Medical Traumatic Stress in Child Welfare | Patient Centered Care and Trauma Informed Care for Pediatric Patients

Providing Trauma Informed Care in Child Welfare

Do children in the child welfare system experience medical treatment in the same ways that children in the general population do? To some degree, yes, they do. At the same time, there are notable differences in the life experiences and family circumstances of children in foster care compared to their peers outside the child welfare system. It's important to understand what these differences are and how they may influence responses to medical events among children in foster care.

Three main issues affect how children in foster care experience medical treatment:

Level of medical and developmental need
How medical services are delivered
Experiences before, during, and after treatment

National data show that children in foster care, on average, have more medical needs than children in the general population. About one in four children in foster care has an ongoing medical condition, and about one in ten has two or more. Children in foster care are more likely to require repeated medical visits and may be at higher risk for medical trauma for that reason alone.

Most common health issues among children in foster care:

Asthma
Repeated ear infections
Other respiratory problems
Severe allergies
Epilepsy
Eczema or other skin diseases

Another layer to consider is developmental and behavioral health issues, or "special needs," among children in foster care. About one in every three children in care has a special need, and about one in every four has two or more special needs. The most common are behavior or emotional disorders, as well as neurodevelopmental conditions such as learning disabilities, attention deficit hyperactivity disorder (ADD and ADHD), speech-language impairment, intellectual disability (formerly known as mental retardation), hearing impairment, vision impairment, and autism. Developmental and behavioral health issues such as these can make it more difficult for children to cope with medical treatment.

Trauma Informed Care in Child Welfare : How Medical Services are Delivered

Emergency Room

All too often, children in foster care receive medical attention in Emergency Departments. The Emergency Department may be a first stop for children after being removed from their homes, or it may be a frequent destination for those who lack a consistent primary care provider due to multiple changes in foster care placement. Patient and family centered care may be disrupted in child welfare families due to this inconsistency, causing increased stress on the child and resource family. The sights and sounds of an Emergency Department can be frightening to any child, and even more so for one who has been separated from family members.

Trauma Informed Care in Child Welfare : Experiences Before, During, and After Treatment

Children typically become involved with the child welfare system because they have been abused or neglected, and these experiences affect their responses to medical care.

When medical treatment is invasive, painful, or prolonged, it may be a trigger or reminder of past traumas, such as physical or sexual abuse.
Even routine physical exams may be extremely uncomfortable for children who have been sexually abused.
Children who have been abused or neglected may not initially trust adults to keep them safe---even health care providers.

Thus, previous traumatic experiences may increase the risk for medical traumatic stress among children in care.

Children in foster care often lack the support of a consistent, nurturing caregiver during medical visits. Biological parents may be prevented by Court order from having contact with their children, or may be occupied with their own treatment goals that prevent their attending their child's medical appointments. Foster parents may be unable to take time off from work or may have difficulty attending all the appointments for multiple children in their care. Whatever the reason, the end result is that children in foster care often lack the type of family support that other children have, support that is crucial to coping with medical treatment and mitigating stress.

Not having an adult caregiver who is consistently present to provide support and information is one of the most critical differences in how these children experience medical care.

Absence of the child's parent and/or foster parent at medical appointments can also compromise quality of care. Pediatric health care providers rely heavily on children's health history in formulating a diagnosis or treatment plan for the child. They rely on the children's caregivers (parents or foster parents) to answer questions about the child's activities of daily living, including sleep, diet, elimination and various symptoms that cannot be answered by a child's caseworker. When children in foster care attend medical appointments without their biological or foster parent present, important information is unavailable to the health care provider, which can delay or derail the treatment the child needs. Lack of coordination impacts family centered care and may have negative impacts on the child and foster parents ability to cope with medical treatment.

More about Medical Traumatic Stress

The resources throughout this site provide more information about medical traumatic stress. Keep in mind the ways in which children in foster care may experience medical treatment differently.

CPTS offers a library of free online courses on medical traumatic stress, including a 1 hour online course about medical traumatic stress and children in out-of-home placement.

Key Intervention Points in Child Welfare

Addressing medical traumatic stress for children in the child welfare system doesn’t have to be complicated, and you don’t have to be a physician or psychologist to help children feel more comfortable with medical care. Most trauma informed interventions fit into activities that child welfare caseworkers and other team members do on a routine basis. The key is to understand how the circumstances of children in foster care (e.g., removal from their biological parents, past histories of abuse or neglect, or moving among multiple foster homes) may affect how they cope with medical treatment. The information that follows highlights key intervention points for addressing medical trauma among children in foster care and provides tips for helping at each point in time.

Key Points for Trauma Informed Care Interventions in Child Welfare

Note: The information offered below is for professionals in both healthcare and child welfare, including resource parents

Other sections of this web site address intervening to prevent or diminish medical traumatic stress among all children who are facing health challenges or medical events.

