Making health a priority for children in foster care system: Connecting to care, wherever kids are
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* Natalie McGill

A foster child’s home may change multiple times, but pediatrician Annalisa Behnken, MD, FAAP, wants to make sure that wherever a child is living, her or his medical home stays consistent.

As medical director of the Healthy Beginnings Foster Care Clinic at the University of New Mexico, Behnken only gets one half-day a week to see as many kids as possible, but she makes it count.

“We provide as much as we can because we’re a small operation,” Behnken told *The Nation’s Health.* “We try to provide a medical home for these kids…we do vision and hearing screenings. We screen for anemia and lead poisoning. We screen for the need for counseling and other medical referrals.”

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/46/7/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/46/7/1.2/F1)

A volunteer comforts children at the Laura Dester Shelter in 2005 in Tulsa, Oklahoma. The shelter is a stopping point between troubled homes and foster care. Public health programs across the nation are working to ensure children in state foster care systems have continuity of health care.

Photo by Andrea Mohin, courtesy The New York Times

Behnken said the demand is huge for such care because in the foster care population, regular health care often falls by the wayside. And the public health community is finding ways to step in before children in foster care fall even further.

At least one-third of children enter foster care with a chronic health issue, such as asthma, and up to 80 percent enter in need of services for significant mental health issues, according to “Health Care Issues for Children and Adolescents in Foster Care and Kinship Care,” an October 2015 policy statement from the American Academy of Pediatrics. The statement outlines health needs of kids in foster care and calls for actions such as advocating for foster children to get their needs met in a medical home.

“Studies have shown that the health needs are tremendous,” Moira Szilagyi, MD, PhD, an associate faculty member of the University of California-Los Angeles’ Center for Healthier Children, Families and Communities and lead author of the AAP statement, told *The Nation’s Health.* “That to me is a public health issue because as a society if we truly believe in improving the health outcomes of our population, then those children who are the most vulnerable and have the least access to services should be pretty high up on that agenda.”

The foster care population is sizable. As of September 2014, there were over 415,000 U.S. children in foster care and 46 percent were in non-relative foster family homes, according to a 2016 report of the Child Welfare Information Gateway, a service of the Children’s Bureau, Administration for Children and Families and U.S. Department of Health and Human Services. While that total is a decrease from 513,000 kids in fiscal year 2005, it is more than fiscal year 2013’s total of over 400,000 children.

Driving chronic physical and mental health issues is the fact that children in foster care are more likely to be coming from traumatic home environments where they may have witnessed or experienced physical, emotional and sexual abuse that causes physical and psychological harm.

Yet despite the increased health risks, many children in foster care face obstacles to getting regular health care, in part because of changing caregivers and locations. Such changes can lead to lapses in medical information about a child, such as current immunizations and medications. Another complication is that not all care providers accept Medicaid, despite the fact most children in the foster care system are insured under Medicaid.

Untreated health and mental health conditions in children can lead to long-term consequences such as failure to finish school, underemployment, unemployment, and risky behaviors such as substance use.

“A significant amount of trauma is linked to depression, post-traumatic stress disorder, other anxiety disorders,” Szilagyi said. “It sets children up for school failure. Only about a third of them graduate on time. Another third gets an equivalency. Not all of them complete a degree.”

Another obstacle is how to involve foster child caregivers in the care of children, which is worsened by the fact that such caregivers may change frequently. It is not enough to have a doctor’s appointment — a caregiver must adhere to a medical care plan for children, said Janet Schneiderman, PhD, RN, a research associate professor at the University of Southern California School of Social Work and an APHA member.

“The access problems depend on a really integrated plan with the health care providers, child welfare workers and caregivers providing care and that hasn’t been the case,” Schneiderman told *The Nation’s Health.*

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[Figure2](http://www.thenationshealth.org/content/46/7/1.2/F2)

Montavius Jones, who moved through more than 20 foster and group homes since his fourth birthday, at home on a university break in December. Making sure kids in foster care have continuity of care is a growing public health priority.

Photo by Andrea Morales, courtesy The New York Times

Health agencies at the state and local levels are working to address such needs. Programs such as the Fostering Healthy Children Program in Utah rely on a model that when possible joins biological parents and foster caregivers with a team of nurses, case workers, mental health therapists and school staff to address a child’s needs. The Utah Department of Health program began in 1997 to connect foster children to a pediatric medical home and regular preventive health care and has grown from a handful of nurses to 32 today, according to LaRene Adams, RN, program manager. The program serves about 4,000 children annually and around 2,700 children at any given time.

“It keeps everybody working together to meet the needs of these children,” Adams told *The Nation’s Health.* “The case workers know the background of the family, but they don’t have the medical knowledge. (Nurses) have the medical knowledge but not the background of the family. If the child is old enough, they have a voice in their care and what happens to them.”

As soon as Utah children enter the child welfare system, program staff retrieve detailed health history through biological parents, if possible, and from available medical records. Children must then receive physical and dental exams within 30 days and mental health assessments for kids ages 5 and older.

While there are existing programs across the U.S. to provide regular care, a need exists for not only training on how to care for the foster care population, but more collaborative care among different health professions.

Public health has an opportunity to be a convener on these issues, said Szilagyi, who participates in quarterly meetings with health officials from Los Angeles County Department of Health Services, county hospitals and experts in child welfare and mental health during which they work to identify barriers to care.

“We all have to work across systems to ensure that children in foster care have what they need: child welfare, mental health, pediatrics and legal,” Szilagyi said.

Schneiderman said the integration of social work and other health care professions is essential to providing the best care.

“One group can’t do everything,” Schneiderman said. “The skills are important, but the medical knowledge for kids who have the most complex medical conditions is needed, as well as health information. Foster children don’t get the kind of information in terms of prevention of STIs that you might think most kids get when they are teens, partly because of movement from place to place and caregivers might not think it is their job to do that. We all are in it together.”

Health professionals who want to learn about foster care and health also have a resource in the Healthy Foster Care America initiative.

Managed by the American Academy of Pediatrics, the initiative is an online resource for health care professionals who work with foster care populations about common health issues, models of care across the U.S. and information on how they can become child welfare advocates. The academy also provides grants to academy chapters across the U.S. to identify pediatricians as “foster care champions” who act as advocates for kids in child welfare and work at solving the problems of lack of health care. Today, 20 chapters have been funded to identify such champions, said Szilagyi, who is chair of the academy’s Council on Foster Care, Adoption and Kinship Care.

“As pediatricians, we can be part of the services and be good advocates for these young people and their families,” Szilagyi said. “We may not be the most important piece but we can do the mental health screenings. We can follow up and make sure kids get connected with services. If it’s not being done by other parts of the system we certainly have a responsibility.”

Back at the University of New Mexico, Behnken encourages medical students to share the responsibility physicians have in making sure foster care children receive the best care.

“The other piece I think that my colleagues and medical students can learn from is that there may be a myriad of paperwork that adds to our burden but ultimately we have to remember what’s best for the kids,” Behnken said.

For more information, visit [bit.ly/HealthyFosterCareAmerica](http://bit.ly/HealthyFosterCareAmerica).

*   Copyright The Nation’s Health, American Public Health Association