 1994;93(4):594-601. PubMed abstract

Child Trends.
Child maltreatment.
US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and families, Children's Bureau; (2019) https://www.childtrends.org/indicators/child-maltreatment.

Child Welfare Information Gateway.
Foster care statistics 2013.
U.S. Dept. of Health and Human Services; (2013) https://www.acf.hhs.gov/cb/research-data-technology/statistics-researc.... Accessed on 6/28/2021.
Report #21 available for 2013, and includes links through reports through 2019

Children's Bureau: An Office of the Administration for Children and Families.
Adoption & Foster Care Statistics.
U.S. Department of Health and Human Services; (2019) https://www.acf.hhs.gov/cb/research-data-technology/statistics-researc.... Accessed on Sept. 2021.

Council on Foster Care; adoption, and Kinship Care.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1131-40. PubMed abstract / Full Text
Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves. American Academy of Pediatrics Policy Statement.

Duffee J, Szilagyi M, Forkey H, Kelly ET.
Trauma-Informed Care in Child Health Systems.
Pediatrics. 2021;148(2). PubMed abstract / Full Text

Espeleta HC, Bakula DM, Sharkey CM, Reinink J, Cherry A, Lees J, Shropshire D, Mullins LL, Gillaspy SR.
Adapting Pediatric Medical Homes for Youth in Foster Care: Extensions of the American Academy of Pediatrics Guidelines.
Clin Pediatr (Phila). 2020;59(4-5):411-420. PubMed abstract

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Am J Prev Med. 1998;14(4):245-58. PubMed abstract
Describes the relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Fraser JG, Noroña CR, Bartlett JD, Zhang J, Spinazzola J, Griffin JL, Montagna C, Todd M, Bodian R, Barto B.
Screening for Trauma Symptoms in Child Welfare-Involved Young Children: Findings from a Statewide Trauma-Informed Care Initiative.
J Child Adolesc Trauma. 2019;12(3):399-409. PubMed abstract / Full Text

Jim Casey Youth Opportunity Initiative.
Time for reform: aging out and on their own.
Pew Charitable Trusts. 2007. / http://www.pewtrusts.org/en/research-and-analysis/reports/2007/05/01/t...
Challenges of adolescents aging out of foster care systems with no permanent home or support; Pew Charitable Trusts.

Jones VF, Schulte EE, Waite D.
Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.
Pediatrics. 2020;146(6). PubMed abstract

Keeshin B, Forkey HC, Fouras G, MacMillan HL.
Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.
Pediatrics. 2020. PubMed abstract
A clinical report that focuses on 2 key issues necessary for the care of maltreated children and adolescents in pediatric settings: trauma-informed assessments and the role of pharmacotherapy in maltreated children and adolescents.

Keeshin BR, Bryant BJ, Gargaro ER.
Emotional Dysregulation: A Trauma-Informed Approach.
Child Adolesc Psychiatr Clin N Am. 2021;30(2):375-387. PubMed abstract

Kerker BD, Zhang J, Nadeem E, Stein RE, Hurlburt MS, Heneghan A, Landsverk J, McCue Horwitz S.
Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.
Acad Pediatr. 2015;15(5):510-7. PubMed abstract / Full Text

Knapp P, Chait A, Pappadopulos E, Crystal S, Jensen PS.
Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management.
Pediatrics. 2012;129(6):e1562-76. PubMed abstract / Full Text

Ringeisen H, Casanueva C, Urato M, Cross T.
Special health care needs among children in the child welfare system.
Pediatrics. 2008;122(1):e232-41. PubMed abstract
Presents levels of special health care need among children in the child welfare system and how these needs may affect children's functioning.

Romanelli LH, Hoagwood KE, Kaplan SJ, Kemp SP, Hartman RL, Trupin C, Soto W, Pecora PJ, LaBarrie TL, Jensen PS.
Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
Child Welfare. 2009;88(1):189-212. PubMed abstract
Summary of guidelines developed at the 2007 Best Practices for Mental Health Child Welfare Consensus Conference related to parent engagement and youth empowerment.

Rosenberg R, Abbott S.
Examining data and trends in extended foster care.
Child Trends; (2019) https://www.childtrends.org/wp-content/uploads/2019/06/ExtendedFosterC....

Rubin DM, Alessandrini EA, Feudtner C, Localio AR, Hadley T.
Placement changes and emergency department visits in the first year of foster care.
Pediatrics. 2004;114(3):e354-60. PubMed abstract
Evaluates the temporal relationship between Emergency Dept. visits and placement changes and underscores the need for better health care management for foster children, particularly in the period after placement changes.

Scotto Rosato N, Correll CU, Pappadopulos E, Chait A, Crystal S, Jensen PS.
Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management.
Pediatrics. 2012;129(6):e1577-86. PubMed abstract / Full Text

Sepulveda K, Rosenberg R, Sunny S, Wilkins A.
Children and youth with special health care needs in foster care.
Child Trends; (2020) https://www.childtrends.org/publications/children-youth-special-health....

Shonkoff JP, Garner AS.
The lifelong effects of early childhood adversity and toxic stress.
Pediatrics. 2012;129(1):e232-46. PubMed abstract
Reaffirmed in 2016, this technical report presents a framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress.

Simms MD, Dubowitz H, Szilagyi MA.
Health care needs of children in the foster care system.
Pediatrics. 2000;106(4 Suppl):909-18. PubMed abstract

Stahmer AC, Leslie LK, Hurlburt M, Barth RP, Webb MB, Landsverk J, Zhang J.
Developmental and behavioral needs and service use for young children in child welfare.
Pediatrics. 2005;116(4):891-900. PubMed abstract / Full Text
Determines the level of developmental and behavioral need in young children entering child welfare (CW), estimates early intervention services use, and examines variation in need and service use based on age and level of involvement with CW.

Stein RE, Hurlburt MS, Heneghan AM, Zhang J, Rolls-Reutz J, Silver EJ, Fisher E, Landsverk J, Horwitz SM.
Chronic conditions among children investigated by child welfare: a national sample.
Pediatrics. 2013;131(3):455-62. PubMed abstract / Full Text

Stirling J Jr, Amaya-Jackson L, Amaya-Jackson L.
Understanding the behavioral and emotional consequences of child abuse.
Pediatrics. 2008;122(3):667-73. PubMed abstract / Full Text
Assists caregivers by helping them recognize the abused or neglected child's altered responses, formulate more effective coping strategies, and mobilize available community resources.

Szilagyi M.
The pediatric role in the care of children in foster and kinship care.
Pediatr Rev. 2012;33(11):496-507; quiz 508. PubMed abstract / Full Text
Describes the purpose and problems of foster care and the primary care clinician's supporting role.

Szilagyi MA, Rosen DS, Rubin D, Zlotnik S.
Health Care Issues for Children and Adolescents in Foster Care and Kinship Care.
Pediatrics. 2015;136(4):e1142-66. PubMed abstract / Full Text

Turney K, Wildeman C.
Mental and Physical Health of Children in Foster Care.
Pediatrics. 2016;138(5). PubMed abstract

Winokur M, Holtan A, Batchelder KE.
Systematic Review of Kinship Care Effects on Safety, Permanency, and Well-Being Outcomes.
Res Soc Work Pract. 2018;28(1):19-32.

Zeanah CH, Chesher T, Boris NW.
Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.
J Am Acad Child Adolesc Psychiatry. 2016;55(11):990-1003. PubMed abstract