While that information also applies to children in the child welfare system, there are several unique considerations for these children at each of the following intervention points:

Initial Removal From the Biological Family’s Home

The period immediately following removal from their birth families is a particularly vulnerable time for children in foster care. Removal from biological caregivers can be traumatic for children, even if they were mistreated by those caregivers. Keep in mind that many children who enter foster care are moved suddenly from their biological homes, with little warning or explanation of the move. They are separated from all that has been familiar to them, including extended family and friends, and unsure what to expect from their new caregivers and surroundings. In short, removal from the home can be a frightening experience. As a result, children who require medical attention during this period may already be anxious and scared. Experiences that prompted removal, such as physical or sexual abuse, may also affect children’s ability to trust adults---even medical providers. Try the following strategies to help diminish or prevent medical traumatic stress among children in foster care:

Learn as much as possible about the child’s previous life experiences prior to or during the medical visit (the child welfare social worker can help with this). Tailor the medical care approach using this information. For example, a child who has been sexually abused may need additional support and explanation during a physical examination.
If the child is old enough, acknowledge the child’s recent removal from the home. Say that other children in this situation have felt scared or worried, and ask the child how s/he is feeling and what might help him or her.
Use the Medical Trauma Assessment and Action Form for Child Welfare Professionals to help determine whether the child is at risk for traumatic stress related to medical care
Explain your role in the child’s life and how often s/he can expect to see you.
Allow the child to ask questions and to control some aspects of the medical visit (for example, choosing a medicine flavor or holding a stethoscope to his or her own chest). This is particularly important for children in foster care, who often have very little control over what happens in their lives. Small gestures such as these can build trust.
Explain possible impacts medical trauma may have on children in child welfare to the foster parent(s), increasing the ability of the foster parent to support the child’s current and ongoing needs.

Any Change of Placement While in the Child Welfare System

Children in the child welfare system often move among foster homes, group homes, inpatient facilities, and adoptive homes. Sometimes these moves take children to entirely different neighborhoods, counties, or even states. Frequent movement can threaten the continuity of medical care and, in turn, have negative effects on the child’s ability to cope with medical issues. Here are some things to keep in mind when children change placements:

Whenever possible, maintain the same primary care physician (PCP) throughout a child’s stay in the system. This is consistent with the “medical home model” proposed by the American Academy of Pediatrics Maintaining the same PCP allows a child to bond to that physician and the practice’s personnel, facilitates communication with the child welfare team, and prevents critical health information from being lost in a transfer to a new physician.
If it’s not possible to keep the same PCP, identify a new physician before the child is moved and ensure that medical information is communicated to that physician.
Meet in person or by phone with the child’s health care team and child welfare team prior to the child’s move. Be sure that all understand how to address the child’s medical needs during the transition.
Designate a member of the child welfare team to be responsible for ensuring continuity of care and completion of follow-up appointments.
Encourage the child to express his or her concerns about changing placements and how this may affect medical care. Give the child as much information as possible about what to expect from the move related to health care.

Exit From the Child Welfare System

A child’s return to his or her birth parents or to the home of a loving relative or adoptive parent is a good thing. At the same time, exiting the system represents yet another transition that may disrupt the continuity of medical care. As with other transitions, make a plan:

Be sure that the permanent caregiver is thoroughly familiar with the child’s medical history and needs and has demonstrated commitment to attending to those needs.
Be sure the permanent caregiver is educated on medical trauma, including experiences and responses to medical events.
Ensure family-centered and trauma informed interventions are in place in the permanent home to increase the child’s adaptation and also the parent’s ability to support the child’s process.
Provide training for the permanent caregiver about the child’s medical needs. Explain and demonstrate all necessary home procedures and any medical equipment that is involved.
Provide guidance to the caregiver until they demonstrate competency with procedures and medical equipment.
Encourage staying with the child’s current PCP, if possible. If this is not possible, identify a new one and make an appointment before the child leaves care.
Encourage staying with child’s medical specialists for continuity of specialty care.
Communicate clearly to the child that the new caregiver is prepared to help them with any medical needs. Allow the child to ask questions and express concerns about leaving the child welfare system.
Be especially mindful that older teens with medical needs or disabilities who are “aging out” of the system, or transitioning to independence without permanent caregivers, may need intensive planning around medical needs well in advance of their exit from the system. Two websites offer helpful information:
- The Children’s Hospital of Philadelphia has resources for youth and caregivers regarding transition to adulthood for those with chronic medical conditions or disabilities.
- The Juvenile Law Center has a trio of publications regarding youth with disabilities transitioning to adulthood.

Outpatient Medical Visits

Whether it is a well-child check up or an appointment to care for an acute or chronic health issue, outpatient medical appointments with primary care providers and medical specialists can be stressful for children in foster care. For newly placed children, they may be attending appointments with unfamiliar physicians and foster parents they do not yet know well. Children in foster care may not have a regular primary care “medical home”, and may have received outpatient care in the Emergency Department. Try these suggestions for helping children cope during outpatient medical visits:

Before the visit, talk with the child about his or her questions or concerns related to the visit, and ask what would help the child cope. If concerns are about a procedure, sometimes having a favorite stuffed animal in hand or listening to music during a procedure can help kids remain calm.
Child welfare professionals and resource parents can talk with the health care provider about the child’s worries in advance of the appointment, and plan strategies for reducing the child’s stress.
Plan foster parent attendance at medical appointments. It is critical for children in foster care to have a consistent, warm, supportive adult accompany them to medical appointments.
If the foster parent cannot attend, work to identify someone else whom the child knows and trusts.

During Hospital Stays

Teen in Hospital

For children in foster care, coping with admission to the hospital can be especially challenging. When children are admitted directly from their biological home, there may be a Court order preventing their biological parents from visiting them and they may not yet have a foster family assigned to them. These children lack a consistent, nurturing caregiver to provide support for them while they are in the hospital. For children admitted during their stays with foster families the situation is more variable. Some foster parents may be unable to take time off work or may have other childcare obligations. Consequently, children in foster care may spend long periods of time alone while in the hospital. They may have to endure painful procedures without trusted caregivers present. All of these things may increase the child’s vulnerability to medical traumatic stress. The following strategies may help during hospital stays:

Identify someone consistent in the child’s life who can be present at the hospital and during procedures. The child may be able to help identify this person. This could be a family member, a foster parent, a social worker, a teacher, etc.
Assist the identified caregiver in locating services to address any barriers to their presence at the hospital. This may include transportation services, child care arrangements, etc.
When possible, make concerted efforts to include biological parents and extended family members. When permitted by the Court to have contact with their children, biological parents can be sources of support. They can also provide medical history and will need to understand the child’s medical issues if the child is to return home. A favorite aunt, a grandfather, or some other extended family member may also be a good source of support for a child in the hospital.

Discharge from the Hospital

Leaving the hospital can be as frightening for children in foster care as being admitted to the hospital. Children who were admitted immediately after removal from their biological homes may not know with whom they will live when discharged. They may be meeting a foster family for the first time, or they may be headed to a group living facility. As if this weren’t stressful enough, these children may also worry that their new caregivers will not understand their medical needs. They have no way of knowing whether they can trust their new caregivers to attend to their medical care. Even for children who are leaving the hospital for familiar foster families or other caregivers, several important considerations remain. A transition plan is critical. Here are some suggestions for diminishing stress associated with leaving the hospital:

If possible, work with the child welfare social worker to identify where the child will go when discharged from the hospital. If the child will be released to a new foster family, advocate for the foster family to visit the child and begin building a relationship while the child is still in the hospital.
Talk with the child about any concerns s/he may have about leaving the hospital. Provide as much information as possible about what to expect related to medical care after discharge from the hospital.
Prior to discharge, provide training for caregivers on the child’s diagnosis, medical needs, and medical equipment. Caregivers should demonstrate clear understanding of this information and demonstrate competence with equipment.
Provide caregivers with concrete connections to and clear instructions for follow-up care. If possible, make appointments for follow-up care before the child is released from the hospital.
Before the child leaves the hospital, arrange a meeting involving the child welfare social worker, the child advocate attorney, other service providers (e.g., mental health, medical specialists, etc.), and the caregivers to ensure that all have a shared understanding of the child’s medical needs and next steps.
Next steps should include the integration of family-centered and trauma informed interventions that will help to reduce the child’s distress as well as foster parents ability to support the child and cope with possible ongoing stressors (in child and foster parent).

Learn more about working with child welfare professionals and earn continuing education credit by completing For Health Care Professionals: Pediatric Medical Traumatic Stress (PMTS) and Working with the Child Welfare System (1.0 CEU)

Child Welfare System for Medical Providers

A working knowledge of the child welfare system may help health care professionals successfully treat children who are under the supervision of child welfare authorities, whether living at home or in foster care, group homes, or other out-of-home settings. This section provides a brief overview of how the child welfare system works and includes information for effective collaboration with child welfare teams.

How the Child Welfare System Works

The child welfare system is complex and varies in structure and operation from State to State under broad Federal regulations. Though States have the authority to customize their child protective efforts, the overarching goals of the child welfare system are the same across the country: to ensure safety, permanency, and well-being for children.

Safety: Children are free from harm
Permanency: Children have permanent homes
Well-being: Children are thriving physically, emotionally, educationally, and in other ways that contribute to healthy development

These goals are accomplished by the coordinated efforts of a network of public and private service providers. State and County child protective services agencies lead child welfare activities and routinely work together with community organizations to provide services to children and families. It is important to understand that no one single organization carries out all child welfare activities. Accordingly, as a health care professional treating a child in foster care, you may interact with a team of people from multiple organizations, such as mental health and substance abuse treatment providers, foster care agencies, residential treatment centers, and educational support programs. Ideally, one person---often the State or County caseworker---acts as a point person and coordinates services.

How Does Child Welfare Involvement Begin?

Child welfare involvement typically begins when a State or County child protective services agency receives a report of suspected child abuse or neglect. Reports are screened in if the information warrants an investigation and screened out if there is insufficient information or if the State's definition of child abuse or neglect is not met. Reports that are screened in are accepted for investigation. Investigations may be initiated immediately or within several days, depending on the urgency of the report and State law. During this investigative period, caseworkers may seek emergency court orders to remove children in immediate danger from their homes and place them with a relative, in a foster home, or in a shelter.

What Happens After the Child Welfare Investigation?

When the investigation is complete, the caseworker determines whether the report is "substantiated" ("founded") or "unsubstantiated" ("unfounded"). In some cases, children can remain safely at home under the frequent supervision of a caseworker while in-home protective services are provided to strengthen the family. Children who are in danger in the home setting may be removed by the Court and usually enter foster care with relatives ("kinship care") or with non-relative "resource parents" (also known as foster parents) who are selected, licensed, trained, and supervised by State or County child welfare authorities or their contract partners. Sometimes children are placed in group homes or residential treatment facilities ("congregate care"), depending on their needs. While in foster or congregate care, children attend school and receive medical care and other needed services. Their families also receive services with the aim of enhancing the parents' ability to provide appropriate care for their children. Visitation plans allow for children to visit with parents and siblings, unless visitation is prohibited by the Court. The Court reviews the progress of children in protective custody at least every 12 months, and more frequently in many jurisdictions.

What is the Goal for Children in the Child Welfare System?

Most often, the goal for children in foster or congregate care is to return home to their parents. Sometimes, this is not possible, and States and Counties are responsible for "concurrent planning." This means that the team must have an alternate plan for the child's permanent living arrangements in the event that reunification becomes unrealistic. Adoption is the most frequent alternate plan for children who cannot return home to their biological parents. Some older youth participate in independent living programs and exit foster care without being adopted.

For a more detailed description of the child welfare system and trauma guide for pediatricians, see the following resources:

Child Welfare Information Gateway. (2020). How the child welfare system works. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau.
American Academy of Pediatrics Helping Foster and Adoptive Families Cope With Trauma: A Guide for Pediatricians

Learn more about working with child welfare professionals and earn continuing education credit by completing a free 1 hour online course.

Who's Who in the Child Welfare System

Health care providers caring for children in the child welfare system may need to interact with a number of different child welfare professionals. Sometimes, understanding everyone's role can become confusing. Below is a list of key child welfare professionals and their responsibilities.

Child protective services

Child protective services(CPS) investigators are State or County employees assigned to investigate reports of child abuse or neglect. In most jurisdictions, the CPS investigator's involvement in a child's case is limited to the investigation period, after which the case is transferred to an "ongoing" caseworker. While their roles are the same, child protective services agencies in different States or Counties may have different names. For example, one County CPS agency may be called the "Department of Human Services," while a neighboring County's CPS agency could be named the "Office of Children and Youth."

State/County Caseworkers

State/County caseworkers are public employees responsible for ongoing case management and oversight. They assess child and family needs, write Family Service Plans (FSP), arrange treatment services and other supports, schedule and monitor visitation, make periodic visits to foster and adoptive homes, work with birth parents, plan for children's permanency, and report to the Court on child and family progress. In some jurisdictions, the State/County caseworker may also be responsible for supervising foster or adoptive parents, though this role is often "contracted out" (see "Private provider caseworkers" below).

Private Provider Caseworkers

Private provider caseworkers are employees of agencies that contract with State/County child protective services agencies. They work together with State/County caseworkers to ensure that children and families involved with the child welfare system receive the services they require. Typically, private provider agencies recruit, train, and maintain foster and adoptive homes, and their caseworkers supervise children's placement experiences in these homes. Their duties sometimes overlap with those of the State/County caseworker, though the State/County caseworker retains oversight of the case. Whenever there is a private provider caseworker assigned to a case, there is also a State/County caseworker involved.

Dependency Court Judges

Dependency Court judges hear cases involving abuse, neglect, or abandonment of minors. There are no juries in Dependency Court. The judge weighs information presented by attorneys, social workers, service providers, family members, and others whose testimony may be required and makes decisions about the child's placement and about services for the child and birth family.

Child Advocate Attorneys

Child advocate attorneys are assigned by the Court to protect the rights of minors in abuse and neglect cases. They represent children in court proceedings and present the child's views and desires for consideration by the judge.

Guardians ad Litem

Guardians ad litem (GAL) are adults appointed by judges to represent the best interests of abused and neglected children in Court. GALs are legally responsible for safeguarding the well-being of children involved in dependency proceedings, though they are not usually attorneys. GALs may engage in interviewing relevant parties, gathering facts, giving testimony, and making recommendations to the Court. (NOTE: GALs are not assigned to every child.)

Court Appointed Special Advocates

Court Appointed Special Advocates (CASAs) are volunteers appointed by judges to represent the best interests of abused and neglected children in Court and in other settings. Though CASA volunteers do not always have legal training, they do have a strong voice in Court and are expected to advocate for children, help ensure their needs are met, and help move cases through social service and Court systems. (NOTE: CASA volunteers are not assigned to every child.)

Resource Parent

Resource parent is a broad term used to refer to foster and adoptive parents.

Foster parents provide a temporary home for children who cannot remain with their birth parents. Foster parents are recruited, trained, licensed, and supervised by State, County, or private provider agencies. They are responsible for providing day-to-day care for children; ensuring they attend school, all necessary appointments, and other activities; and working with caseworkers to facilitate visitation with birth family. Foster parents do not have legal custody of the children placed in their homes. (See Tips for Working with Child Welfare Teams below for more on consent issues.)
Adoptive parents are caregivers who are granted legal custody of children placed in their care by child welfare authorities. They often adopt children who have been living with them in a foster care arrangement, but not all adoptive parents begin as foster parents. As with foster parents, adoptive parents are recruited, trained, and approved by State, County, or private provider agencies. If an adoptive parent has no previous relationship with the child they wish to adopt (i.e., they have not fostered that child), a supervised pre-adoptive placement period is required before an adoption is finalized.
Kinship caregivers are foster or adoptive parents who are also relatives of the children placed in their care. Their role and responsibilities are the same as with non-kin foster or adoptive parents.

Tips for Working with Child Welfare Teams

Doctors and nurses can use the tips below to have more effective interactions when working with foster care children and child welfare professionals.

Try the private provider caseworker first

Keep in mind that many cases have both a State/County caseworker and a private provider caseworker. Private provider workers are usually more directly involved in children's day-to-day placement experiences. If it becomes necessary to contact a caseworker about a child's medical needs, start with the private provider caseworker, if there is one. That person can, in turn, involve the State/County worker or other team members, as necessary.

Ask about the child welfare goals for your patient

Government intrusion into the family is a sensitive issue. To protect the rights of all involved, the child welfare system is highly regulated, and the work of child welfare professionals is governed by strict legal guidelines. If at times it seems difficult to reach agreement with child welfare workers on specific issues (e.g., keeping birth parents involved in a child's medical care), ask about the child welfare goals and mandates involved and help negotiate a plan to meet everyone's needs.

Contact supervisors when necessary

Caseworkers often have very high caseloads and may be overburdened. If they do not return calls or emails right away, gentle reminders often work well in producing a response. If an immediate response is required or a caseworker fails to communicate despite reminders, proceed up the chain to the caseworker's supervisor.

Learn who can provide consent for treatment

Be aware that foster and pre-adoptive parents are not legal guardians and cannot give consent for medical procedures. Consent guidelines vary from State to State, and it is important to check with your local child welfare authority regarding the specifics of consent. Generally, approaches to consent follow the patterns below:

Consent for routine medical care (e.g., annual physicals, dental check-ups, eye exams, immunizations) is typically granted by statute or obtained from birth parents when a child enters the system.
For any medical care beyond routine care, consent is required from the birth parent, the child welfare authority, or the Court, depending on the circumstances of the case (e.g., if the birth parent cannot be located) and whether or not parental rights are terminated. When in doubt, contact the child's caseworker for guidance.
The child advocate attorney may be helpful when there is a delay in obtaining consent or when medically necessary procedures are disputed. You may work with the child's caseworker, attorney and larger team to resolve consent issues.
The following resource can be accessed online and provides additional information about consent for treatment where foster children are involved. See especially Chapter 6: American Academy of Pediatrics. (2005). Fostering Health: Health Care for Children and Adolescents in Foster Care, 2nd Ed.

Involve birth parents when possible

When contact is not restricted, birth parents are encouraged to attend their children's medical appointments and may display varying levels of involvement, cooperation, or ability. Understand that birth parents often have their own trauma histories and may feel guilt and anger related to the removal of their children from their care. Most birth parents hope to regain custody of their children and respond well to a warm, respectful approach that involves speaking to them directly and involving them in discussions and decision-making. Also remember that birth parents are an important source for child and family health history. Some may be more comfortable having a private discussion with the child's healthcare professional regarding these matters. While most birth parents will be cooperative, be prepared to set limits for those who become disruptive and upset their children during medical visits or inpatient stays.

Encourage cooperation between birth parents and resource parents

Sometimes there is tension between birth parents and resource parents, particularly when a child is first placed in a foster home. This tension can occasionally be reduced by involving both in discussions of the child's medical needs and encouraging cooperation and mutual support in meeting them. A hospital social worker may be a good resource for promoting good working relationships between birth parents and foster parents.

Request team meetings or conference calls

Consider using team meetings or conference calls to address concerns related to medical care. For example, if birth parents are disruptive at medical visits, plan with the team who should attend medical appointments and how the parents can be supported in changing their behavior. Contact the child's caseworker to arrange the meeting or call.

Ensure continuity of medical care

When children are discharged from the hospital or transferred to another primary care provider, request a team meeting or conference call to discuss the child's medical needs and ensure continuity from hospital to placement or from one primary care physician to the next. Again, this type of meeting or call can be arranged through the child's caseworker.

Learn more about working with child welfare professionals and earn continuing education credit by completing a free 1 hour online course.

Health Care System for Child Welfare Professionals

Children in foster care are a medically vulnerable group. On average, they have greater healthcare needs than most kids yet they usually received inconsistent health care before entering placement. As a result, children often enter placement with unidentified and unmet health problems. Even after placement many do not receive adequate and timely healthcare.

Neglect, physical and sexual abuse, exposure to violence, and other psychosocial and environmental challenges further impact the well-being of kids in foster care. These difficult life experiences increase the likelihood that a child or youth has experienced traumatic stress, and intensify the risk for medical traumatic stress.

The Adoption and Safe Families Act (ASFA) of 1997 mandates that child welfare agencies ensure that children in foster care have access to quality health care to promote their healthy well-being.

Children in Foster Care are Children with Special Health Care Needs (CSHCN)

Why do we consider children and youth in foster care as having special health care needs?

High rates of chronic medical, developmental and emotional/behavioral health conditions
High rates of emotionally traumatizing experiences
Multi-system involvement underscoring the need for care coordination

Confused about job titles and who does what in the health care system? Check out who’s who in the health care team.

The federal Maternal Child Health Bureau (MCHB) define children with special health care needs (CSHCN) in a non-categorical way that cuts across different types of diseases and medical conditions. These are children and youth who

… have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally…

McPherson M, Arango P, Fox HB, A new definition of children with special health care needs. Pediatrics. 1998; 102: 137-140.

This category is suitable for all children and youth in foster care.

Understanding there are special health concerns in child welfare, that children entering foster care have more unmet health needs and require greater health surveillance, the American Academy of Pediatrics (AAP) has specific recommendations for this vulnerable group:

Health assessment within 72 hours of placement
Comprehensive physical, mental health, and developmental evaluation within 1 month of placement
More frequent health status monitoring
Child welfare case plans should include health assessment results and incorporate physician recommendations
Participation in all federal and state entitlement programs to which they are entitled (e.g., EPSDT, Early Intervention Services, WIC)
Collaboration between child welfare agencies and health care providers to ensure necessary health information sharing

Comprehensive Health Care for Children in Foster Care

Because the majority of families involved with child protective services struggle with poverty, they have often depended on hospital clinics with an ever-changing panel of providers, or relied on emergency rooms for sick care. Emergency rooms do not provide optimal pediatric preventive care, nor the continuity that is critical for growing children. This fragmented medical care can delay prompt identification of health problems. However, when child welfare and medical professionals work together, they can provide effective and timely comprehensive health care for children in foster care.

Access to Care

The law requires that children in foster care receive comprehensive health care services to address their physical, dental, developmental, mental and emotional health needs. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. All children adjudicated dependent and placed in out-of-home care are eligible for the federal Medicaid program. Medicaid pays for all medically necessary treatment for enrolled children, and it is the most comprehensive program through which children can obtain health services.

Standards for Health Care of Children and Youth in Foster Care

The American Academy of Pediatrics (AAP) Task Force on Health Care for Children in Foster Care has defined the standards of comprehensive health care delivery and management for the complex needs of children in foster care: Fostering Health: Health Care for Children and Adolescents in Foster Care.

An Identified Primary Healthcare Provider and Providing a Medical Home in Child Welfare System

Children placed in foster care should have a consistent primary healthcare provider for routine care. Consistency supports the child or adolescent in developing a relationship with his/her healthcare provider, which is so critical for developing trust. Familiarity with a healthcare practice, its staff and a team of trusted healthcare providers can help decrease the child’s anxiety regarding health care. These factors are fundamental for children who have been traumatized. Whenever possible, efforts should be made to maintain children in the same healthcare practice even after changes in placement.

All children in substitute care need a Medical Home. This model of care extends routine pediatric care with strategies to ensure that children receive comprehensive health care that is coordinated, accessible, family-centered and culturally effective. Ideally, the primary healthcare provider should understand trauma and foster care.

A medical home:

allows a child to develop a bond with the provider
improves communication, record-keeping, and coordination of healthcare services
provides care coordination, for the complex needs of kids involved with the child welfare system
facilitates long-term relationships and collaboration among team members
is emphasized by the Child Welfare League of America (CWLA) and the American Academy of Pediatrics

Increased Need for Specialty Care

Children in foster care have much higher rates of chronic conditions and need continuity of care by the specialists who treat their often complex conditions. Specialty care doctors include neurologists, ophthalmologists (eye doctors), orthopedic surgeons, allergists and numerous others. Allied health specialists include audiologists (addressing hearing loss), speech therapists, physical and occupational therapists, and others. Children with chronic illnesses or developmental disorders often have these conditions monitored by specialty care providers, however, their preventive and routine care, health guidance, and treatment of acute illness continue to be delivered by the primary care provider. When children who change placements have to change primary health care providers, whenever possible they should continue to see the medical specialists who have been monitoring their condition.

Transition to Adulthood: Health Care Issues

Child welfare professionals are used to thinking about transition to adulthood for the children they serve. Health care needs should be high on the list of transition issues, especially when a child has a chronic health condition.

For youth with special health care needs who are in foster care or other placements, health care transition preparation and planning is critically important yet frequently over looked. According to the Juvenile Law Center:

The transition to adulthood is challenging for youth, even in the best of circumstances. Youth with disabilities in the child welfare system face many additional barriers to a successful transition. These young adults are leaving a system that provided for all their needs, including a place to live, health care, education, and connections with family. To plan for care in the adult world, not only must these youth navigate complex adult systems that operate with rules very different from child-serving systems, but often they must do so alone, without the guiding hand of a parent. They are entering an adult world where the rules for access to benefits and services are quite different: health care coverage is much more limited, most services are not entitlements, and many services have long waiting lists.

To successfully transition from the child welfare system, young adults with disabilities and special health care needs—and the professionals and advocates working with them—must begin planning early and need to know what benefits and services are available in the adult system and how to access them. Good planning and knowledge of the law, services, and supports that individuals with disabilities need as they make the transition to adulthood from the child welfare system can improve outcomes tremendously for these emerging adults.

The Juvenile Law Center has developed an excellent transition planning toolkit for youth with disabilities involved with the child welfare system and child welfare professionals. It includes a guide for professionals, a parallel guide for youth, and a useful, easy-to-use tool to facilitate the process.

Health care transition preparation ideally should start when the child first receives a diagnosis of a chronic condition. Transition preparation involves helping the child or youth develop skills to be their own health advocate. The Children's Hospital of Philadelphia website has helpful resources for children and youth and for their parents/caregivers.

Primary care practices that are aligned with the Medical Home model utilize tools to monitor transition readiness and support transition preparation and planning. Visit the national Health Care Transition Center and their Six Core Elements of Health Care Transition , a set of tools to help pediatric practices build their capacity in transition preparation and planning. This site is helpful for child welfare professionals, too.

Tips for Working with the Health Care Team

A working knowledge of the healthcare system may help child welfare professionals maintain an essential medical routine for their clients. The family centered tips for caseworkers below will guide professionals through the healthcare system, whether their client needs a simple check-up, or has illness or injury.

Routinely Obtain Child Medical Records

Caseworkers should routinely obtain medical records for the children in their care. Physicians rely heavily on an individual’s past medical history for their decision-making about diagnoses and treatment – having records available is crucial to a child’s health.

Seek appropriate authorization for the release of the following records. (In some states authorization rests with the state or county child welfare authority, while in other states the biological or adoptive parent has the authority.)

For infants and toddlers under 3 years old, obtain the birth discharge summary from the maternity hospital. The medical record will be in the mother’s name and you will need the child’s date of birth.
For any hospitalizations the child has experienced, request the discharge summary.
If the child has chronic conditions, find out what medical specialists treat the child and request records.
To obtain primary health care and immunization records for children in elementary through high school, the school nurse may be a source for immunization records.

You may need to be persistent. Obtaining medical records from hospitals can be challenging and may require repeated efforts. When a medical setting or practice cites the HIPAA privacy rule restrictions, you can seek a court order, which overrules HIPAA.

Obtain information on child’s health history.

Whenever a case is new to you, routinely gather basic health history information to share with the healthcare team.

This information should be sought from several sources: family members, current and former foster parents. Some questions can also be asked of the foster youth. Other useful sources of a child’s health history include baby books, shot records, letters from specialists, and bottles of medications. Birth parents are a key source for child and family health history. Some may be more comfortable having a private discussion with the child’s healthcare professional regarding these matters.

A basic health history includes the following:

What is known about the child’s birth?
- Pregnancy complications
- Prenatal exposures to drugs, medications, alcohol
- Prematurity
What is the child’s history of illness, injury, treatment?
- Hospitalizations, Surgeries, Emergency Room visits
- Ongoing illnesses
- Injuries
Does the child take any medications?
- If so, what are they and in what doses?
Does the child use any medical equipment (e.g., nebulizers and spacers for asthma, eye glasses, hearing aid, wheel chair)
Does the child have any allergies?
- Drug, food, or environmental allergies
Who were the child’s last health care providers?
- Primary care physician or nurse practitioner
- Medical specialists
- Dentist
- Therapists

Learn about and implement strategies to assist children with medical traumatic stress.

Working from the foundation of a solid health history, caseworkers can help the child with fears, worries, and traumatic stress related to past and current traumatic experiences, medical events, and medical treatment.

Ensure that the child’s resource parent accompanies the child to medical appointments.

The healthcare professional will have questions that can only be answered by an adult caring for the child and not a caseworker or other staff person. Health care providers often need to know about the child’s response to diet, elimination patterns, sleep behaviors, etc. Children need the presence of their caregiver to cope with the stress of a medical visit. Those who are deprived of support and soothing from a trusted adult during medical visits experience much greater distress.

Involve birth parents in medical appointments when possible

When contact is not restricted, encourage birth parents to attend their children’s medical appointments. By attending the appointments the parent learns directly from the healthcare professional what their child needs, has the opportunity to ask questions and can develop a relationship with the healthcare provider. Any guidance the healthcare professional provides at the appointment can help build the parent’s capacity to better care for their child following reunification. In turn, the birth parent can provide the health care provider with important information, such as the family health history.

Understand that birth parents often have their own trauma histories and may feel guilt and anger related to the removal of their children from their care. Most birth parents hope to regain custody of their children and respond well to a warm, respectful approach that involves speaking to them directly and involving them in discussions and decision-making. While most birth parents will be cooperative, be prepared to set limits for those who become disruptive and upset their children during medical visits or inpatient stays.

Any tension between birth parents and resource parents can occasionally be reduced by involving both in discussions of the child’s medical needs and encouraging cooperation and mutual support in meeting them. A hospital social worker may be a good resource for promoting good working relationships between birth parents and foster parents.

Build the child’s and caretaker’s capacity to get the most out of a medical appointment.

Before the appointment

Help the child and caretaker(s) to articulate their concerns or questions. Work with them to make a written question list to bring to the appointment. Encourage the child and caretaker(s) to present these concerns or questions early in the health care visit so they are not forgotten in the rush of the appointment.
Coach resource parents to prepare a child for medical examinations / treatment by:
- explaining the general process
- exploring the child’s feelings and worries about medical visits
- providing reassurance and learning what helps the child when s/he is scared

During the appointment

It can be helpful for the child welfare professional to attend a visit with the primary healthcare provider when a child is new to placement, and to attend visits with specialists.
Provide any paperwork or forms that the doctor needs to complete at the start of the visit to ensure its timely completion.
Encourage the resource parent and birth parent to ask questions.

After the appointment

Review the visit with the child and caregivers. Is anything confusing or unclear? Seek clarification as needed via a follow-up call to the practice to speak with the physician or a nurse.
Ensure that resource and birth parents have the support and information they need to attend to the child’s medical needs.
Secure referrals and consents for recommended care.
Plan with caregivers and child: When and who will follow up on each of the healthcare provider’s specific recommendations?
Track completion of the plan. Request documentation that the resource parent or birth parent completed any recommended health care visits or follow-up appointments.

Learn who can provide consent for treatment

As you are aware, foster and pre-adoptive parents are not legal guardians and cannot give consent for medical procedures. Consent guidelines vary from State to State; check with your local authority regarding the specifics of consent. Generally, approaches to consent follow the patterns below:

Consent for routine medical care (e.g., annual physicals, dental check-ups, eye exams, immunizations) is typically granted by statute or obtained from birth parents when a child enters the system.
For any medical care beyond routine care, consent is required from the birth parent, the child welfare authority, or the Court, depending on the circumstances of the case (e.g., if the birth parent cannot be located) and whether or not parental rights are terminated.

The child advocate attorney may be helpful when there is a delay in obtaining consent or when medically necessary procedures are disputed.

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Most common health issues among children in foster care: